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THE 


PATHOLOGY  AND  TREATMENT 


VENEREAL  DISEASES. 


/ 


BY 


ROBERT   W.  TAYLOR,  M.  D., 

CLINICAL  PROFESSOR  OF  VENEREAL  DISEASES   AT  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS 
(COLUMBIA  COLLEGE),   NEW  YORK  ;    SURGEON  TO  BELLEVUE  HOSPITAL,   AND  CON- 
SULTING SURGEON  TO  CITY   (CHARITY)   HOSPITAL,  NEW   YORK. 


WITH  TWO  HUNDRED  AND  THIRTY  ILLUSTRATIONS  AND  SEVEN  COLORED  PLATES, 


PHILADELPHIA: 

LEA  BROTHERS  &  CO. 

1895. 


Entered  according  to  Act  of  Congress  in  the  year  1895,  by 

LEA   BROTHERS   &   CO., 

in  the  Office  of  the  Librarian  of  Congress,  at  Washington.     All  rights  reserved. 


PRINTED  BY 
■WESTCOTT  A  THOMSON,  PHILADA.  ""'  "  '  ^' 


ELECTROTYPED  BY 

WILTJ.VM  J.    D0RN.\N,  PHILADA. 


TO 


JAMES  W.  McLANE,  A.M.,  M.D., 

DEAN    OF  THE  FACULTY   AND  PROFESSOR  OF  OBSTETRICS  AT  THE  COLLEGE 
OF  PHYSICIANS  AND  SURGEONS,   NEW  YORK, 


J^S   A.lSr    TCXFRESSIOlSr    OF    HIGH    REGARD, 


THIS   WORK   IS   DEDICATED   BY 


THE  AUTHOR. 


PREFACE. 


In  preparing  this  volume  the  endeavor  has  been  made  to  present  the 
subjects  herein  considered  on  a  level  with  our  advanced  knowledge  of 
to-day.  So  vast  is  the  mass  of  accumulated  knowledge  regarding 
venereal  diseases,  their  sequehB,  and  allied  conditions,  that  no  one 
man's  experience  can  cover  the  whole  ground.  Consequently,  the 
author  Avho  would  offer  to  the  profession  an  acceptable  text-book  on 
these  subjects  must  supplement  his  own  studies  and  observations  by 
the  experience  of  all  observers  whose  works  show  inherent  evidence 
of  truth  and  progress,  and  he  must  deduce  therefrom,  in  a  thoroughly 
scientific  and  conservative  spirit,  the  essential  facts  and  the  concrete 
knowledge  thus  far  obtained. 

The  advancement  made  in  the  study  of  the  nature  and  treatment  of 
Gonorrhoea  up  to  the  present  time  is  so  great  that  its  portrayal  really, 
amounts  to  a  revelation.  The  pathology  of  this  disease  will  be  found  to 
be  very  thoroughly  considered,  the  various  chapters  being  based  on  my 
own  studies,  supplemented  and  supported  by  the  labors  of  many  zealous 
and  intelligent  men.  An  attempt  has  been  made  to  determine  the 
pathological  scope  and  the  limitations  of  the  gonococcus  as  a  cause 
of  urethral  suppuration,  and  to  tone  down  the  too  far-reaching  and 
absolute  views  of  those  who  see  nothing  beyond  this  virulent  microbe. 
The  treatment  of  gonorrhoea  in  all  its  stages  and  forms  has  been 
exhaustively  considered,  and  it  is  hoped  that  the  methods  recommended 
will  be  found  to  be  rational,  safe,  and  effective.  Much  stress  has  been 
laid  on  the  fads,  the  hobbies,  and  the  visionary  views  held  by  many  as 
to  the  therapeutics  of  gonorrhoea,  and  their  fallacies,  shortcomings,  and 
dangers  have  been  prominently  brought  forward.  The  sequelae  of 
gonorrhoea  and  their  allied  conditions  have  been  duly  considered.  The 
subject  of  gonorrhoea  in  women,   concerning  which  there   is   so   much 


6  .  PREFACE. 

doubt  and  obscurity,  has  been  very  fully  considered,  and  it  is  hoped 
that  the  systematic  chapter  treating  thereon  may  be  of  benefit. 

Stricture  of  the  urethra  has  received  such  careful  and  extended 
consideration  as  the  importance  of  the  subject  demands.  There  is  no 
morbid  condition  in  the  whole  field  of  surgery  concerning  which  the 
invaluable  teachings  of  pathological  anatomy  have  been  so  persistently 
neglected,  resulting  in  errors  and  dangers  which  it  has  been  mv  earnest 
effort  to  point  out.  Much  space  has  been  devoted  to  the  treatment  of 
urethral  stricture,  Avhich  has  been  rendered  necessary  by  the  prevalent 
but  unscientific  tendency  to  cut  a  urethra  in  which  the  slightest  symp- 
tom of  inflammatory  change  is  detected.  On  this  subject  it  is  hoped 
the  reader  will  find  sound  conservative  statements  as  to  Avhat  should 
and  what  should  not  be  done. 

The  various  genito-urinary  affections  included  in  this  volume  receive 
proper  attention,  and  for  them  the  latest  surgical  procedures  are  advised. 

In  the  section  on  Chancroid  the  subject  of  etiology  is  fully  considered, 
together  with  all  questions  and  conditions  relating  to  this  hybrid  ulcer, 
which  in  other  days  was  a  bone  of  contention  in  the  medical  mind. 

So  extensive  has  been  the  accumulation  of  facts  relating  to  Syphilis 
that  the  subject  has  called  for  extended  consideration.  Its  pathology,  its 
position  among  general  infectious  diseases,  its  far-reaching  tendencieSj 
its  various  symbioses  and  relations  to  surgical  pathology  and  to  other 
diseases  and  conditions,  have  received  especial  attention,  while  its 
lesions  proper  have  been  fully  but  succinctly  described.  In  the  matter 
of  the  treatment  of  syphilis  the  effort  has  been  made  to  consider  the 
subject  exhaustively,  to  point  out  the  fallacies  and  dangers  of  several 
methods  now  more  or  less  in  use,  and  to  lay  down  on  broad  lines  certain 
directions  for  a  general  methodical  treatment  which  are  the  outcome  of 
prolonged  experience  and  are  founded  on  a  solid  scientific  basis. 

Hereditary  syphilis  has  received  due  consideration. 

The  chapter  on  Syphilitic  Affections  of  the  Ear  has  been  written  by 
that  accomplished  specialist,  my  friend  Dr.  J.  A.  Andrews. 

Much  care  and  attention  have  been  given  to  the  matter  of  illus- 
trating various  morbid  conditions,  and  with  two  or  three  exceptions  all 
the  illustrations  contained  in  this  volume  have  been  made  under  my 
personal  supervision,  selected  from  a  vast  number  of  tA'pical  cases  that 
have  been  in  my  care. 


PREFACE.  7 

In  so  large  an  undertaking  as  the  preparation  of  this  volume  one 
must  of  necessity  sometimes  seek  aid  of  others,  and  it  affords  me  pleasure 
to  make  this  acknowledgment  of  my  obligations.  To  Prof.  George  S. 
Huntington  of  the  College  of  Physicians  and  Surgeons,  New  York,  I 
am  indebted  for  many  courtesies  extended  to  me  in  his  anatomical  lab- 
oratory ;  to  Dr.  Ira  Van  Gieson  for  aid  in  some  pathological  questions ; 
and  to  Dr.  J.  R.  Hayden  for  several  good  offices. 

In  presenting  this  volume  to  the  profession  I  venture  to  hope  that  it 
may  find  the  same  favor  which  was  accorded  to  the  works  written  by  my 
eminent  and  lamented  colleague,  Dr.  Bumstead,  and  myself,  of  which 
the  treatise  on  Venereal  Diseases  passed  through  five  editions. 

EGBERT  W.  TAYLOR. 
40  West  21st  Street,  New  York, 
September  12,  1895. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/pathologytreatmeOOtayl 


CONTENTS. 


PAGE 

INTRODUCTION 17 


PART    I. 
GONORRHCEA  AND   ITS   COMPLICATIONS. 

CHAPTER  I. 

Anatomy  and  Physiology  of  the  Penis,  the  Urethra,  the  Blad- 
der, THE  Prostate,  and  Accessory  Parts 31 

CHAPTER    II. 
Gonorrhoea  in  the  Male 65 

CHAPTER  III. 
The  Gonococcus .     57 

•                                               CHAPTER   IV. 
The  Pathogenic  Action  of  the  Gonococcus 62 

CHAPTER  V. 
Invasion  of  the  Tissues  by  the  Gonococcus 76 

CHAPTER  VI. 

The  Pathology  of  Chronic  Gonorrhoea  and  of  Stricture  of  the 

Urethra 78 

CHAPTER  VII. 
The  Etiology  of  Gonorrhcea 85 

CHAPTER   VIII. 

The  Period  of  Incubation  and  the  Predisposing  Conditions  and 

Causes  of  Acute  Anterior  Urethritis  or  Gonorrhcea     ....    107 

9 


10  CONTENTS. 

CHAPTER   IX. 

PAGE 

Acute  Anterior  Goxorrhcea,  or  Urethritis 112 

CHAPTER  X. 
Treatment  of  Acute  Urethritis,  or  Gonorrhoea 125 

CHAPTER  XI. 
Acute  Posterior  Urethritis,  or  Gonorrhcea 156 

CHAPTER   XII. 
Urethritis  in  Young  Boys 1G3 

CHAPTER  XIII. 
Chronic  Urethritis,  or  Gonorrhcea,  Anterior  and  Posterior  .   .   .    165 

CHAPTER   XIV. 
Urethro-cystitis  and  Cystitis 184 

CHAPTER  XV. 

Membranous  Desquamative  Urethritis 189 

CHAPTER  XVI. 

External    Urethritis,    Preputial    Folliculitis,  Juxta-urethral 

Sinuses,  and  Follicular  Abscesses  due  to  Gonorrhoea  ....    190 

CHAPTER   XVII. 
Peri-urethral  Abscesses 196 

CHAPTER  XVIII. 
Gonorrhcea  of  the  Rectum 204 

CHAPTER    XIX. 
Gonorrhcea  of  the  Mouth 208 

CHAPTER    XX. 

Congestion   of   the  Prostate,  Acute  Prostatitis,  and  Prostator- 

rhcea 211 

CHAPTER    XXI. 

Inflammation  of  the  Seminal  Vesicles 219 

CHAPTER  XXII. 

Epididymitis  and  Epididymo-orchitis  (Swelled  Testicle) 228 


CONTENTS.  11 

CHAPTER  XXIIL 

PAGE 

GONORRHCEAL   OPHTHALMIA   AND    SeRO-VASCULAR  CONJUNCTIVITIS    .    .     .     254 

CHAPTER  XXIV. 

GONORRHCEAL  RHEUMATISM 260 

CHAPTER  XXV. 
Peritonitis  in  the  Male  due  to  Gonorrhcea 268 

CHAPTER  XXVI. 

Cardiac  Affections  and  Pyemia 270 

CHAPTER  XXVII. 

Affections  of  the  Spinal  Cord 273 

CHAPTER  XXVIII. 
Cutaneous  Affections 275 

CHAPTER  XXIX. 

Lymphangitis  and  Adenitis 277 

CHAPTER  XXX. 
Gonorrhoea  in  the  Female 279 

CHAPTER  XXXI. 

VULVO-VAGINITIS   IN   INFANTS   AND    YoUNG   CHILDREN 315 

CHAPTER  XXXII. 
Stricture  of  the  Urethra , 323 

CHAPTER   XXXIIL 
Balanitis  and  Balano-posthitis 392 

CHAPTER   XXXIV. 
Phimosis 401 

CHAPTER  XXXV. 
Paraphimosis 417 

CHAPTER  XXXVI. 
Herpes  Progenitalis 424 

CHAPTER  XXXVII. 
Vegetations 431 


12  CONTEXTS. 

CHAPTER   XXXVIII. 

PAGE 

HoRXY  Growths  of  the  Penis 440 

CHAPTER   XXXIX. 
Caxcer  of  the  Pexis 442 

CHAPTER   XL. 
Elephantiasis  of  the  Genitals 457 

CHAPTER   XLI. 
Varicocele 460 

CHAPTER   XLII. 
Hydrocele  and  Hematocele 467 


PAET    11. 
THE    CHANCROID    OR    SOFT    CHANCRE. 

CHAPTER   XLIII. 

Nature  of  the  Chancroid 481 

CHAPTER   XLIV. 
Etiology  of  the  Chancroid  as  observed  in  Clinical  Practice    .   .    486 

CHAPTER   XLV. 
Bacteriology  of  the  Chancroid 491 

CHAPTER    XLVI. 
Clinical  History  of  the  Chancroid 493 

CHAPTER  XLVII. 
Cephalic  and  Extragenital  Chancroids 502 

CHAPTER  XLVIII. 
Diagnosis,  Prognosis,  and  Treatment 505 

CHAPTER   XLIX. 
Buboes •   •   •    513 


CONTENTS.  13 

PAET     III. 
SYPHILIS. 

CHAPTER   L. 

PAGE 

General  Considerations  as  to  its  Nature,  Evolution,  and  Course   519 

CHAPTER  LI. 

Pathology  of  Syphilitic    Infection  and  of  the  Syphilitic  Pro- 
cesses  528 

CHAPTER   LII. 

Vehicles  of  Syphilitic  Infection:  Normal  Secretions  Non-infec- 
tious; AND  the  Various  Modes  of  Syphilitic  Infection  ....    535 

CHAPTER  LIII. 
The  Chancre,  or  the  Initial  Lesion 540 

CHAPTER   LIV. 
Extragenital  Chancres 552 

CHAPTER   LV. 
Genital  and  Extragenital  Chancres  in  Women 559 

CHAPTER   LVI. 

Hyperplasia  of  the  Ganglia  and  Perivascular  Spaces. — Adenitis 

AND  Lymphangitis 572 

CHAPTER  LVII. 

General  Outline  of  the  Symptoms  at  the  Evolution  of  the  Sec- 
ondary Stage 576 

CHAPTER  LVIII. 

The  Various  Morbid  Conditions  and  Affections  of  the  Secondary 

Stage 578 

CHAPTER  LIX. 
Hemorrhagic  Syphilis  AND  H.emoglobinuria 593 


14  COXTEXTS. 

CHAPTER   LX. 

PAGE 

General  Consider atioxs  on  the  Affections  of  the  Skin,  or  Syph- 

ILIDES 595 

CHAPTER   LXI. 

The  Early  or  Secondary  Syphilides 604 

CHAPTER   LXII. 
Affections  of  the  Various  Mucous  Membranes 645 

CHAPTER   LXIII. 
Affections  of  the  Hair 656 

CHAPTER    LXIV. 
Affections  of  the  Xails 660 

CHAPTER   LXV. 

Reinfection  with  Syphilis;  Syphilis  in  Elderly  and  Old  Persons; 

AND  the  Immunity  of  Animals 666 

CHAPTER    LXVI. 

The  Influence    of  Syphilis  upon,  and  its  Relations  to,  Various 

Diseases  and  Morbid  Conditions 671 

CHAPTER   LXVII. 
Affections  of  the  Eye 679 

CHAPTER    LXVIII. 
Affections  of  the  Ear 709 

CHAPTER  LXIX. 
Tertiary  Syphilis 715 

CHAPTER    LXX. 
The  Tertiary  Syphilides •   •    723 

CHAPTER    LXXI.    " 
Gangrene  and  Gangrenous  Ulcers 743 


CONTENTS.  15 

CHAPTER   LXXII. 

PAGE 

Affections  of  the  Tokgue,  the  Soft  Palate,  the  Pharynx,  the 
Larynx,  and  the  Esophagus 745 

CHAPTER   LXXIII. 
Affections  of  the  Trachea,  Bronchi,  Lungs,  and  Heart 754 

CHAPTER   LXXIV. 
Affections  of  the  Liver  and  Spleen 758 

CHAPTER   LXXV. 

Affections  of  the  Stomach,  Intestines,  and  Rectum 761 

CHAPTER  LXXVL 
Various  Rare  Affections 765 

CHAPTER   LXXVn. 

Affections  of  the  Muscles,  of  the  Tendinous  Sheaths,  and  of  the 

Aponeuroses  and  Burs^^e 767 

CHAPTER  LXXVIIL 
Affections  of  the  Bones  and  Joints 772. 

CHAPTER  LXXIX. 

Affections  of  the  Fingers  and  Toes , 778 

CHAPTER   LXXX. 
Lesions  of  the  Kidneys,  Late  Glycosuria,  and  Diabetes  Insipidus  783 

CHAPTER   LXXXI. 

Affections  of  the  Penis,  Os  Uteri,  Uterus,  and  Vagina 785 

CHAPTER  LXXXIL 

Affections  of  the  Epididymis  and  Testis 788 

CHAPTER  LXXXIII. 

Affections  of  the  Nervous  System  .....,, 791 


16  CONTENTS. 

CHAPTER   LXXXIV. 

PAGE 

The  Abortive  Treatment,  and  Treatment  of  Chancres 806 

CHAPTER    LXXXV. 

The  General  Methodical  Treatment  of  Syphilis 820 

CHAPTER   LXXXVL 
Hereditary  Syphilis , 920 

CHAPTER  LXXXVII. 
Lesions  of  the  Placenta  .   ,    .   . .,.,...,..    975 


VENEREAL    DISEASES. 


INTRODUCTION. 

In  the  light  of  our  present  knowledge  it  may  be  stated  that  there  are 
three  distinct  forms  of  venereal  disease — namely,  gonorrhoea,  the  chan- 
croid, and  syphilis.  Although  there  are  yet  many  unsettled  points 
relating  to  all  these  diseases,  the  broad  fact  remains  that  they  are,  in 
essence,  etiologically  distinct.  To-day  our  knowledge  of  the  nature  of 
gonorrhoea  is  tolerably  clear  and  full,  and  we  know  far  more  than  we 
knew  in  years  gone  by  of  the  pathology  of  that  virulent  process. 

Though  there  are  many  essential  facts  lacking  for  a  thoroughly 
scientific  knowledge  of  the  chancroidal  ulcer,  much  has  of  late  been 
learned  concerning  its  origin  and  pathogeny.  Nothing  in  medicine  is 
to-day  better  demonstrated  than  that  chancroid  and  syphilis  are  entirely 
distinct  morbid  processes.  Syphilis  has  a  distinct  virus  of  its  own; 
chancroid  has  no  essential  virus,  and  may  arise  de  novo  independently 
of  contagion,  and  may  be  produced  by  the  inoculation  of  the  products 
of  simple  inflammation. 

It  is  unnecessary  to  devote  very  much  space  and  time  to  a  consid- 
eration of  the  history  of  the  venereal  disease,  since  with  the  expansion 
of  our  knowledge  in  recent  years  many  of  the  old  issues  have  been 
removed  and  explained,  so  that  to-day  the  subject  can  be  presented  in  a 
very  compact  form.  To  this  end  I  shall  touch  lightly  upon  old  issues 
and  consider  fully  all  the  new  ones. 

HISTORY  OF  THE  VENEREAL  DISEASE. 

There  is  no  fact  more  clearly  established  than  that  gonorrhoea  ex- 
isted among  all  nations  and  peoples  in  the  earliest  times.  It  is  referred 
to  by  Moses  in  the  fifteenth  chapter  of  Leviticus,  and,  although  it  seems 
probable  that  the  disease  was  not  as  common  among  the  Greeks  and 
Romans  as  among  the  Hebrews,  there  is  unquestionable  evidence  that 
these  nations  suffered  from  it.  Herodotus  ^  states  that  the  Scythians 
having  pillaged  the  temple  of  Venus  Urania,  that  angry  goddess  sent 
upon  them  and  their  posterity  the  woman's  disease,  which  is  character- 
ized by  a  running  from  the  penis.  Those  attacked  were  looked  upon  as 
accursed.  Later  writings  by  authors  of  all  nations  and  of  all  ages 
clearly  show  that  gonorrhoea  and  its  complications  were  well  known  to 
them. 

The  Chancroid. 

Nearly  all  the  Greek,  Latin,  and  Arabian  writers  on  medicine 
describe  a  contagious   ulcer  of  the  genitals   which  was   called  caroli 

1  Clio,  lib.  1. 
2  17 


18  VENEREAL  DISEASES. 

taroli,  caries  pudendorum,  robigo,  or  cancer,  and  undoubtedly  iden- 
tical with  our  chancroid.  Celsus  is  particularly  explicit  in  describ- 
ing the  simple  phagedenic  and  serpiginous  chancroid,  and  Hippocrates 
gives  minute  directions  for  the  treatment  of  abscesses  in  the  groin 
dependent  upon  ulcerations  of  the  Avomb  and  of  the  genitals. 

The  history  of  the  chancroid  in  early  ages  is  tolerably  well  made 
out,  and  we  find  that  the  views  concerning  it  remained  clear  till  toward 
the  end  of  the  fifteenth  century,  when  it  became  confounded  with 
syphilis. 

Syphilis. 

It  is  absolutely  impossible  to  say  whether  syphilis  existed  in 
remote  antiquity  or  whether  it  first  appeared  and  aifected  mankind 
toward  the  end  of  the  fifteenth  century.  During  the  past  twenty  years 
many  articles  and  books  have  been  published  with  the  intent  of  proving 
that  syphilis  was  observed  among  many  nations  at  the  very  earliest 
periods  of  the  world's  history.  But  an  unprejudiced  study  of  these 
contributions  fails  to  carry  conviction  to  my  mind.  Many  plausible  and 
seemingly  convincing  statements  are  made,  but  critical  analysis  of  them 
shows  so  many  misconstructions,  so  many  mistranslations,  and  in  fact  so 
many  distortions  of  fact,  that  one  cannot  but  remain  unconvinced. 

Two  orders  of  proof  are  offered  as  to  the  antiquity  of  origin  or  pre- 
historic existence  of  syphilis  :  the  one  is  the  evidence  of  certain  diseased 
bones ;  the  second,  the  description  of  certain  lesions  of  the  genitals,  the 
ganglia,  the  skin,  the  mucous  membranes,  and  the  viscera.  The  evi- 
dence of  these  ancient  bones  makes  out  a  very  lame  case.  It  is  asserted 
that  certain  swellings,  atrophic  conditions,  and  curvatures  are  undoubt- 
edly due  to  syphilis,  acquired  or  hereditary.  The  statements  are  mag- 
isterially made,  and  little  other  than  plausible  reasons  in  explanation 
of  the  osseous  lesions  are  given.  There  are  no  facts  to  prove  that  these 
pathological  relics  are  not  the  result  of  tuberculosis,  leprosy,  rickets, 
rheumatism,  gout,  osteomyelitis,  traumatism,  and  of  simple  inflamma- 
tory processes.  In  truth,  the  only  scientific  fact  in  our  possession  is 
that  demonstrated  by  my  friend  Dr.  J.  N.  Hyde,^  and  that  is  of  an  unan- 
swerably negative  character.  At  the  suggestion  of  Dr.  Hyde  a  morbid 
and  ancient  tibia  which  had  been  sent  to  him  from  Colorado  as  an 
example  of  the  ravages  of  prehistoric  syphilis  was  submitted  to  that 
eminent  pathologist,  Dr.  T.  M.  Prudden,  for  microscopical  study,  and 
was  pronounced  by  him  to  be  an  example  of  rarefying  osteitis,  a  simple 
inflammatory  process.  Therefore,  until  it  is  scientifically  demonstrated 
to  us  that  certain  undoubtedly  very  ancient  and  prehistoric  bones  (and 
their  great  antiquity  must  be  substantially  proved)  present  unmistakable 
evidence  of  having  been  the  seat  of  true  syphilitic  processes,  the  con- 
tention that  these  fossil  remains  indicate  a  very  early  existence  of  syph- 
ilis is  void. 

The  most  elaborate  recent  attempt  to  prove  the  antiquity  of  syphilis 
is  the  work  of  Dr.  Buret,^  and  besides  this  there  have  been  many  other 
shorter  essays.     Buret  claims  that  syphilis  existed  five  thousand  years 

^  "A  Contribution  to  the  Study  of  Pre-Columbian  Sypliilis  in  America,"  Am,  Journ. 
Med.  Science,  Aug.,  1891. 

^  La  Syphilis  aujourcV hui  et  chez  les  Ancieni<,  Paris,  1890. 


INTRODUCTION.  19 

ago  among  the  Chinese,  among  the  Japanese,  the  Egyptians,  the 
Assyrians,  the  Babylonians,  and  the  Hebrews.  He  explains  every 
quotation  of  ancient  writings  in  the  light  most  favorable  to  his  own 
views,  distorts  the  meaning,  and  in  several  instances  offers  positive  mis- 
translations. Any  wart,  ulcer,  skin  eruption,  or  affection  of  the  genitals 
is  regarded  by  him  as  evidence  of  syphilis,  and  every  ill  alluded  to  in 
the  Scriptures  or  in  the  classics  which  can  be  tortured  into  being  con- 
strued as  eruptive  is  incontinently  set  down  by  him  as  proving  his 
theory. 

We  do  not  find  in  classical  writings  any  allusion  or  statement  which 
seems  to  indicate  syphilis.  Petronius  certainly  would  have  revelled  in 
the  opportunity  of  picturing  Trimalchio  as  suffering  from  the  ravages 
of  the  morbus  Gallicus,  and  how  much  could  the  picture  of  Quartilla 
and  her  associates  be  heightened  by  the  description  of  a  sunken  nose,  of 
the  corona  Veneris,  total  alopecia,  or  by  some  other  hideous  disfigure- 
ment !  Nor  do  Horace  and  Juvenal,  as  we  might  expect  them  to  do, 
make  allusion  to  any  ravages  of  syphilis,  and  the  former  certainly  had 
a  fine  field  in  describing  in  his  ode  to  an  old  woman,  in  addition  to  her 
many  repulsive  qualities,  a  gruesome  picture  of  syphilis  of  the  face.  Dr. 
Buret  quotes  many  passages  from  Martial,  but  he  fails  utterly  in  clearly 
proving  that  that  vigorous  epigrammatist  of  Roman  morals  knew  any- 
thing about  syphilis. 

So  that  it  may  be  stated  without  fear  of  contradiction  that  there  is 
no  absolutely  clear  authentic  statement,  record,  or  collection  of  facts 
thus  far  adduced  which  will  carry  enough  weight  with  it  to  convince  an 
unbiassed  student  that  syphilis  existed  prior  to  the  close  of  the  fifteenth 
century.  Littre's  statement,  then,  still  stands  uncontroverted :  "0>i  ne 
rencontre  aucune  indication  precise  de  la  syphilis  proprement  dite  dans 
les  tnedecins  de  la  Grrece  et  de  Rome  et  eela  jette  le  doubte  siir  ce  point 
d'Jdstoire  medicale."  And,  further,  Lancereaux's  contention  still  holds 
good.  He  says :  "  (Test  en  vain  quon  cherche  dans  antiquite  line  expo- 
sition dogmatique  de  la  syphilis.,  elle  ne  s'y  rencontre  pas." 

The  first  authentic  account  of  syphilis  is  given  by  medical  writers 
about  the  end  of  the  fifteenth  and  the  beginning  of  the  sixteenth  cen- 
tury. These  w^riters,  who  were  familiar  with  the  chancroidal  ulcer, 
describe  syphilis  as  the  morbus  Gallicus  and  the  morbus  novus  et  inaudi- 
tus.  They  recognized  the  initial  lesion  and  described  its  physical  qual- 
ities, particularly  its  hardness.  Its  venereal  origin  was  soon  definitely 
settled,  and  the  fact  that  it  was  the  forerunner  of  constitutional  syphilis 
is  clearly  brought  out  in  their  detailed  and  graphic  descriptions  of  the 
evolution  of  the  disease.^  The  virulence  of  this  terrible  disease  caused 
horror  and  amazement,  for  in  this  famous  epidemic  none  seemed  to  be 
spared.      Men,    women,    and   children   of    high    and  low   degree   were 

'  Jacobus  Cutaneus,  in  his  Traetatus  de  Morbo  Galileo,  1504,  ■writes:  "Anno  Viro;inei 
partus  millesinio  quadragentisimo  nonagesimo  quarto,  invadente  Carolo  Octavo,  Fran- 
corum  Rege,  Regnum  Parthenopppura,  Alexandro  Vero,  Sexto  ea  tempestate  summum 
pontificatuni  gerente,  exortus  est  in  Italia  monstrosus  morbus,  nullis  ante  seculis  visus 
totoque  in  orbe  terraruin." 

For  the  history  of  the  origin  of  syphilis  in  the  Middle  Ages  the  reader  is  referred  to 
Geigel,  Geaehlelite,  PatJiolnr/ie,  mid  Thernpie  der  Sypli  1 1  isf,  Vi'uvzhurg,  1867;  Auspitz,  Die 
Lehrenvom  Syphllitlxehen  contagium,  Wien,  1866;  and  Proksch,  i>ie  Geschichte  des  Vener- 
ischen  Krankheiten,  Bonn,  1895. 


20  VENEREAL  DISEASES. 

attacked.  The  disease,  in  the  language  of  a  poet  of  that  period,  is  said 
to  have  "neither  spared  the  crown  nor  the  cross." 

The  epidemic  of  syphilis  which  stands  out  so  boldly  in  medical  his- 
tory occurred  about  the  time  (the  latter  part  of  the  year  1494)  when 
Charles  VIII.,  king  of  France,  Avith  a  large  army  invaded  Italy  Avith 
the  intent  of  taking  possession  of  the  kingdom  of  Naples,  which  he 
claimed  by  right  of  inheritance.  Charles  left  Rome  on  his  way  to 
Naples  January  28,  and  reached  the  latter  city  February  21,  1495. 
After  a  time  the  Neapolitans  revolted  against  the  authority  of  Charles, 
and,  aided  by  a  Spanish  army  under  the  command  of  Gonsalvo  of  Cor- 
dova, they  endeavored  to  drive  the  French  out  of  Italy.  There  were 
then  three  armies  encamped  near  Naples,  and  about  this  time  the  fear- 
ful epidemic  broke  out.  It  is  not  definitely  established  that  the  disease 
first  appeared  among  the  troops,  but  they  certainly  were  attacked,  and 
were  one  of  the  means  of  conveying  the  disease  into  other  countries. 
There  is  ample  evidence  to  prove  that  within  a  few  years  the  disease  had 
spread  over  the  greater  part  of  Europe.  Thus  we  find  that  syphilis  was 
by  the  Neapolitans  called  the  morbus  Gallicus,  by  the  French  mal  de 
Naples,  and  was  also  called  the  Polish,  Spanish,  Turkish,  and  Christian 
disease.  It  was  also  named  after  some  saints,  and  was  called  the  disease 
of  the  holy  man  Job,  of  St.  Leonard,  St.  Clement,  St.  Mevius,  and  St. 
Roche.  It  was  not  known  as  the  American  disease  until  twenty  years 
after  the  return  of  Columbus  from  his  first  trip  (1493).  A  writer 
named  Oviedo,  long  after  the  death  of  that  great  navigator,  by  means 
of  far-fetched  arguments  and  distortions  of  facts  tried  to  prove  that  his 
sailors  became  infected  Avith  syphilis  from  the  Indians  in  America,  and 
that  they  carried  the  disease  to  Europe.  Oviedo  and  his  statements 
and  claims  are  really  unworthy  of  historical  chronicle. 

It  seems  strange — and  it  is  certainly  unparalleled — that  such  a 
strikingly  well-marked  disease  as  syphilis  should  thus  break  forth  in 
epidemic  form  Avithin  a  quite  restricted  area  of  territory,  and  that  its 
nature  and  origin  should  be  wholly  unknoAvn  to  all  observers  and  Avriters 
(and  very  many  of  them  AA'ere  learned  and  experienced  men)  of  that 
period.  Yet  the  fact  remains  that  it  Avas  unknoAvn  in  Europe  prior  to 
the  last  decade  of  the  fifteenth  century. 

Those  physicians  who  had  been  familiar  Avith  the  chancroid  and 
gonorrhoea  prior  to  the  year  1494  had  very  clear  ideas  as  to  their 
nature,  and  they  kncAv  perfectly  well  that  they  Avere  not  in  any  Avay 
related  to  the  new  disease.  Consequently,  early  in  the  sixteenth  cen- 
tury there  Avas  no  confusion  as  to  the  nature  of  any  of  these  diseases. 
As  time  went  on,  however,  the  men  who  witnessed  the  famous  epidemic 
died,  and  in  a  few  years  Avhat  is  knoAvn  as  the  "age  of  confusion  "  in 
venereal  diseases  appeared.  Then  syphilis,  chancroid,  and  gonorrhoea 
came  to  be  regarded  as  one  disease,  having  one  origin,  and  Avas  knoAvn 
as  the  venereal  disease — lues  Venerea. 

The  above-mentioned  confusion,  Avith  the  resulting  indiscriminate 
mode  of  treating  these  diseases,  existed  unabated  until  toAvard  the  close 
of  the  last  century,  and  did  not  Avholly  cease  until  the  first  half  of  the 
present  century  had  been  passed. 

The  identity  of  gonorrhoea  Avith  syphilis  Avas,  hoAvever,  denied  even 


INTE  OD  UCTION.  21 

in  the  last  century  by  Astruc/  Balfour,^  and  Benjamin  Bell.^  It  was 
believed  in  by  Hunter,  but  met  with  further  opponents  in  Swediaur/ 
Hernandez,^  and  especially  Ricord,''  who  by  the  use  of  the  speculum 
in  venereal  diseases,  by  means  of  experimental  inoculations,  and  his 
discovery  of  the  chancre  larve,  refuted  the  chief  arguments  which  had 
been  adduced  in  its  favor,  and  established  the  non-identity  of  the  two 
diseases  beyond  dispute  for  ever.  This  was  the  first  great  step  out  of 
darkness  into  light. 

The  idea  that  all  venereal  sores  are  due  to  a  single  virus,  the  virus 
of  syphilis,  had  been  the  prevailing  one  for  nearly  three  centuries 
prior  to  the  year  1852.  At  the  same  time,  it  had  not  escaped  the 
notice  of  many  observers  that  the  results  of  infection  were  by  no  means 
identical — that  in  some  cases  the  persons  infected  showed  no  symptoms 
after  the  healing  of  their  ulcers,  while  others  developed  a  train  of  symp- 
toms lasting  through  years,  and  even  transmissible  to  their  children. 

In  the  year  1852,  Bassereau^  claimed  a  distinct  cause  or  origin  for 
each  of  these  two  classes  of  cases.  He  founded  his  claim,  first,  on 
the  history  of  venereal  sores,  which  we  have  already  referred  to,  and 
which  shows  that  although  contagious  ulcers  of  the  genital  organs, 
communicated  in  sexual  intercourse,  had  been  well  known  to  the  an- 
cients, yet  that  the  constitutional  disease  which  we  call  syphilis  made 
its  appearance  in  Europe  in  the   latter  part  of  the  fifteenth  century. 

Bassereau's  second  argument  Avas  based  upon  the  "  confrontation  " 
of  persons  affected  with  venereal  diseases,  and  he  and  others  were 
able  to  prove  in  several  hundred  cases  that  when  the  disease  was  local 
in  the  giver  it  was  also  local  in  the  recipient,  and  that  when  it  was  con- 
stitutional in  the  giver  it  was  always  constitutional  in  the  recipient ;  in 
other  words,  that  the  broad  line  of  distinction  separating  a  local  disease 
on  the  one  hand  from  a  constitutional  disease  on  the  other  was  constant 
in  successive  generations  without  limit. 

It  will  be  observed  that  this  proof  does  not  involve  any  diff'erences, 
real  or  supposed,  in  venereal  ulcers  themselves  ;  it  may  be  said  to  rise 
above  such  consideration  in  that  it  ascends  to  the  source  and  origin  of 
such  sores. 

Though  to  Bassereau  is  certainly  due  the  credit  (which  was  even 
conceded  by  Ricord)  of  sharply  distinguishing  the  non-identity  of 
syphilis  with  chancroid,  yet  it  is  evident  in  the  writings  of  the  latter^ 
that  he  Avas  convinced  that  the  hard  and  the  soft  sores  were  entirely 
different  in  nature  and  in  origin.  Ricord  comes  so  near  in  some 
passages,  particularly  in  his  nineteenth  letter,  saying  what  Bassereau 
afterward  proclaimed  as  a  doctrine,  that  it  is  surprising  that  the  whole 
truth  did  not  flash  through  his  mind,  for  he  says  that  syphilis  is  abso- 
lutely inseparable  from  the  indurated  ulcer.  Undoubtedly,  the  master 
gave  his    disciple  the   clue  which  he  worked  out  so  successfully  and 

^  De  morhis  venereif^,  Paris,  1740. 

^  Dissert,  de  (jonorrhma  virulenta,  Edinburgh,  1767. 

^  Treatise  on  Gon.  Virulenta  and  Lues  Venerea,  Edinburgh,  1793. 

*  Traite  complet  des  Maladies  veneriennes,  Paris,  1801. 

*  Essai  analytique  sur  la  Non-identite  des  ViniJi  fjonorrheique  et  syphilitique,  Toulon,  1812. 
^  Traite  pratique  des  Maladies  veneriennes,  Paris,  18.38. 

^  Traite  des  Affections  de  la  Peau  symptomatiques  de  la  Syphilis,  Paris,  1852. 
^  "  Lettres  sur  la  Syphilis,"  L'  Union  niedicale,  1850-51,  and  Paris,  1852. 


22  VENEREAL  DISEASES. 

clearly.  Ricord  was  fully  convinced  that  antecedent  constitutional 
conditions,  temperament,  bad  food,  alcoholics,  bad  hygiene,  and  inter- 
current diseases  had  not,  as  was  claimed,  any  influence  in  causing  a 
hard  chancre  in  one  man  and  a  soft  one  in  another.  He  saw,  though 
he  does  not  specifically  say  so,  that  the  two  lesions  were  due  to  two 
distinct  causes. 

Bassereau's  lucid  separation  of  the  chancroid  from  syphilis  was  the 
second  step  in  the  era  of  light. 

Unfortunately  for  medical  science,  this  doctrine,  so  modestly  put 
forward  by  Bassereau,  Avas  not  allowed  to  rest  in  its  clearness  and  sim- 
plicity. Clerc,  also  a  disciple  of  Ricord,  while  he  recognized  the  clinical 
distinctions  between  the  initial  lesion  of  syphilis  and  the  chancroid,  put 
forward  the  claim  that  in  essence  they  Avere  related.  Clerc's  thesis  ^  was 
that  the  simple  non-infective  chancre  is  the  result  of  the  inoculation  of 
the  secretion  of  an  infecting  chancre  upon  a  subject  who  has  or  who  has 
had  syphilis,  and  that  it  is  the  analogue  of  varioloid  or  false  vaccinia; 
hence,  that  the  term  "chancroid"  should  be  given  to  it.  This  much 
may  be  said,  that  while  Clerc's  theory  has  not  been  accepted,  his  name 
— chancroid — for  the  soft  non-infecting  sore  is  the  best  that  we  have. 

Lntil  the  time  of  Bassereau's  essay  the  doctrine  of  unicism  held 
sway  in  venereal  diseases :  that  is,  that  syphilis  and  the  soft  sore  were 
alike  in  nature  and  origin.  To  the  minds  of  many  Bassereau's  modest 
statement  of  facts  was  not  radical  enough ;  so  Rollet  ^  of  Lyons  and 
others  set  themselves  to  the  task  of  proving  that  the  chancroid  was  the 
expression  of  a  distinct,  special  virus,  and  as  a  result  they  put  forward 
the  doctrine  of  dualism  in  syphilis,  the  essence  of  which  was  that  syphilis 
originated  in  its  OAvn  virus,  and  that  the  chancroid  was  also  the  expres- 
sion of  a  distinct  virus.  The  stability  of  this  doctrine  depended  upon 
the  sharpness  and  precision  in  distinguishing  these  two  poisons  and 
their  results.  It  was  very  easy  to  present  clearly-cut  lines  of  diflfer- 
ential  diagnosis  between  the  two  kinds  of  sores,  but  Avhen  the  advocates 
of  dualism  made  the  claim  that  the  chancroid  was  peculiar  in  the  fact 
that  the  tissues  of  the  head  were  immune  to  it,  and  advanced  the  tenet 
(which  was  vital  to  their  theory)  that  the  secretion  of  syphilitic  lesions 
could  not  be  (as  were  those  of  the  chancroid)  inoculated  with  success 
upon  the  person  bearing  them  or  any  syphilitic  individual,  they  exposed 
themselves  to  attacks  which  have  since  demolished  their  main  theory. 
There  were,  therefore,  four  principal  contentions  and  many  minor  ones 
now  unnecessary  to  consider  in  the  doctrine  of  dualism  :  1st,  that  the 
chancroid,  like  syphilis,  was  due  to  a  specific,  special  virus ;  2d,  that 
this  virus  never  originated  de  novo,  but  was  handed  down  in  generations, 
each  sore  propagating  only  its  own  kind ;  3d,  that  syphilitic  secretions 
produced  hard  chancres  about  the  head  and  face,  Avhich  parts  were  iln- 
aff"ected  by  chancroidal  pus ;  and  4th,  that  the  pus  of  chancroids  was 
also  inoculable,  while  the  secretions  of  syphilitic  sores  were  not.  These 
tenets  were  very  soon  vigorously  attacked.  The  claim  that  the  tissues 
of  the  head  and  face  possessed  an  immunity  against  the  action  of  chan- 

^  "Du  Chancroi'de  syphilitique,"  Extrait  du.  Moniteur  des  Hopitaia,  1854. 

^"De  la  Pliiralite  des  Maladies  veneriennes,"  Gaz.med.de  Lyon, 'So.  3,  1860;  J?€- 
cherches  cliniques.  et  experimentales  aur  la  Siiphili.%  le  Chancre  simple,  et  la  Blennorrhagie,  1861 ; 
and  Traite  des  Maladies  venenennes,  Paris,  1865. 


INTRODUCTION.  23 

croidal  pus,  while  they  readily  reacted  under  the  influence  of  syphilitic 
secretions,  was  soon  demolished  by  the  publication  of  cases  in  w^hich 
true  chancroids  were  found  upon  these  parts.  The  main  points  of 
attack  of  the  antagonists  of  dualism  were — first,  that  each  sore,  hard 
and  soft,  propagated  only  its  own  kind;  second,  that  the  soft  sore  always 
originates  in  one  of  its  oAvn  species.  The  first  blow  delivered  by  the 
antagonists  of  this  doctrine  was  the  fact  brought  out  by  the  experi- 
ments of  Clerc,  Melchoir  Robert,^  and  others,  who  succeeded  in  inocu- 
lating the  secretion  of  syphilitic  sores  on  their  bearers,  with  the  result 
of  producing  ulcers  without  an  incubation  period  which  presented  all 
the  characteristics  of  the  chancroid  and  were  inoculable  in  successive 
generations.  Then,  following  up  this  line  of  attack,  Henry  Lee,^  Kob- 
ner,^  and  Pick^  clearly  proved  that  the  secretion  of  a  true  chancre 
could  become  purulent  and  auto-inoculable  when  irritated  by  any  agent 
or  means  (powdered  savin,  tartar  emetic,  setons,  etc.).  This  fact  was 
also  proved  by  Boeck,  Bidenkap,  and  Gjor  in  their  experiments  in 
syphilization.  These  early  observers  had  at  their  command  only  clin- 
ical observation  and  experimental  inoculations.  They  made  no  use  of 
the  microscope,  and  in  those  days  it  would  have  profited  them  nothing. 
To-day  we  know  that  the  syphilitic  chancre,  when  kept  clean  and  un- 
irritated,  gives  issue  only  to  serum  or  sero-mucus.  If  it  is  irritated,  as 
it  usually  is  by  the  deposition  of  dirt  of  many  kinds,  it  gives  issue  to 
pus  which  contains  pyogenic  microbes,  which  pus  will  produce  chan- 
croidal ulcers  on  its   bearer  and  on  the  non-infected. 

If  the  early  disputants  on  the  doctrines  of  unicism  and  dualism 
had  only  known  that  pus-producing  micro-organisms  were  at  the  bottom 
of  all  the  changes  in  the  irritated  ha]:d  chancre,  and  that  their  presence 
in  either  is  accidental  or  the  result  of  their  own  blundering  manipula- 
tions, their  controversy  would  have  been  short-lived.  The  unicists  at 
once  claimed  that  the  results  of  these  various  experiments,  above  men- 
tioned, confirmed  their  doctrine  and  demolished  that  of  the  dualists. 
The  experiments  in  reality  proved  that  the  chancroid  might  originate 
de  novo.  They  certainly  do  not  prove  a  common  origin  for  the  hard 
and  the  soft  sore. 

To  defend  itself,  the  dualistic  school  then  took  refuge  in  the  doc- 
trine of  the  "mixed  chancre,"  a  sore  combining  both  the  syphilitic  and 
chancroidal  poisons,  which,  it  was  asserted,  would  satisfactorily  explain 
all  these  cases  and  still  leave  the  tenets  of  dualism,  as  at  that  time 
understood,  intact.  This  explanation  was  for  a  while  regarded  as  satis- 
factory, but  it  could  no  longer  be  upheld  when  such  experiments  had 
been  multiplied  indefinitely ;  when  their  number  was  so  great  that  the 
chance  of  the  commingling  of  two  kinds  of  specific  virus  in  their  simul- 
taneous inoculation  was  reduced  to  an  absurdity ;  when  an  indurated 
syphilitic  primary  lesion  could  be  taken  at  random,  and,  after  due  irri- 
tation, its  secretion  could  be  successfully  inoculated,  with  the  eifect  of 

^  Nouveau  Traite  des  Maladies  veneriennes,  Paris,  1853  and  1861,  pp.306  et  seq. 

'^  Brit,  and  Fm-eir/n  Med.-Chir.  Review,  vol.  xxiii.,  April,  1859,  pp.  496  et  seq.,  and 
Lancet,  1856,  1869,  1860,  and  1861. 

^  Klin,  und  Experiment.  3Iittheiiungen  aus  der  Deiinatologie  und  Syphilidolo(/ie,EiTla.ngen, 
1864,  pp.  70  et  seq. 

*  Auspitz,  op.  cit.,  pp.  335  et  seq. 


24  VENEREAL  DISEASES. 

producing  pustules  and  ulcers  bearing  every  characteristic  of  the  chan- 
croid ;  and  when  the  same  result  could  even  be  obtained  at  will  by  the 
inoculation  of  the  secretion  from  a  purely  secondary  lesion,  as,  for  in- 
stance, a  syphilitic  mucous  patch.  If  the  chancroid  was  dependent  upon 
a  distinct  specific  virus,  its  presence  in  all  these  cases  was  simply  impos- 
sible, and  yet  not  a  single  shade  of  difference  could  be  pointed  out 
between  the  result  produced  and  that  from  the  most  emblematic  chan- 
croid ever  met  with  in  practice.  Dualism  was  indeed  henceforth  dead, 
if  by  "dualism"  be  meant  that  each  of  the  two  kinds  of  venereal  sore 
has  a  distinct,  specific  virus  of  its  own. 

A  mixed  chancre  is  simply  an  accident,  and  is  by  no  means  a  uni- 
form pathological  process.  Any  hard  chancre  may  be  attacked  by  pus- 
microbes  and  its  general  appearances  much  changed.  There  is,  then, 
the  same  aggregated  mass  of  specific  syphilitic  cells  which  has  become 
the  seat  of  ulcerative  action. 

But  the  last  word  had  not  been  spoken  in  favor  of  a  distinct  origin 
of  the  chancroid  from  that  of  syphilis,  nor  the  last  experiment  made 
and  recorded  which  would  decide  this  question.  Let  us  examine  more 
carefully  the  experiments  just  referred  to.  What  w^as  the  matter  so  suc- 
cessfully inoculated  ?  The  pure,  unmixed  virus  of  syphilis  ?  By  no 
means.  It  was  a  compound  product,  taken,  to  be  sure,  from  a  syphilitic 
lesion,  but  a  lesion  irritated  commonly  to  suppuration  by  artificial  means, 
containing  possibly  the  germ,  of  syphilis,  but  containing  also,  and  in 
fact  chiefly  composed  of,  jjus,  which  we  know  to-day  contains  pyogenic 
micro-organisms.  Which  of  these  two  factors  was  responsible  for  the 
effect  produced  ?  The  syphilitic  virus  ?  In  that  case  this  virus  should 
have  preserved  its  poAver  of  infecting  the  constitution,  and  matter  taken 
from  these  ulcers  and  inoculated  upon  healthy  individuals  should  have 
invariably  produced  syphilis,  which  has  been  shown  not  to  be  true.  More- 
over, if  it  could  be  proved  that  pus  alone,  free- from  all  suspicion  of 
syphilitic  mixture,  Avas  capable  of  producing  the  same  result,  then  pus 
was  the  pathogenic  factor.  This  idea  opened  up  a  new  line  of  attack, 
led  mainly  by  Pick,  Reder,  and  Kraus. 

In  1865,  Pick,  at  the  suggestion  of  Zeissl,^  inoculated  simple,  non- 
venereal  pus  of  inflammatory  origin  upon  syphilitic  subjects.  Taking 
the  secretion  of  pemphigus,  acne,  scabies,  ecthyma,  and  lupus,  he  in- 
oculated it  upon  persons  affected  with  syphilis  and  produced  pustules 
not  preceded  by  incubation,  and  the  matter  of  which  was  further  inocu- 
lable  through  several  generations.  Counter-inoculations  upon  the  per- 
sons free  from  syphilis  who  were  the  bearers  of  these  affections  were 
without  effect.  The  same  result  was  attained  by  Kraus  and  Reder  ^  with 
the  pus  of  scabies,  and  by  Henry  Lee  ^  with  pus  from  a  non-syphilitic 
child.  The  late  Mr.  Morgan  *  of  Dublin  also  succeeded  in  producing 
pustules  and  ulcers  identical  in  appearance  Avith  the  chancroid,  and 
capable  of  reinoculation  through  a  number  of  generations  by  inoculat- 
ing syphilitic  women  with  their  vaginal  secretions. 

It  is  unnecessary  to  further  amplify  this  subject,  for  to-day  there  is 
no  fact  more  clearly  proved  in  medicine  than  that  pus  applied  to  the 

^  Lehrbuch  cler  Syphilis,  Stuttgart,  od  ed.,  1875,  pp.  180  et  seq. 

^Pathologic  und  Therapie  der  Veiierischen  Kmnkheilcn,  Wien,  1868,  pp.  25  et  seq. 

^  Op.  cit.  *  Practical  Lessons  in  Contagious  Diseases,  London,  1872. 


INTB  OD  UCTION.  25 

skin,  particularly  of  those  actively  attacked  by  syphilis,  will  produce 
suppurative  dermatitis.  The  evidence  oflFered  by  cases  of  ecthyma  and 
impetigo  contagiosa  proves  very  conclusively  that  these  diseases  are  due 
to  pus-implantation. 

What  is  thus  far  in  our  study  proved  by  scientific  investigations  is, 
that  the  secretions  of  irritated  syphilitic  lesions,  primary  and  secondary, 
when  inoculated  on  persons  suffering  more  or  less  from  active  syphilis 
produce  pustules  and  ulcers  absolutely  like  chancroids  in  all  their  cha- 
racteristics and  attributes.  The  fact  that  the  skin  and  the  mucous 
membranes  in  early — and  sometimes  in  late — syphilis  are  peculiarly  sus- 
ceptible to  irritation  and  inflammation  is  undoubtedly  the  underlying 
factor  in  this  pyogenic  process. 

Thus  far,  it  will  be  seen  that  the  inoculations  had  only  been  made 
upon  syphilitic  subjects,  and  the  burning  question  which  then  arose  was  : 
What  effect  had  this  pus,  experimentally  produced  on  a  syphilitic,  when 
inoculated  upon  a  non-syphilitic  subject?  To  prove  that  this  same  in- 
oculation was  possible  on  non-syphilitics  without  the  transmission  of 
syphilitic  infection  to  them  was  then  the  crucial  point  in  the  controversy. 
Strange  as  it  may  seem,  the  necessary  evidence  presented  itself  by  mere 
chance  in  the  experience  of  men  who  were  not  working  in  this  direction. 
The  following  observations  by  Boeck,  Danielssen,  Bidenkap,  and  Gjor 
paved  the  way  to  a  correct  understanding  of  this  obscure  point : 

Boeck  ^  in  1856  treated  a  non-syphilitic  woman  suffering  from  chronic 
eczema  rebellious  to  all  forms  of  treatment  by  means  of  repeated  inocula- 
tions with  the  irritated  secretion  of  hard  chancres.  The  woman  was  bene- 
fited, and  was  not  rendered  syphilitic.  Five  years  afterward  this  treatment 
was  again  employed  on  the  same  woman  at  the  hands  of  Dr.  Bidenkap, 
who  took  matter  from  a  typical  hard  chancre  which  had  been  irritated. 
The  result  was  the  production  of  pustules,  but  syphilis  was  not  trans- 
mitted. 

Danielssen's  ^  observation  is  still  more  striking :  A  man  thirty  years 
old,  free  from  syphilis,  was  inoculated  three  hundred  and  ninety-three 
times  with  pus  derived  from  irritated  hard  chancres,  and  Avas  not  ren- 
dered syphilitic.  Later  on  he  was  inoculated  directly  with  the  natural 
secretion  of  a  hard  chancre,  and  became  the  victim  of  syphilis. 

Bidenkap's  *  case  is  also  very  convincing.  It  was  that  of  a  non- 
syphilitic  woman  suffering  from  gonorrhoea,  who  inoculated  herself  with 
the  pus  derived  through  several  generations  from  an  initial  syphilitic 
lesion,  with  the  result  of  producing  a  sore  identical  with  a  chancroid, 
the  secretion  of  which  was  accidentally  auto- inoculated  with  success. 
At  this  time  the  woman  was  not  infected  with  syphilis,  but  a  year  and 
a  half  later  she  became  infected. 

Gjor's  cases,  communicated  in  writing  to  Dr.  Bumstead,  offer  import- 
ant cumulative  evidence.  Gjor  was  practising  the  now  obsolete  method 
of  treating  syphilis  by  syphilization,  which  consisted  in  the  continuous 
inoculation  of  the  patient  with  virus  derived  from  irritated  early  syphi- 

'^  Recherches  sur  la  Syphilis,  Christiania,  1862,  p.  686.  Tliis  is  the  case  usually  attrib- 
uted to  Bidenkap,  who  experimented  on  it  under  Boeck's  direction. 

'^  Die  Syphilisation  in  ihre  Aruvenduny  yeyen  Syphilis  unci  Spedalskecl,  1858.  This  case 
was  also  reported  by  Dr.  Gjor,  Deutsche  klinik,  1858,  33. 

^  Om  del  syphilitiske  Vii-us,  Christiania,  1863,  and  Wien.  med.  Wochemchrift,  1865,  No.  34. 


26  VENEREAL  DISEASES. 

litic  lesions.  The  cases  now  detailed  became  inoculated  with  pus  derived 
from  irritated  mucous  patches.  The  first  case  was  that  of  a  girl  twenty- 
five  years  old,  free  from  syphilis  and  under  treatment  for  some  simple 
afi"ection.  She  stealthily  procured  some  of  the  pus  and  inoculated  her- 
self, with  the  result  of  producing  chancroid-like  pustules.  She  has 
never  presented  any  symptoms  of  syphilis. 

The  second  case  was  that  of  a  girl  aged  nineteen,  free  from  syphilis, 
who  inoculated  herself  in  a  similar  manner  with  a  similar  result.  For 
several  months  after  this  experience  she  was  kept  under  observation,  but 
showed  no  signs  of  syphilis.  A  year  and  a  half  later  she  contracted  a 
true  chancre  in  sexual  intercourse,  which  was  followed  by  secondary 
manifestations.  The  third  case  was  that  of  a  girl  eighteen  years  old, 
who  followed  the  examples  of  the  two  preceding  girls  and  produced 
chancroids,  but  was  not  infected  with  syphilis. 

These  observations  and  experiments  warrant  the  following  conclu- 
sions : 

1.  That  irritation  of  syphilitic  lesions,  particularly  the  early  ones, 
gives  rise  to  an  actively  destructive  form  of  pus  which  by  auto-inocula- 
tion produces  ulcers  identical  in  all  characteristics  and  attributes  with 
chancroids. 

2.  That  this  pus  inoculated  upon  subjects  virgin  to  syphilis  produces 
ulcers  unmistakably  chancroidal  and  inoculable  in  generations  like  chan- 
croids. 

3.  That  this  form  of  pus,  though  very  irritating  and  destructive,  does 
not  contain  the  germ  of  syphilis. 

Clear  and  convincing  as  this  evidence  is,  it  can  be  urged  against  it 
that  it  is  experimental  and  not  clinical.  It  was  my  good  fortune  early 
in  1870  to  observe  an  undoubted  and  incontrovertible  case  in  which 
chancroids  were  contracted  by  a  non-syphilitic  woman  from  irritated 
lesions  resembling  chancroids  in  her  syphilitic  husband.  This  man, 
syphilitic  in  1869,  came  in  March,  1870,  with  a  papular  syphilide  and 
acute  gonorrhoea.  A  few  days  later  he  came  with  a  group  of  unruptured 
herpetic  vesicles  on  the  under  surface  of  the  prepuce  near  the  fr^enum. 
He  had  not  had  coitus  in  three  weeks.  During  the  Aveek  following  his 
gonorrhoea  remained  active,  and  at  the  end  of  that  time  I  found  that 
the  herpetic  vesicles  presented  the  appearance  of  oval,  absolutely  typical 
chancroids.  A  few  days  later  his  gonorrhoea,  being  on  the  decline, 
while  intoxicated  he  had  connection  with  his  wife,  who  ten  days  later 
came  to  me  with  five  or  six  large  typical  chancroids  on  the  fourchette 
and  inner  aspect  of  the  labia  minora.  The  wife  also  was  careless,  and 
her  chancroids  became  large  and  deep  and  gave  rise  to  a  typical  bubo. 
The  husband  also  had  a  chancroidal  bubo.  Two  years  later  the  woman 
contracted  syphilis  from  a  lover.  Here,  then,  is  a  case  of  a  man  suffer- 
ing from  active  syphilis  who  had  undoubted  herpetic  vesicles,  which, 
owing  to  contamination  Avith  pus-microbes,  become  converted  into  true 
chancroids,  which  chancroids  gave  rise  to  similar  lesions  in  his  wife. 
This  clinical  observation,  very  carefully  made  and  duly  noted,  confirms 
in  every  particular  the  results  of  experimental  inoculation.  During  the 
past  twenty  years  I  have  seen  several  cases  of  chancroids  in  men  which 
have  been  traced  to  purulent  and  muco-purulent  genital  discharges  in 
women  in  the  secondary  stage  of  syphilis.    It  can  be  safely  asserted  that 


INTR  OD  UCTION.  27 

any  observer  may  obtain  similar  results  if  he  will  take  the  pains  to  fol- 
low up  to  their  origin  a  series  of  cases  of  chancroid  in  the  male.  I  have 
also  seen  chancroids  in  the  female  which  had  been  contracted  from  men 
whose  hard  chancres  in  their  period  of  decline  had  become  irritated, 
and  then  resembled  chancroids. 

Thus  far  we  have  seen  that  the  chancroid  may  become  developed 
de  novo  from  the  secretion  of  irritated  syphilitic  lesions  both  in  syphi- 
litic and  virgin  subjects.  It  has  also  been  shown  that  pus  taken  from 
healthy  persons  and  inoculated  upon  syphilitic  subjects  has  produced 
pustules  and  ulcers  in  all  particulars  like  chancroids.  Thus  far,  how- 
ever, although  it  has  been  shown  that  the  chancroid  may  originate 
de  novo,  the  inoculations  have  been  upon  syphilitic  subjects  by  means 
of  their  own  irritated  secretions,  or  these  secretions  have  been  inocu- 
lated upon  healthy  persons.  The  case,  therefore,  cannot  be  considered 
complete,  and  the  doctrine  of  dualism  effectually  destroyed,  until  we 
have  cut  adrift  wholly  from  syphilis,  and  have  proved  that  pus  from 
non-syphilitic  subjects  may  be  inoculated  on  its  bearers  or  other  healthy 
subjects,  and  that  from  such  inoculations  ulcerations  similar  to  chan- 
croids have  been  produced. 

Though  the  inoculability  of  many  forms  of  pus  is  well  known  and 
generally  conceded,  it  is  best  to  give  here  the  evidence  as  it  has  thus 
far  been  presented  in  its  bearings  upon  the  doctrine  of  dualism.  The 
first  experiments  are  those  of  Dr.  E.  Wigglesworth  ^  of  Boston,  made  in 
1867-68  upon  himself.  He,  being  free  from  all  disease  and  only  a 
little  run  down  from  over-study,  took  pus  from  an  acne-pustule  upon 
himself  and  inoculated  his  arm.  The  result  Avas  the  development  of 
well-marked  pustules  which  were  successfully  inoculated  in  three  gen- 
erations. On  the  removal  of  the  crusts  perceptible  ulceration  of  the 
skin  was  seen.  Wigglesworth  then  made  the  claim,  which  has  since 
been  substantiated,  that  the  products  of  simple  inflammation  if  properly 
introduced  into  the  skin  will  cause  local  ulcers  resembling  chancroids. 

Next  in  importance  are  the  results  obtained  by  VidaP  in  1846  and 
again  in  1852,  which,  while  they  amply  proved  (at  a  time  when  this 
subject  was  enveloped  in  doubt  and  obscurity)  that  simple  non-specific 
pus  was  auto-inoculable  upon  its  bearer,  had  much  influence  upon  the 
trend  of  thought  in  this  direction.  Vidal  inoculated  ecthymatous  pus 
upon  its  bearers,  who  also  suffered  with  typhoid  fever :  the  result  was 
the  development  of  pustules  identical  with  those  from  whence  they  were 
derived. 

Kaposi's^  testimony  has  also  had  much  weight  in  determining  the 
exact  nature  of  the  chancroid.  He  says  :  "  My  own  experiments  have 
taught  me  that  non-specific  pus,  such  as  that  from  acne  and  scabies 
pustules,  when  inoculated  upon  the  bearers,  as  well  as  upon  other  non- 
syphilitic  persons,  will  produce  pustules  whose  pus  proves  to  be  con- 
tinuously inoculable  in  generations." 

Further  evidence  is  given  by  Tanturri,^  who  by  inoculations  of  pus 

^  Written  communication  to  Dr.  Burastead. 

'^  "  Inoculabilite  des  Pustules  d'Ecthyma,"  Annates  de  Deiitiat.  et  de  Syphiligraph.,  1872 
and  1873,  vol.  iv.  pp.  350  et  seq. 

^  Die  Sijpkilis  der  Haul  und  der  ungrenzenden  Schleimhdute,  p.  47,  Wien,  1873. 

*  "  Suir  eterogenia  dell'  ulcera  non-sifilitica,"  Giornale  ltd.  delle  Malat.  Vemr.  e  della 
Pelle,  vol.  ix.  1874,  pp.  257  et  seq. 


28  VENEREAL  DISEASES. 

from  various  sources  succeeded  in  producing  characteristic  ulcers. 
These  experiments  of  AVigglesworth,  Kaposi,  and  Tanturri,  taken  in 
connection  with  those  previously  detailed,  are  of  the  greatest  value,  and 
they  certainly  warrant  the  conclusion  that  ulcers  similar  to  the  chan- 
croid may  be  produced  by  the  products  of  simple  inflammation.  Some- 
thing more,  however,  was  needed  to  clinch  the  matter,  and  this  has  been 
supplied  by  the  very  convincing  experiments  of  Finger.^  This  observer 
took  for  his  subject  a  woman  suffering  from  leucorrhoea  and  eczema. 
These  affections  were  cured ;  the  uterine  and  vaginal  secretions  Avere 
then  demonstrated  to  be  innocuous,  and  it  was  established  beyond  doubt 
that  the  woman  was  not  suffering  from  chancroids.  Further  than  this, 
there  had  not  been  a  case  of  chancroid  in  the  hospital  for  several  weeks. 
Every  care  was  exercised  that  no  contamination  of  the  woman  from 
without  could  occur.  Finger  then  with  the  curette  irritated  the  poste- 
rior vulvar  commissure,  and  Avithout  cleansino;  or  bandagincr  the  parts 
he  put  the  woman  to  bed.  Inoculations  with  the  scant  secretion  of  this 
erosion  were  unsuccessful.  Then  Finger  smeared  the  lesion  over  with 
powdered  savin.  On  the  following  day  there  was  an  abundance  of  true 
pus,  from  which  a  series  of  successful  inoculations  were  made  upon  the 
patient's  thighs,  which  were  further  followed  by  an  inflammatory  bubo 
in  the  groin.  A  man  was  successfully  inoculated  with  the  pus  from  the 
woman's  thighs.  Four  more  cases  were  experimented  upon  in  like 
manner,  with  similar  results. 

The  teachings  of  these  cases  are  particularly  striking  in  the  fact  that 
the  suppurative  process  was  developed  upon  the  genitals,  and  that  with 
the  pus  thus  obtained  ulcers  in  all  respects  like  chancroids  were  pro- 
duced. These  observations  are  sujiported  by  facts  observed  by  Tom- 
masoli^  in  clinical  practice.  Tommasoli  had  under  his  care  a  man  who 
did  not  contract  chancroids  in  coitus,  and  was  not  exposed  to  any 
infection.  He  simply  suffered  from  severe  balanitis,  which  was  further 
complicated  by  the  development  of  vegetations  in  the  coronal  sulcus. 
As  a  result  of  these  combined  inflammatory  conditions  a  purulent  dis- 
charcre  was  established  which  gave  rise  to  ulcers  identical  with  chan- 
croids,  from  Avhich  inoculable  pus  was  obtained. 

In  the  section  on  the  etiology  of  chancroid  as  presented  in  clinical 
practice  many  cases  corroborative  of  Tommasoli  will  be  found. 

At  this  late  day  it  may  seem  almost  unnecessary  to  follow  the  fore- 
going series  of  cases  in  their  full  detail,  since  they  only  prove  what  is 
so  generally  known  and  conceded,  that  pus  rich  in  pyogenic  microbes 
is  promptly  and  freely  inoculable  and  auto-inoculable.  But  even  now 
there  are  physicians  (usually  those  who  have  failed  to  acquaint  them- 
selves with  all  the  facts  involved  in  the  battle  between  the  unicists  and 
the  dualists)  Avho  have  vague  ideas  as  to  the  nature  of  the  chancroid, 
and  Avho  prefer  to  look  upon  it  as  an  occult  and  mysterious  ulcer  rather 

^  "Ueber  die  Natur  des  Weichen  Schaiikers"  (Vierteljahr.fur  Derm,  und  Syph.,  1885, 
pp.  670  et  seq.)  and  "Zur  Frage  iiber  die  Xatur  des  Weichen  Schankers  und  die 
Infectiositiit  tertiarer  syphilisprodukte "  {AUc/.  Wien.  Med.  Zeituny,  1887,  Xos.  9,  10,  11, 
13,  14,  and  15). 

^  "  Beitrag  zur  Kenntniss  des  Weichen  Schankers,"  Allg.  Wien.  Med.  Zeitung,  1886, 
vol.  xxxi.  p.  351. 


INTR  on  UCTION.  29 

than  as  one  whose  origin  is  clearly  known,  and  which  at  best  is  a  hybrid 
affair,  an  ordinary  septic  ulcer  of  the  genitals. 

Carefully  reviewing  and  weighing  all  the  foregoing  facts,  we  are 
warranted  in  stating  that  ivhile  the  chancroid  may  he — and  very  com- 
monly is — derived  from  a  jyrevious  chancroid,  a  chancroidal  bubo,  or  chan- 
croidal lymphangitis,  it  may  also  07'iginate  in  the  pus  derived  from 
irritated  lesions  of  syphilis  and  from  irritated  simple  lesions  in  syphilitic 
subjects,  and  also  in  simjjle  pus,  particularly  when  originating  in  active 
or  intensely  irritated  lesions. 

"With  this  disposal  of  the  question  of  the  essential  virulence  of  chan- 
croid, the  assertion  which  is  loudly  proclaimed  by  some,  that  "  if  all  the 
patients  in  the  world  with  chancroid  would  avoid  contact  with  others 
until  their  malady  got  well,  the  disease  would  cease  from  off  the  face  of 
the  earth,"  is  at  least  amusing. 

Experimental  studies  in  pus-inoculation  show  that  the  intensity  of 
the  destructive  action  of  the  secretion  depends  largely  on  the  degree 
of  irritation  to  which  the  producing  lesion  is  subjected,  and  that  its 
unknown  quality,  which  has  wrongly  been  called  "  a  special  specific 
virus,"  is  really  due  to  that.  Pathology  further  teaches  that  the  activity 
of  the  pus  resides  in  the  vast  number  of  microbes  proliferated  and  in 
the  toxines  Avhich  they  give  rise  to.  A  common-sense  view  of  the  course 
of  these  destructive  ulcers  of  the  genitals  does  away  with  the  necessity 
of  assuming  a  subtle  virulent  action  as  being  possessed  by  them.  Of  all 
parts  of  the  human  frame,  the  genital  organs  are  those  most  prone  to 
irritation.  In  them  the  circulation  in  capillaries  and  sinuses  is  very 
abundant.  They  are  the  seat  of  frequently-recurring  congestions  with 
or  without  coitus,  and  are  largely  under  the  control  of  the  mental 
emotions.  Their  conformation  is  such  that  unless  kept  continually  and 
scrupulously  clean  inflammations  are  sure  to  occur.  What  wonder,  then, 
that  ulceration  is  severe  upon  these  exuberant  regions  ! 

Syphilis  is  a  virulent  disease ;  chancroid  is  a  hybrid,  heterogeneous 
lesion,  a  septic  ulcer,  and  in  many  cases  an  active  form  of  wound-infec- 
tion. 

The  unicists  would  have  been  right  if  they  had  claimed  a  special 
virus  for  syphilis  only,  but  they  erred  in  attributing  a  similar  origin  to 
the  chancroid. 

The  dualists  were  warranted  in  asserting  that  there  is  a  specific 
syphilitic  virus,  but  the  reader  can  judge  from  what  has  been  presented 
in  the  foregoing  pages  how  much  importance  he  shall  attach  to  their 
claim  that  there  is  a  special  specific  virus  for  the  chancroid. 

It  may  be  mentioned,  as  a  matter  of  history,  that  gonorrhoea  was 
relegated  to  the  plane  of  a  catarrhal  process  by  Ricord  when  he  demon- 
strated its  non-identity  and  non-relationship  to  syphilis.  It  is  no  longer 
necessary  to  burden  the  mind  with  the  points  brought  out  by  the  advo- 
cates of  the  catarrhal  origin  of  gonorrhoea  against  the  claim  of  the 
virulists  that  it  was  a  virulent  process,  since  to-day  it  is  clearly  proved 
that  the  contention  of  the  latter  is  correct. 


PART  I. 
GONORRHCEA  AND  ITS  COMPLICATIONS. 


CHAPTER   I. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    PENIS,    THE    UEETHRA, 
THE  BLADDER,  THE  PROSTATE,  AND  ACCESSORY  PARTS. 

For  a  thorough  knowledge  of  gonorrhoea  and  its  complications  and 
sequelae  a  clear  general  understanding  of  the  anatomy  and  physiology 
of  the  genito-urinary  tract  is  necessary. 

The  penis  is  a  pendulous  organ  consisting  of  root,  body,  and  glans, 
and  through  it  three-fourths  of  the  urethra  runs.  It  is  the  organ  of 
copulation  and  of  urination,  and  is  composed  of  two  parallel  cylindrical 
bodies  called  the  corpora  cavernosa,  which,  lying  side  by  side,  have  a 
groove  on  their  under  surface  in  which  is  situated  the  corpus  spongio- 
sum. These  cylindrical  bodies,  with  connective  tissues,  vessels,  nerves, 
and  lymphatics,  together  with  the  tegumentary  investment-sheath,  form 
the  penis. 

Each  corpus  cavernosum  has  a  dense,  quite  thick,  but  very  elastic 
fibrous  investment,  from  which  thin  processes  or  trabeculge  pass  inwardly 
and  form  cavities  which  are  filled  with  erectile  tissue.  The  inner  sur- 
face of  each  cavernous  body  is  thick  and  complete  in  the  proximal  part 
of  the  penis  ;  consequently,  there  is  at  that  part  a  distinct  septum  formed 
by  the  fusion  of  these  two  inner  surfaces.  More  anteriorly  or  distally 
there  are  only  a  number  of  vertical  bands  of  fibrous  tissue  arranged 
like  the  teeth  of  a  comb,  and  hence  called  the  septum  jjeetiniforme.  It 
is  important  to  bear  in  mind  the  structure  and  relations  of  the  cavernous 
bodies,  as  well  as  of  the  spongy  body,  in  operations  on  the  penile  ure- 
thra. The  corpus  spongiosum  also  consists  of  a  firm,  fibrous  sheath, 
from  which  trabecular  processes  pass  inward  and  form  meshes  which 
contain  erectile  tissue.  In  the  outer  coat  of  the  corpus  spongiosum  is 
a  thin  layer  of  circular  muscular  fibres  continuous  with  those  of  the 
bladder.  A  second  layer  of  longitudinal  muscular  fibres  is  situated 
between  the  inner  surface  of  the  corpus  spongiosum  and  the  mucous 
membrane  of  the  urethra. 

The  corpora  cavernosa  constitute  the  chief  bulk  of  the  penis,  and 
each  one  begins  in  a  tapering  portion,  the  crus  penis,  which  is  attached 
along  a  groove  in  the  rami  of  the  ischium  and  os  pubis.  They  are  fur- 
ther attached  to  the  symphysis  pubis  by  a  strong  elastic  suspensory 
ligament,  the  base  of  which  is  fused  in  their  fibrous  tissue  and  the  apex 
is  inserted  into  the  symphysis.     Converging  together  at  once  at  the  root 

31 


32  GONORBHCEA  AND  ITS  COMPLICATIONS. 

of  the  penis,  these  cylindrical  bodies  run  parallel  side  by  side,  and  each 
ends  in  a  bluntly-rounded  extremity  Avhich  fits  in  a  depression  in  the 
base  of  the  glans  penis. 

The  corpus  spongiosum  surrounds  the  urethra  from  the  triangular 
ligament  to  the  meatus  urinarius.  It  begins  in  the  centre  of  the  peri- 
neum in  an  expanded  form  called  the  bulb,  which  rests  directly  on 
the  anterior  surface  of  the  triangular  ligament.  It  then  runs  under 
the  corpora  cavernosa  in  the  groove  left  for  it,  like  a  ramrod  under  a 
double-barrelled  gun,  and  ends  in  an  expanded  extremity,  the  glans 
penis,  the  apex  of  which  corresponds  to  the  meatus. 

The  glans  penis  is  therefore  the  expanded  distal  portion  of  the  cor- 
pus spongiosum,  Avhile  the  bulb  is  its  proximal  expanded  portion.  The 
glans  is  an  obtusely-conical,  acorn-shaped  body,  somewhat  flattened  on  its 
upper  surface,  and  ending  in  a  rounded,  expanded  portion  called  the 
corona,  which  rounds  off  abruptly  and  projects  like  a  collar  beyond  the 
body  of  the  penis  proper,  and  behind  it  is  seen  when  the  prepuce  is 
retracted  a  nearly  circular  groove  called  the  coronal  sulcus,  the  balano- 
preputial  furrow,  and  the  cervix.  A  little  below  the  centre  of  the  apex 
is  the  vertical  slit-like  opening  of  the  urethra,  called  the  meatus.  The 
under  surface  of  the  glans  is  flat  and  triangular  in  shape,  the  apex  of 
which  usually  ends  at  the  inferior  commissure  of  the  meatus,  and  into 
it  the  fraenum  of  the  prepuce  is  inserted.  The  integument  of  the  penis 
forms  an  investing  sheath  w^hich  retains  its  tubular  form  in  the  normal 
condition  up  to  a  little  beyond  the  extremity  of  the  glans  penis.  Then 
it  is  reflected  or  folds  on  itself,  backward,  in  the  form  of  a  mucous  mem- 
brane, and  is  inserted  by  gradual  merging  into  the  whole  length  of  the 
coronal  sulcus.  It  is  then  reflected  forward  over  the  glans,  to  which  it 
is  firmly  adherent,  and  ends  at  or  a  little  wathin  the  orifice  of  the  meatus, 
with  the  mucous  membrane  of  which  it  is  continuous.  Thus  it  is  that 
for  a  short  distance  (one-quarter  to  one  inch  or  more)  the  mucous  mem- 
brane of  the  urethra  consists  of  squamous  or  pavement  epithelium. 

The  fact  of  the  firm  adherence  of  the  mucous  membrane  to  the  glans 
and  of  the  absence  of  loose  connective  tissue  explains  why  hard  chan- 
cres of  this  part  are  not  much  indurated,  and  Avhy  chancroids  are  slow 
in  their  destructive  action.  That  portion  of  the  under  surface  of  the 
prepuce  which  is  in  the  median  line  becomes  transformed  into  a  fibrous 
band  which  is  called  the  frgenum  preputii,  and  which,  as  we  have  seen, 
is  inserted  just  under  the  lower  part  of  the  meatus  urinarius.  The 
prepuce,  therefore,  consists  of  two  layers — the  outer  one  integumentary 
and  continuous  with  the  skin  of  the  penis,  and  the  inner  or  reflected 
one  formed  of  mucous  membrane,  w^hich  is  covered  with  stratified  pave- 
ment epithelium,  which  extends,  as  already  stated,  into  the  meatus  for 
a  varying  distance. 

The  integument  of  the  penis  is  very  thin  and  extensible,  and  very 
readily  movable  over  the  cavernous  and  spongy  bodies  by  means  of  a 
very  delicate,  loose,  and  abundant  connective  tissue  destitute  of  fat-cells. 

The  integument  of  the  penis  is  plentifully  supplied  with  sebaceous 
and  hair-follicles,  which  frequently  become  the  seat  of  inflammatory 
processes  and  of  new  growths  (milia  and  wens). 

In  the  normal  condition  the  prepuce,  or  foreskin,  forms  a  tube  of 
quite  uniform  calibre,  which  is  loose  and  roomy  and  readily  admits  of 


ANATOMY  AND  PHYSIOLOGY  OF  THE  PENIS,   ETC. 


33 


its  retraction  and  replacement  over  the  glans  penis.  Usually  it  ends  at 
or  just  beyond  the  meatus.  In  some  cases,  however,  it  is  redundant 
and  extends  more  or  less  beyond  the  end  of  the  penis.  Then,  again,  it 
may  be  short,  so  as  only  to  cover  a  portion  of  the  glans,  and  in  quite 
exceptional  cases  in  the  adult  there  is  no  prepuce  at  all.  In  this  event 
it  has  happened  that  as  the  penis  developed  the  integumentary  layer 
did  not  correspondingly  increase. 

Sometimes  the  preputial  orifice  is  very  small,  so  that  it  will  Avith 
difficulty  allow  the  glans  to  emerge  through  it.  Then,  again,  this  con- 
traction may  be  so  great  that  only  a  pin-sized  aperture  is  seen,  in  which 
event  retraction  is  impossible  and  very  little  of  the  glans  or  meatus  can 
be  seen.  In  some  cases  the  calibre  of  the  prepuce  is  decidedly  too 
small  for  its  easy  retraction,  and  it  then  may  exert  injurious  pressure 
upon  the  glans.  In  other  cases  the  frgenum  is  too  short  (and  it  is  then 
usually  a  rather  thick  cord),  and  by  the  contraction  which  it  exerts 
upon  the  prepuce  some  deformity  results.  These  conditions  are  shown 
in  the  chapter  on  Phimosis. 

The  penis  is  cylindrical  when  flaccid,  triangular  in  shape  when  tur- 
gid, and  therefore  has  three  sides  with  corresponding  rounded  margins. 
The  dorsal  flat  surface  is  broader  than  the  lateral  surfaces. 

It  is  widely  stated  that  the  mucous  layer  of  the  prepuce  normally 
contains  minute  sebaceous  glands  called  by  old  writers  glanduloe  Tysonii 
odoriferce.  This,  however,  is  erroneous.  Whenever  present,  Tyson's 
glands  are  situated  externally  on  the  penis,  and  are  distributed  along 
the  corona  glandis  in  the  sulcus  and  on  the  reflection  of  the  prepuce 
and  near  the  frgenum.     In  young  children  these  glands  are  fairly  numer- 


Showing  a  section  through  one  of  Tyson's  glands  in  the  prepuce  of  a  young  child. 

ous,  but  in  adults  they  are  much  more  difficult  to  find,  as  they  seem  to 
become  atrophied  to  a  large  extent.     Tyson's  glands  are  identical   in 
every  respect  in  structure  to  the  sebaceous  glands  of  the  skin  or  scalp. 
3 


34  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

They  consist  of  two  or  more  bag-like  acini  lying  just  beneath  the  epi- 
dermis, which  open  into  a  common  duct,  and  the  whole  cellular  lining 
of  the  duct  and  the  gland  is  continuous  with  the  epithelium  of  the  skin. 
(See  Fig.  1.) 

Von  Diiring  ^  has  made  an  exhaustive  study  of  the  microscopical 
anatomy  of  the  preputial  mucosa,  and  he  claims  that  it  contains  no 
glandular  structures  whatever,  but  that  there  are  minute  inversions  or 
invaginations  of  the  mucous  membrane  in  the  form  of  diverticula,  and 
longer  and  narrower  ones  found  near  the  frsenum,  which  he  calls  cys- 
ternse  frsenuli.  The  so-called  glands  are  therefore  simply  reduplicatures 
or  invaginations  of  the  membrane  in  the  form  of  minute  shallow  or  deep 
crypts. 

Von  Diiring's  conclusions  have  been  confirmed  by  investigations 
made  for  me  by  Dr.  Van  Gieson.  Certain  clinical  and  pathological 
observations,  however,  seem  to  show  that  occasionally  one  or  more 
Tyson's   glands   persist  in   later  life.     (See   p.    193.) 

•  Preputial  smegma,  that  whitish  coating  of  cheesy  odor,  is  therefore 
simply  effete  epithelium,  perhaps  formed  in  the  crypts  or  on  the  mucous 
membrane  itself. 

The  meatus  is  normally  a  constricted  part  of  the  urethra.  In  struc- 
ture it  varies  more  or  less  in  diiferent  individuals.  In  some  its  vertical 
lips  are  thin  and  coapt  with  each  other  like  the  leaves  of  a  book,  form- 
ing a  not  prominent  vertical  slit.  In  other  cases  the  lips  are  more  or 
less  rounded  and  the  meatus  has  a  rather  expanded,  pouting  appearance. 
Then,  again,  owing  to  the  fact  that  the  mucous  membrane  is  rather 
redundant  and  loose,  its  lips  sometimes  have  an  uneven,  somewhat  mam- 
millated  appearance.  In  some  very  rare  cases  the  mucous  membrane 
forms  a  cylinder  of  a  line,  or  even  a  third  of  an  inch,  in  length  beyond 
the  apex  of  the  glans,  constituting  a  membranous  extension  of  the 
urethra  to  which  my  friend  Dr.  Otis  ^  applies  the  term  "  fusiform 
meatus."  In  somewhat  rare  cases  a  thin  septum  is  seen  to  extend  hori- 
zontally across  from  one  lip  to  the  other,  seemingly  dividing  the  meatus 
into  two  parts.  Separation  of  the  lips,  however,  shows  that  this  septum 
simply  forms  a  blind  pocket  which  may  be  shallow  or  rather  deep.  In 
this  condition  the  narrowing  of  the  meatus  is  at  its  superior  portion, 
and  therefore  the  surgical  indication  here  is  to  relieve  the  trouble  by 
cutting  toward  the  roof  of  the  urethra,  while  in  almost  all  other  cases 
the  rule  is  to  cut  toward  its  floor. 

In  somewhat  exceptional  cases  the  meatus  is  very  small,  even  of  pin- 
head  size.  In  this  case  it  will  generally  be  found,  by  passing  the  tip  of 
a  probe  inward  and  downward,  that  the  abnormal  smallness  of  the  cali- 
bre is  due  to  the  fusion  of  the  mucous  membrane  at  the  lower  commissure. 

While  a  full  consideration  of  the  malformations  of  the  meatus  and 
glans  (which  belong  to  the  domain  of  general  surgery)  is  not  germane 
to  this  w^ork,  it  is  well  to  mention,  in  a  general  way,  that  there  may  be 
more  or  less  absence  of  the  floor  of  the  urethra  in  its  glandular  portion, 
in  which  case  the  urethral  orifice  is  a  small,  round,  or  a  transverse,  slit- 
like hole.     This  condition  is  called  hypospadias. 

■*  "Beitrage  zur  Anatomie  des  Penis,"  Monatshefte  fur  Prakt.  Dermalologie,  vol.  vii.  pp. 
1117  et  seq.,  18S8. 

2  The  Male  Urethra,  p.  10,  Detroit,  1888. 


ANAT03IY  AND  PHYSIOLOGY  OF  THE  PENIS,   ETC. 


35 


Fig.  2. 


The  seat  of  the  urethral  orifice  or  meatus  is  sometimes  found  higher 
up  on  the  dorsum  of  the  glans,  and  in  one  case  I  found  that  the  urethra 
at  the  base  of  the  glans  turned  upward  quite  abruptly  and  ended  in  a 
well-marked  slit  seated  in  the  middle  line  of  the  coronal  eminence. 
Absence  of  the  distal  part  of  the  upper  wall  of  the  urethra  is  called 
epispadias. 

The  male  urethra  is  a  slit-like  canal,  regarded  by  some  as  a  closed 
valve,  which  extends  from  the  bladder  to  the  meatus  urinarius.  It  is 
the  vent-pipe  for  the  urine  and  gives 
issue  to  the  seminal  fluid.  It  there- 
fore has  two  functions,  which  must 
be  kept  in  mind  in  order  that  its 
diseases  may  be  clearly  understood. 
It  is  in  direct  relation  with  the  kid- 
neys, the  ureters,  and  the  bladder, 
and  may  be  the  means  of  trans- 
mitting disease  to  these  organs  of 
the  urinary  system,  or  it,  in  turn, 
may  become  diseased  by  the  exten- 
sion of  pathological  processes  from 
these  organs  and  structures.  Then, 
again,  pathological  processes  attack- 
ing the  urethra  may  extend  to  all 
or  to  certain  portions  of  the  geni- 
tal system — namely,  the  testicles, 
the  vasa  deferentia,  the  seminal 
vesicles,  and  the  prostate  and  its 
crypts  and  follicles.  In  its  turn  the 
urethra  may  be  involved  by  the 
extension  of  disease  from  either  of 
these  structures  and  appendages, 
with  which  it  is  in  direct  anatomi- 
cal relation.  If  the  function  of  the 
urethra  were  simply  that  of  trans- 
mitting the  urine,  a  length  of  about 
two  inches  would  be  sufficient,  as  it 
is  in  the  female,  but,  being  also  a 
part  of  the  genital  apparatus,  its 
length  is  necessarily  much  increased 
for  purposes  of  intromission  and  fec- 
undation of  the  female.  This  in- 
crease in  length,  as  Ave  have  seen, 
is  due  to  the  existence  of  the  cav- 
ernous and  spongy  bodies. 

The  urethra  is  composed  of 
three  layers — a  mucous  layer,  a 
submucous  connective-tissue  layer, 
and  a  muscular  layer.  Its  walls 
are  always  in  contact,  except 
during  the  passage  of  urine  and  semen,  a  period  of  three  or  four  minutes 
during  the  day.     The  average  length  of  the  urethra  is  from  seven  to 


Showing  the  normal  urethra  opened  longitudi- 
nally on  its  upper  surface. 


36 


GONORRHCEA  AND  ITS  C03IPLICATI0NS. 


eight  and  a  half  inches,  but  it  may  be  shorter  or  longer.     It  is  increased 
in  length  during  erection  and  in  hypertrophy  of  the  prostate. 

When  the  urethra  is  split  longitudinally  in  its  whole  extent  on  its 
upper  surface,  its  course,  with  its  varying  expansions,  comes  into  view. 
(See  Fig.  2.)  At  the  meatus  urinarius  we  find  a  normal  narrowing  of 
the  canal,  w^hich  then  expands  into  a  spindle-shaped  portion  which  is 
called  the  fossa  navicularis  ;  hence  this  is  called  the  navicular  portion 
of  the  urethra.  As  this  part  emerges  into  the  spongy  or  penile  por- 
tion a  slight  constriction  occurs.  The  canal  then  expands,  and  we  find 
it  of  somewhat  uniform  calibre  in  its  course  through  the  corpus  spon- 
giosum for  a  distance  of  four  or  five  inches.  It  then  expands  again, 
in  conformity  with  the  bulbous  expansion  of  the  corpus  spongi- 
osum, and  a  spindle-shaped  canal  is  formed,  which  is  from  an  inch  to 
an  inch  and  a  half  in  length,  and  which  is  called  the  sinus  of  the  bulb 
or  the  bulbous  portion  of  the  urethra.  Again  becoming  contracted  at 
the  anterior  layer  of  the  triangular  ligament,  it  has  a  uniform  calibre 
for  a  distance  of  about  three-quarters  of  an  inch,  when,  at  the  posterior 
layer  of  this  ligament,  it  emerges  to  expand  again  into  the  prostatic 
urethra.  In  its  course  through  the  triangular  ligament  it  is  simply  a 
membranous  canal  seated  about  an  inch  beneath  the  summit  of  the 
pubic  arch  and  surrounded  by  the  compressor  urethr?e  muscle.  The 
prostatic  urethra  is  the  direct  continuation  of  the  membranous  urethra. 
It  also  has  a  spindle  shape,  and  is  about  an  inch  and  a  quarter  in 
length.  (See  Fig.  2.)  Thus,  anatomically,  there  is  a  navicular,  a 
spongy,  a  bulbous,  a  membranous,  and  a  prostatic  portion  of  the  ure- 
thra, making  five  divisions  in  all.  The  term 
"penile,"  or  pendulous,  urethra  is  also  applied 
to  that  portion  which  extends  from  the  glans  to 
the  peno-scrotal  angle. 

Clinically,  in  a  general  Avay,  we  speak  of  the 
anterior  and  posterior  urethra,  the  former  ex- 
tending to  the  anterior  layer  of  the  triangular 
ligament,  and  the  latter  including  the  portion 
beyond. 

The  mucous  membrane  of  the  urethra  is 
smooth  and  shining  and  of  a  yellowish-pink 
color,  which  is  deeper  at  the  first  inch  and  at  the 
bulbous  portion.  For  a  short  distance — one- 
fourth  to  one  inch  w^ithin  the  meatus — the  mem- 
brane is  covered  with  flat  pavement  epithelium  ^ 
beyond  that  part  it  is  of  the  columnar  variety 
as  far  as  the  vesical  orifice.  With  the  naked 
eye  we  observe,  particularly  on  its  upper  wall, 
certain  valve-  or  pocket-like  reduplications  of 
the  mucous  membrane,  which  are  called  lacunae. 
Generally  there  is  but  one  large  one,  which  is 
seated  on  the  upper  wall  of  the  navicular  por- 
tion of  the  urethra,  one-half  to  three-quarters 
of  an  inch  from  the  meatus.  This  structure 
is  called  the  lacuna  magna,  and  is  well  shown 
There  may  be,  exceptionally,  several  of  these  valve-like  struc- 


FlG 


Sectirn  f  tht  urethia  slit  up 
on  Its  lower  wall,  show  ing  the 
lacuna  magna  and  a  deeper, 
valve-like  pocket  and  the 
orifice  of  numerous  mucous 
glands. 


in  Fig.  3. 


ANAT03IY  AND  PHYSIOLOGY  OF  THE  PENIS,  ETC. 


37 


tures,  which,  however,  are  not,  as  a  rule,  found  deeper  than  three  inches 
from  the  meatus.  In  Fig.  3  a  second  lacuna  is  portrayed,  about  an  inch 
and  a  half  beyond  the  lacuna  magna. 

With  the  naked  eye — or,  better,  with  the  aid  of  a  pocket-lens — a  num- 
ber, sometimes  large,  of  minute  pits  or  openings  may  be  seen,  particularly 
on  the  upper  wall  of  the  urethra,  for  a  distance  of  three  or  more  inches. 
These  are  the  orifices  of  the  mucous  follicles  or  glands  of  the  urethra. 
Though  they  are  generally  found  on  the  upper,  they  are  sometimes  seen 
on  the  lower,  wall,  as  shown  in  Fig.  2,  which  was  drawn  from  nature. 
These  glands  are  usually  not  very  closely  grouped  together,  being  sepa- 
rated from  each  other  by  about  three  or  four  millimetres,  and  the  excre- 
tory duct  appears  as  a  tiny  pit  about  one-half  millimetre  in  diameter.  If 
a  flap  of  urethral  mucous  membrane  is  dissected  up,  these  follicles  can 
be  seen  in  the  submucous  connective  tissue  in  the  shape  of  very  minute 
yellowish  masses. 

The  mucous  glands  of  the  urethra  are  said  to  be  the  follicles  or 
glands  of  Littre  and  the  lacunce  or  crypts  of  Morgagni,  but  there  is 
a  general  lack  of  directness  of  statement  on  the  subject,  and  our  know- 
ledge is  therefore  not  precise.  The  truth  is,  that  the  crypts  of  Morgagni 
are  nothing  but  the  glands  or  follicles  of  Littre,  which  have  an  unusually 
tortuous  or  wide-mouthed  duct,  and  structurally  they  are  simply  mucous 
glands  which  are  a  trifle  larger  or  more  prominent  macroscopically  than 
the  remainder  of  the  glands. 


Fig  4 


One  of  the  mucous  glands,  or  glands  of  Littre,  opening  into  the  lumen  of  the  urethra :  x,  y,  lateral 
branches  of  the  main  duet  with  their  more  supurflcially-situated  acini;  z,z,  continuation  of 
the  main  duct  witli  deeply-situated  acini ;  s,  s,  sinuses  of  the  cavernous  tissue ;  tv,  w,  tunica 
albuginea. 

In  structure  these  glands  or  follicles  follow  the  type  of  the  compound 
racemose  gland  (Fig.  4).     The  duct  divides  into  one  or  more  branches 


38 


GONORRHCEA  AND  ITS  COMPLICATIONS. 


Fig.  5. 


which  pass  directly  into  a  cluster  of  two  or  three  or  more  acini  lined 
with  cylindrical  epithelium  like  that  lining  the  ordinary  mucous  glands, 
as  of  the  trachea  or  duodenum.  As  a  rule,  the  main  duct  divides  into 
one  or  more  secondary  branches.  In  Fig.  4,  for  example,  there  are  in 
the  particular  plane  of  the  section  three  branches  of  the  main  duct, 
each  becoming  continuous  with  a  cluster  of  a  rather  limited  number  of 
terminal  acini.  The  epithelium  of  the  urethra  passes  over  into  the 
mouths  of  the  ducts  and  lines  them  almost  down  to  the  junction  with 
the  acini.  While  the  branches  of  the  main  duct  pass  oif  laterally  and 
more  or  less  parallel  to  the  surface  of  the  urethra,  the  main  duct  passes 
down  more  vertically,  deep  into  the  cavernous  tissue 
of  the  urethra;  consequently  some  of  the  gland-acini, 
as  those  of  the  branches  x,  y  in  Fig.  4,  are  quite 
superficially  situated,  while  the  acini  belonging  to 
the  main  duct  lie  very  deep,  sometimes  almost  reach- 
ing down  to  the  tunica  albuginea  (Fig.  4,  z). 

The  lacuna  magna  is  a  large,  tortuous  mucous 
gland  which  opens  into  the  apex  of  the  valve- 
like reduplication  of  the  urethral  mucous  mem- 
brane just  at  the  posterior  limit  of  the  fossa  navi- 
cularis.  In  structure  all  these  valve-like  pock- 
ets are  the  same.  The  ducts  of  the  follicles  or 
glands  pursue  a  more  or  less  oblique  course,  di- 
rected forward  toward  the  meatus.  This  condition 
is  well  shown  in  Fig.  5.  When  the  urethra  is  col- 
lapsed the  mouths  of  the  ducts  generally  open  into 
the  bottom  of  the  folds  or  creases  into  which  the 
urethral  lumen  is  thrown.  If  the  urethra  is  dis- 
tended or  stretched  out  flat  (as  was  the  case  in 
Fig.  4),  the  relation  of  the  ducts  of  the  glands  to 
the  surface  of  the  urethra  becomes  much  plainer. 
One  point  of  practical  importance  in  reference 
to  these  mucous  glands,  as  Avill  be  shown  later  on, 
is  the  considerable  involvement  of  their  mouths 
and  deeply-situated  ducts  by  the  extension  of  the 
inflammation  in  acute,  and  especially  in  chronic, 
gonorrhoea.  Another  important  point  to  be  remem- 
bered is,  that  in  passing  large  and  particularly 
small  instruments  through  the  urethra  it  is  neces- 
sary to  hug  the  lower  wall  in  order  that  the  point 
of  the  instrument  may  not  be  caught  in  the  vari- 
ous pockets  and  follicular  orifices.  A  glance  at 
Fig.  5  will  make  these  points  very  evident  to  the 
mind.  This  figure  shows  the  upper  wall  of  the 
urethra,  in  which  are  very  many  quite  patulous 
ducts  of  mucous  glands  into  which  bristles  have 
been  passed.  It  will  be  seen  that  the  course  of 
the  duct  outlet  is  obliquely  outward  toward  the 
meatus. 
The  male  urethra  is  best  studied  by  tracing  its  course  from  the 
bladder  toward  the  meatus.     The  relations  between  the  urethra,  the 


n 


/I 


Section  of  the  urethra  on  its 
lower  wall,  showing  the 
upper  wall,  with  bristles 
passed  into  the  ducts  of 
mucous  glands. 


ANAT03IY  AND  PHYSIOLOGY  OF  THE  PENIS,   ETC.  39 

bladdei',  and  the  prostate  are  so  intimate  that  a  kno'wledge  of  these 
organs  is  essential. 

The  bladder  is  the  musculo-membranous  reservoir  for  the  urine,  and 
is  seated  in  the  pehds  behind  the  pubes  and  in  front  of  the  rectum.  When 
empty  and  contracted  it  is  a  small  triangular  sac  deeply  seated  in  the  pel- 
vis. When  distended  it  assumes  a  rounded  form,  partly  fills  the  pelvis, 
and  rises  into  the  abdominal  cavity.  In  many  cases  of  retention  of  urine 
it  is  so  distended  that  its  apex  reaches  the  umbilicus.  Its  vertical  is  greater 
than  its  lateral  diameter,  and  its  long  axis  is  obliquely  downward  and  back- 
ward, owing  to  the  fact  that  it  curves  slightly  toward  the  abdominal 
wall.  The  apex  of  the  bladder  is  rounded  and  connected  to  the  umbil- 
icus by  the  urachus.  The  front  of  the  body  of  the  bladder  is  not  cov- 
ered with  peritoneum,  and  is  in  relation  with  the  triangular  ligament, 
the  symphysis  pubis,  and  the  internal  obturator  muscles. 

The  peritoneum  is  reflected  from  the  anterior  surface  of  the  rectum 
to  the  lower  and  back  part  of  the  bladder  about  an  inch  distant  from 
the  base  of  the  prostate  and  just  behind  the  points  where  the  ureters 
pass  into  the  bladder.  It,  however,  in  some  cases  comes  down  as  low 
as  the  base  of  the  prostate.  It  then  passes  to  the  summit,  and  from 
there  is  reflected  upon  the  abdominal  wall.  As  a  result  of  this  arrange- 
ment the  peritoneum  sags  down  behind  the  pubes  when  the  bladder  is 
empty.  As  the  viscus  becomes  distended  its  base  extends  toward  the 
perineum  and  its  summit  comes  in  contact  Avith  the  abdominal  walls. 
As  it  rises  in  the  abdomen  the  prevesical  peritoneal  covering  of  the 
bladder  gradually  forms  a  pouch  which,  when  the  organ  is  much  dis- 
tended, and  particularly  when  the  base  of  the  bladder  is  elevated  by  a 
distended  rubber  bag  in  the  rectum,  becomes  more  and  more  elevated 
above  the  pubes,  and  leaves  a  space  of  two  or  three  inches  of  the  ante- 
rior wall  of  the  bladder  free  from  peritoneum.  This  arrangement  of 
the  anterior  bladder-wall  and  of  the  peritoneum  must  be  borne  in  mind 
in  the  operations  of  aspiration  and  of  suprapubic  cystotomy. 

It  is  also  necessary  to  be  familiar  with  the  space  between  the  pubes 
and  the  anterior  wall  of  the  bladder,  called  the  prevesical  space  or  the 
cavity  of  Retzius.  This  cavity  is  pyramidal  in  shape,  and  is  formed  by 
the  oblique  position  of  the  bladder  as  it  tilts  forward  toward  the  abdom- 
inal wall.  The  prevesical  space  is  formed  by  the  transversalis  fascia, 
which  divides  into  two  layers  just  above  the  pubes,  the  anterior  layer 
passing  down  behind  the  pubes  and  there  becoming  merged,  while  the 
posterior  one  passes  over  and  behind  the  bladder,  merging  with  the 
pelvic  fascia.  Thus  there  is  a  triangular  space  formed,  the  apex  of 
which  corresponds  with  the  line  of  the  fusion  of  the  fascia  above  the 
pubes,  while  the  base  of  it  is  behind  the  pubes.  In  this  space  more  or 
less  fatty  tissue  and  blood-vessels  are  found,  and  it  is  through  it  that 
the  incision  is  carried  in  the  suprapubic  operation. 

The  mucous  membrane  of  the  bladder  is  of  a  pale  yellowish-red  or 
pale  rose  color,  and  is  covered  by  flat  polyhedral  epithelium,  under- 
neath which  are  club-shaped  and  spindle-shaped  cells.  It  has  a  few  fol- 
licles, and  some  small  racemose  glands  lined  with  columnar  epithelium 
near  its  neck,  which  are  seated  in  the  submucous  connective-tissue  coat. 

When  the  bladder  is  opened  on  its  anterior  surface,  togetber  with  the 
upper  wall  of  the  prostate,  it  is  seen  to  be  thrown  into  folds  or  rugae, 


40  QONORRHCEA  AND  ITS  COMPLICATIONS. 

which  for  the  most  part  pass  horizontally  around  the  viscus.  Other 
rugge  run  longitudinally  and  obliquely,  and  as  a  result  the  membrane  is 
divided  up  into  more  or  less  square  and  irregular  flat  eminences.  This 
queer  appearance  is  due  to  the  contraction  of  the  muscular  fibres  acting 
upon  the  mucous  membrane  and  its  submucous  coat.  It  gradually  dis- 
appears when  the  bladder  becomes  distended.  When  in  health  the 
bladder  is  examined  by  means  of  the  cystoscope,  the  membrane  is  seen 
to  be  smooth  and  of  light  pink,  sometimes  with  a  yellowish  tinge.  It 
follows  from  what  has  been  said  that  the  mucous  coat  of  the  bladder 
is  loosely  attached  to  the  muscular  coats.  This  is  the  case  in  its  whole 
extent  except  at  its  base.  At  this  part  we  find  the  trigone  or  trian- 
gular space,  which  is  bounded  on  each  side  by  a  slight  but  well-marked 
ridge  which  corresponds  with  the  position  of  the  muscles  of  the  ureters. 
These  ridges  begin  and  form  the  apex  of  the  trigone  near  the  vesical 
orifice  and  uvula  vesicae,  and  run  outward  and  backward  about  two 
inches.  At  its  base  the  trigone  is  about  two  inches  wide,  and  at  each 
angle  of  it  the  orifice  of  a  ureter  opens  into  the  bladder.  From  apex 
to  base  the  trigone  is  about  one  and  a  half  inches  in  length.  The  mu- 
cous membrane  of  the  trigone  is  of  pale  color,  smooth,  never  wrinkled, 
and  firmly  attached  to  the  parts  beneath.  (See  Fig.  2.)  That  portion 
of  the  bladder  situated  just  behind  the  trigone  is  called  the  post-trigonal 
space,  and  is  of  great  surgical  interest  in  the  matter  of  pouches,  stones, 
and  tumors. 

The  prostate  gland  is  situated  at  the  neck  of  the  bladder,  and  is  a 
firm  body  having  the  shape  of  a  horse-chestnut  or  truncated  cone,  its 
base  corresponding  with  the  vesical  orifice  and  its  apex  being  continuous 
with  the  membranous  urethra  and  deep  perineal  fascia. 

The  prostate  gland  encloses  the  first  part  of  the  urethra.  Its  upper 
surface  is  about  three-quarters  of  an  inch  below  the  pubic  arch  and 
about  an  inch  behind  it.  Its  base  is  about  two  and  a  half  inches  from 
the  anus,  while  its  apex  is  about  one  inch  and  a  half  from  that  orifice. 
It  is  formed  of  glandular  tissue  which  consists  of  an  aggregation  of  mu- 
cous follicles  similar  to  those  of  the  anterior  urethra,  Avhich  form  about 
one-third  of  the  whole  structure.  In  addition  to  this  there  is  a  com- 
pact mass  of  unstriped  muscular  fibres  arranged  in  varying  directions, 
transverse,  longitudinal,  and  oblique,  which,  together  with  connective 
tissue,  elastic  fibres,  vessels,  lymphatics,  and  nerves,  form  the  body  of 
the  gland.  The  prostate  therefore  is  a  musculo-glandular  body  capable 
of  much  dilatability.  It  is  covered  by  two  sheaths  or  capsules,  the  ex- 
ternal one,  of  firm  fibrous  structure,  being  a  reflection  of  the  recto- 
vesical fascia,  which  merges  into  the  deep  perineal  fascia  at  the  apex  of 
the  gland.  The  inner  or  true  capsule  is  a  thin  but  firm  structure  com- 
posed of  muscular  and  connective  tissues  and  elastic  fibres,  which  are 
continuous  with  those  of  the  parenchyma  of  the  gland.  A  plexus  of 
veins  is  found  between  the  capsules  of  the  prostate. 

There  are  two  lobes  of  the  prostate  which  are  always  present,  and 
these  are  called  the  lateral  lobes.  They  are  of  equal  size,  and  in  many 
cases  can  be  clearly  made  out  by  the  tip  of  the  finger  in  the  rectum, 
which  usually  discovers  a  more  or  less  superficial  or  deep  groove  or 
notch  between  them.  In  the  healthy  adult  the  width  of  the  prostate 
as  felt  in  the  rectum  is  about  an  inch  and  a  half,  while  its  length  is 


ANAT03IY  AND  PHYSIOLOGY  OF  THE  PENIS,  ETC.  41 

about  an  inch  or  an  inch  and  a  half.  In  hypertrophy  these  measure- 
ments become  greatly  increased.  As  the  two  lobes  merge  behind,  a 
pyramidal-shaped  space  is  left  on  their  upper  surface,  which  is  filled  up 
by  what  is  called  the  middle  or  third  portion  (wrongly  called  lobe)  of 
the  prostate.  This  part  of  the  organ  is  particularly  rich  in  glands, 
muscular  tissue,  and  blood-vessels,  and  is  the  one  most  prone  to  hyper- 
trophy after  middle  age.  This  middle  portion  lies  behind  the  veru- 
montanum,  and  is  tunnelled  by  the  two  ejaculatory  ducts.  When  this 
portion  becomes  of  such  size  and  extent  as  to  constitute  a  true  lobe,  it 
is  then  a  pathological  growth  and  a  decided  obstruction  to  urination. 
It  may  form  a  well-marked  bar  at  the  entrance  of  the  bladder,  and  it 
may  be  formed  in  the  shape  of  a  small  round  ball,  Avhich  on  urination 
is  pushed  over  the  urethral  orifice  like  a  valve,  producing  more  or  less 
complete  obstruction  to  urination.  Dr.  Measor'^  claims  that  in  subjects 
over  sixty  years  of  age  the  middle  lobe  is  enlarged  in  20  per  cent.  In 
old  age  enlargement  of  the  lateral  lobes  is  sufficiently  common.  This 
enlargement  may  be  concentric,  in  which  case  the  calibre  of  the  urethra 
is  more  or  less  lessened,  or  it  may  be  in  a  longitudinal  direction,  in 
which  event  the  length  of  the  prostatic  urethra  is  more  or  less  increased. 

We  are  now  in  a  position  to  study  the  posterior  urethra. 

The  posterior  urethra  includes  the  membranous  and  prostatic  por- 
tions, and  extends  from  the  vesical  orifice  to  the  anterior  layer  of  the 
triangular  ligament. 

The  prostatic  portion  of  the  urethra  extends  from  the  apex  to  the 
base  of  the  prostate,  and  is  situated  about  one-third  nearer  the  upper 
than  the  lower  surface  of  the  gland.  (See  Fig.  11.)  In  exceptional 
cases  prostatic  tissue  is  absent  for  a  short  distance  on  the  roof  of  the 
urethra.  This  is  compensated  for  by  fibrous  and  elastic  tissues  which 
are  merged  with  the  sphincter.  It  is  an  inch  and  a  quarter  in  length, 
but  it  may  become  much  longer  in  cases  of  hypertrophy.  The  pros- 
tatic urethra,  also  called  the  neck  of  the  bladder,  is  spindle-shaped  and 
has  a  diameter  of  30  F.  at  the  apex,  45  in  its  middle  portion,  and  33 
at  its  vesical  end.  This  portion  of  the  urethra  contains  some  very  im- 
portant structures.  On  the  floor  is  a  narrow  longitudinal  ridge,  the 
verumontanum,  also  called  the  caput  gallinaginis,  crista  galliTe,  or  collic- 
ulus  seminalis.  This  structure  is  composed  of  erectile  tissue  and  mus- 
cular fibres,  w^hich  during  erection  become  turgid  and  prevent  the  passage 
of  semen  back  into  the  bladder.  It  likewise  temporarily  prevents  the 
passage  of  the  urine.  The  verumontanum  is  continuous  with  the  uvula 
vesicae,  and  is  eight  or  nine  lines  long  and  one  and  a  half  lines  in  height. 

In  the  verumontanum  and  in  the  neighborhood  of  the  prostatic  ori- 
fices the  tissues  are  richly  supplied  with  nerves  of  peculiar  sensibility, 
and  it  is  here  that  the  seat  of  the  sense  of  pleasure  in  the  sexual  act  is 
centred.  It  is  here  that  inflammatory  processes  give  rise  to  disturb- 
ances of  the  sexual  function  and  to  various  painful  sensations  which 
may  extend  to  parts  beyond.  When  the  seminal  fluid  is  poured  into 
the  urethral  canal  mixed  with  the  secretion  of  the  seminal  vesicles  and 
with  the  prostatic  fluid,  it  is  prevented  from  passing  backward  by  the 
verumontanum  and  uvula  vesicae ;  then  the  muscles  of  the  gland  power- 
fully contract  and  discharge  it. 

^  Med.-Chir.  Trans.  London,  vol.  xliii.,  quoted  by  Holden  in  Manual  of  Dissection. 


42  GONORBHCEA  AND  ITS  COMPLICATIONS. 

When  one  considers  the  complexity  of  structure  of  the  posterior 
urethra  with  its  multitude  of  crypts  and  follicles  and  its  great  vascular- 
ity, it  can  readily  be  seen  why  the  gonorrhoeal  process  becomes  so  firmly 
seated  there. 

On  the  summit  of  the  verumontanum,  sometimes  at  its  fore  part  and 
sometimes  about  its  middle,  is  a  slit-like  depression  which  leads  to  a 
cul-de-sac,  or  flask-shaped  cavity,  of  about  one  to  three-quarters  of  an 
inch  in  length,  directed  upward  and  backward.  This  is  called  the  sinus 
pocularis,  vesicula  prostatica,  and  uterus  masculinus  from  its  homology 
with  the  female  uterus.  In  its  lips  or  vertical  Avails,  and  sometimes 
just  on  each  side  of  it,  are  openings  of  the  ejaculatory  ducts.  (See 
Fig.  2.)  In  some  cases  both  of  these  ducts  open  into  the  sinus  pocu- 
laris itself;  in  other  cases  only  one  duct  is  thus  placed.  On  each  side 
of  the  verumontanum  is  a  slight  depression  which  is  called  the  prostatic 
sinus,  and  into  these  sinuses  the  twenty  or  thirty  orifices  of  the  pros- 
tatic ducts  of  the  lateral  lobes  open.  The  ducts  of  the  middle  portion 
open  behind  the  verumontanum.  On  section  the  prostatic  urethra  is 
like  an  inverted  y?  thus — /^.  When  the  bladder  is  empty  its  walls, 
contracted  into  a  rounded  or  triangular  mass,  are  in  coaptation.  At 
this  time  the  lumen  of  the  prostatic  urethra  is  effaced  by  the  contraction 
of  the  muscular  fibres.  The  vesical  end  of  the  prostate  is  then  in  the 
form  of  a  well-defined  but  not  very  resistant  sphincter,  which  divides 
the  urethra  sharply  from  the  bladder.  As  the  viscus  gradually  fills  the 
pressure  of  the  accumulating  water  overcomes  the  tonicity  of  the  inter- 
nal sphincter.  Dilatation  of  the  prostatic  urethra  then  begins,  and  as 
this  progresses  it  gradually  loses  its  spindle  shape  and  becomes  de- 
cidedly funnel-shaped  and  directly  continuous  with  the  bladder.  Thus, 
when  the  bladder  is  empty  the  prostatic  urethra  is  essentially  its  neck, 
but  when  it  is  quite  fully  distended  the  neck-like  arrangement  becomes 
lost  and  the  bladder  and  prostatic  urethra  arc  continuous  without  any 
barrier  between  them.  It  follows  from  what  has  been  said  that  the 
urethra  proper  is  longer  when  the  bladder  is  only  slightly  full  than  it 
is  when  it  is  quite  fully  distended.  When  the  bladder  is  nearly  empty 
it  Avill  be  found  that  it  is  necessary  to  introduce  the  catheter  nearly  an 
inch  farther  than  it  is  necessary  to  introduce  it  when  it  is  full.  The 
reason  of  this  is  obvious :  with  the  bladder  only  slightly  distended  the 
internal  sphincter  is  still  contracted  and  the  eye  of  the  instrument  must 
pass  that  part  before  urine  is  reached.  Later  on,  when  the  sphincter 
is  much  dilated  and  the  prostatic  urethra  is  transformed  into  a  funnel- 
shaped  cavity  continuous  with  the  bladder,  it  is  only  necessary  for  the 
eye  of  the  catheter  to  pass  behind  the  external  sphincter,  when  it  en- 
counters urine.     Finger  is  certainly  right  in  his  claims  on  this  subject. 

In  this  connection  it  is  necessary  to  more  fully  call  attention  to  the 
two  sphincters  of  the  prostate.  The  internal  prostatic  sphincter  is 
situated  at  the  point  of  the  junction  of  the'  prostate  with  the  bladder, 
and  is  merged  with  the  substance  of  the  former.  It  is  composed  of 
smooth  muscular  tissue  and  elastic  fibres  arranged  in  the  form  of  a 
ring,  into  the  meshes  of  which  muscular  and  elastic  fibres  from  the 
bladder  enter  at  right  angles.  The  internal  prostatic  sphincter  there- 
fore contains  no  voluntary  muscular  fibres.  The  external  prostatic  or 
vesical  sphincter  is  situated  at  the  apex  of  the  prostate,  and  is  composed 


ANATOMY  AND  PHYSIOLOGY  OF  THE  PENIS,  ETC. 


43 


of  smooth  muscular  fibres,  together  with  a  greater  quantity  of  voluntary 
muscular  fibres.  The  involuntary  fibres  are  arranged  in  the  form  of  a 
ring.  The  voluntary  fibres  at  first  (that  is,  in  the  portion  toward  the 
apex  of  the  prostate)  form  a  transverse  band  across  the  upper  portion 
of  the  urethra,  stretching  from  lobe  to  lobe.  At  the  apex,  however, 
they  are  quite  numerous  and  form  a  distinct  ring,  which  with  the  ring 
of  involuntary  fibres  constitutes  a  very  strong  sphincter.  It  is  this 
sphincter,  when  the  bladder  is  full  and  the  internal  sphincter  is  much 
dilated  and  lost  in  the  bladder-tissue,  Avhich  remains  firm,  occludes  the 
canal,  and  prevents  the  passage  of  the  urine.  The  relation  of  the  pros- 
tatic urethra  and  the  sphincter  to  the  bladder  when  empty  and  full  is 
well  shown  in  Figs.  6  and  7,  which  are  modified  from  Finger's  pictures. 


Fig.  6. 


Fig.  7. 


Showing  a  partially-filled  bladder  sepa- 
rated from  the  prostatic  urethra. 


Bladder  much  distended  and  fused  with  the 
prostatic  urethra,  which  is  funnel-shaped. 


In  Fig.  6  the  bladder  is  only  partly  full,  and  the  well-defined  vesical 
orifice  is  still  intact  by  reason  of  the  tonus  of  the  internal  sphincter. 
In  Fig.  7  the  bladder  is  much  distended  and  the  prostatic  urethra  is 
obliterated,  of  a  funnel-shape,  and  merges  directly  with  the  bladder- 
cavity.  In  this  case  the  external  vesical  or  prostatic  sphincter  exerts 
its  tonus  and  retains  the  urine. 

The  direction  of  the  prostatic  urethra,  Avhich  is  in  a  fixed  position, 
is  downward  and  forward  until  it  reaches  the  posterior  layer  of  the 
triangular  ligament,  when  it  becomes  the  membranous  urethra,  which 
pursues  nearly  the  same  direction  with  a  slightly  upw^ard  tendency. 

The  membranous  urethra  is  from  three-quarters  to  an  inch  in  length 
and  of  a  calibre  of  27  F.,  and,  owing  to  the  fact  that  this  segment  of 
the  canal  forms  a  part  of  the  subpubic  curve  of  the  urethra,  its  superior 
wall  is  somewhat  shorter  than  the  inferior  wall.  It  is  peculiar  in  the 
fact  that  it  is  composed  wholly  of  mucous  membrane  with  a  submucous 
connective-tissue  coat  and  some  unstriped  muscular  fibres.     It  is  the 


44 


GONOBRHCEA   AND  ITS  COMPLICATIONS. 


least  vascular  part  of  the  urethral  canal,  and  has  very  few  mucous 
glands  and  crypts.  By  reason  of  its  anatomical  structure  it  is  not  so 
severely  affected  by  the  gonorrhoeal  process  as  the  other  portions  are  ; 
consequently  it  is  rarely,  if  ever,  the  seat  of  true  stricture.  When 
strictures  are  found  in  this  region  they  are  usually  the  result  of  trau- 
matism. Indeed,  traumatic  strictures  are  usually  found  in  the  mem- 
branous and  bulbous  portions  of  the  urethra,  resulting  from  wounds  and 
contusions  of  the  perineum  against  the  pubic  arch. 

The  membranous  urethra  is  situated  and  held  in  a  fixed  position 
between  the  two  layers  of  the  triangular  ligament,  a  knowledge  of  which 
is  essential. 

The  triangular  ligament,  which  is  a  portion  of  deep  perineal  fascia, 
consists  of  two  layers,  an  anterior  and  a  posterior  layer,  between 
which  is  the  compressor  urethrje  muscle.  In  Fig.  8  the  anterior  layer 
is  shown  as  a  dense  fibrous  membrane,  stretching  from  the  posterior  lip 
of  the  OS  pubis  and  ischium,  from  which  the  crura  of  the  penis  have 
been  dissected  off.  This  anterior  layer  is  about  an  inch  and  a  half  in 
length,  and  in  accord  with  the  direction  of  the  pubic  bone  its  base  is 
directed  backward.  About  an  inch  below  the  symphysis  pubis  is  the 
urethral  orifice,  the  external  termination  of  the  membranous  urethra. 
Around  this  orifice,  as  shown  in  Fig.  8,  the  fibrous  membrane  is  seen, 

Fig.  8. 


Showing  the  anterior  layer  of  the  triangular  ligament  and  Henle's  deep  transverse  ligament  of 
the  pelvis,  with  openings  for  vessels  and  nerves. 

which  is  continued  forward  over  the  bulbous  portion  of  the  urethra. 
The  triangular  ligament  extends  upward  toward  the  symphysis  to  a  dis- 
tance just  above  the  hole  for  the  urethra,  and  is  shown  in  Fig.  8  as  a 
curved  line.  Above  that  is  the  dense  fibrous  tissue  called  '•  Henle's 
deep  transverse  ligament  of  the  pelvis,"  which  is  pierced  by  the  open- 


ANATOMY  AND  PHYSIOLOGY  OF  THE  PENIS,  ETC. 


45 


ings  for  the  vessels  and  nerves.     The  triangular  ligament  and  Henle's 
ligament  therefore  close  this  part  of  the  pelvic  outlet. 

The  posterior  layer  of  the  triangular  ligament  is  derived  from  the 
obturator  fascia,  and  from  it  a  prolongation  passes  backward  and  forms 
the  outer  capsule  of  the  prostate.  Its  upper  portion,  called  Henle's 
ligament,  is  pierced  by  the  opening  for  the  plexus  venosus  ijuhicus 
impm\  which  consists  of  veins  returning  from  the  penis  and  of  the 
dorsal  arteries.  The  triangular  ligament  proper  is  pierced  by  the  mem- 
branous urethra,  as  shown  in  Fig.  9,  which  also  shows  the  apex  of  the 

Fig.  9. 


Showing  the  posterior  layer  of  the  triangular  ligament. 

prostate  and  the  external  prostatic  sphincter  blending  with  the  mem- 
branous urethra. 

When  the  anterior  layer  of  the  triangular  ligament  is  dissected  off, 
•the  compressor  urethrse  muscle  is  exposed  in  the  form  of  a  firm,  flat 
muscular  band,  rather  more  than  an  inch  wide,  stretched  between  the 
pubic  rami,  but  not  wholly  covering  the  pelvic  outlet  at  its  apex.  (See 
Fig.  10.)  This  muscle,  also  called  the  constrictor  urethra,  the  cut-off 
muscle,  is  composed  of  transverse  fibres  of  the  striped  variety,  some  of 
which  pass  directly  over  and  some  under  the  urethra,  while  others  pass 
around  and  encircle  it.  This  muscle  is  very  powerful,  and,  being  under 
the  control  of  the  Avill,  it  can  at  any  time  suddenly  stop  the  flow  of 
urine.  Though  the  external  prostatic  sphincter  consists  of  rings  of  un- 
striped  muscular  fibres  at  the  apex  of  the  prostate,  the  greater  part  of 
the  true  sphincteric  action  is  performed  by  the  compressor  muscle.  In 
the  course  of  acute  and  chronic  gonorrhoea,  and  during  irritative  pro- 
cesses in  the  prostate,  seminal  vesicles,  and  bladder,  tliis  muscle  may 
undergo  spasm  and  produce  what  is  wrongly  termed  "spasmodic  stric- 
ture."    Under  the  influence  of  rough  manipulation  by  instruments  in 


46 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


the  urethra,  of  cold,  and  of  very  strong  and  irritating  urethral  injec- 
tions, spasm  may  also  be  produced.  Then,  again,  as  a  result  of  opera- 
tions about  the  rectum,  abdomen,  lower  limbs,  etc.,  this  muscle  may  be 
thrown  into  spasm  and  retention  of  urine  may  result.     Some  authors 


Fig.  10. 


Showing  the  compressor  urethrse  or  cut-off  muscle. 

claim  that  this  muscle  is  always  in  a  state  of  rigid  contraction  or  tonus, 
so  that  the  lumen  of  the  urethra  is  of  the  fineness  of  a  hair,  and  that 
this  contraction  tends  to  prevent  the  extension  of  the  gonorrhoeal  pro- 
cess from  the  anterior  into  the  posterior  urethra,  and  also  acts  as  a  dam, 
preventing  secretions  in  the  prostatic  and  membranous  urethra  escaping 
into  the  anterior  urethra.  This  is  far  too  sweeping  a  statement.  When 
the  bladder  is  more  or  less  full  the  compressor  or  constrictor  urethrge 
closes  up  the  membranous  urethra  and  prevents  the  escape  of  urine; 
but  when  the  bladder  is  not  full,  even  in  cases  of  subacute  inflamma- 
tion in  any  part  of  the  urethra,  bulbous  or  prostatic,  there  is  not  in  the 
majority  of  cases  any  unusual  tonus  or  spasm  of  this  muscle.  This  fact 
can  be  readily  demonstrated,  as  I  have  done  hundreds  of  times,  by  the 
gentle  passage  into  the  bladder  of  a  soft  catheter  or  bougie  of  a  calibre 
of  12  or  14  French.  This  instrument,  causing  no  irritation  or  nervous 
shock,  glides  easily  first  into  the  membranous  urethra,  then  along  the 
prostatic  urethra  into  the  bladder.  The  excessive  tonus  claimed  to  be 
peculiar  to  this  muscle  in  general  occurs  when  rigid  instruments,  par- 
ticularly of  large  size  and  when  not  skilfully  passed,  are  used,  or  Avhen 
injections  have  been  forcibly  made.  Then  the  nerves  of  the  urethra  are 
disturbed,  and  prompt  reflex  spasm  of  the  muscle  occurs.  In  the  major- 
ity of  persons  the  compressor  muscle  and  the  external  prostatic  sphinc- 
ter keep  the  urethral  canal  mildly  compressed.  Tliat  is,  its  tonicity  is 
such  that  the  lumen  of  the  canal  is  obliterated  by  the  coaptation  of  the 


ANATOMY  AND  PHYSIOLOGY  OF  THE  PENIS,  ETC. 


47 


folds  of  membrane,  but  there  is  no  spasm.  Consequently,  it  occurs,  as 
a  rule,  that  the  secretions  of  the  prostatic  urethra  are  kept  from  escap- 
ing into  the  anterior  urethra.  Though  this  may  be  stated  as  the  law,  it 
has  exceptions  in  some  cases  of  acute  posterior  urethritis,  in  some  of 
prostatorrhoea,  and  in  some  of  suppuration  of  the  seminal  vesicles. 
Though  Finger  and  some  other  authors  deny  this  occurrence,  I  am  posi- 
tive that  it  sometimes  occurs. 

When  the  bladder  is  only  slightly  full  the  internal  prostatic  sphincter 
is  sufficiently  competent  to  occlude  the  vesical  orifice,  and  thus  prevent 
the  escape  of  urine  into  the  prostatic  urethra.  As  the  fluid  accumu- 
lates, however,  such  expansive  pressure  is  exerted  that  the  vesical 
sphincter  gradually  yields  and  allows  the  escape  of  urine  into  the  pros- 
tatic urethra.  For  a  time  the  external  prostatic  sphincter,  which  is 
stronger  than  the  internal,  is  strong  enough  to  keep  the  urine  back, 
but  when  the  bladder  becomes  very  full  the  sphincteric  action  is  per- 
formed by  an  effort  of  the  will  through  the  compressor  urethras  muscle. 

On  each  side  of  the  membranous  urethra,  quite  near  to  it  and  seated 
in  the  substance  of  the  compressor  muscle,  are  Cowper's  glands.  These 
glands  are  of  pea  size  and  of  the  compound  racemose  variety.  From 
each  one  a  duct  three-quarters  of  an  inch  in  length  passes  through  the 
anterior  layer  of  the  triangular  ligament  and  opens  obliquely  into  the 
floor  of  the  bulbous  portion  of  the  urethra  near  the  median  line.  These 
glands  secrete  a  mucous  fluid  during  sexual  excitement  and  coitus. 
They  are  interesting  clinically  as  being  sometimes  the  seat  of  gonor- 
rhoeal  inflammation.     (See  Fig.  11.) 

Fig.  11. 


Showing  the  normal  contractions  and  expansions  of  the  urethra  from  the  meatus  to  the  bladder, 
with  Cowper's  gland  opening  by  its  duct  into  the  bulbous  urethra. 

Lying  just  upcn  the  anterior  layer  of  the  triangular  ligament  is  the 
bulb  of  the  corpus  spongiosum,  containing  the  bulbous  expansion  of  the 
urethra.  Here  the  membranous  urethra  ends,  and  the  part  is  called 
the  bulbo-membranous  junction.  The  urethra  enters  the  bulbous  ex- 
pansion nearer  its  upper  than  its  lower  half;  consequently  the  pouch- 
like dilatation  of  the  urethra  is  greater  on  its  lower  surface.  It  is  this 
condition  which  sometimes  causes  trouble  in  the  passage  of  sounds  and 


48  GONOBBHCEA   AND  ITS  COMPLICATIONS. 

catheters,  to  obviate  which  it  is  necessary  here  to  keep  the  point  of  the 
instrument  toward  the  roof  of  the  urethra,  and  to  put  the  penis  on 
stretch  in  order  to  eiface  the  pouchy  pocket  as  much  as  possible.  As 
age  advances  the  bulb  frequently  becomes  more  roomy  and  lax,  and 
thus  it  often  presents  in  old  men  greater  obstacles  to  the  passage  of  the 
catheter.  The  bulbous  portion  of  the  urethra  or  the  sinus  of  the  bulb 
is  unusually  vascular,  and  its  tissues  are  soft  and  succulent.  Conse- 
quently, the  gonorrhoeal  process  is  often  very  acute  and  severe  at  this 
part,  and  the  disease  shows  a  tendency  here  to  remain  in  a  chronic 
condition.  As  a  result  we  find  the  larger  number  of  true  strictures  in 
this  region. 

The  direction  of  the  bulbous  urethra  is  forward  and  upward,  and  its 
calibre  is  from  33  to  36  French.  The  downward  and  forward  direction 
of  the  prostatic  urethra  and  the  slightly  upward  direction  of  the  mem- 
branous urethra,  with  the  decidedly  upward  direction  of  the  bulbous 
urethra,  form  what  is  called  the  subpubic  curve.  Continuous  out- 
wardly with  the  bulbous  portion  of  the  urethra  is  the  spongy  penile  or 
pendulous  urethra.  It,  like  the  bulbous  portion,  is  contained  in  the 
corpus  spongiosum.  It  is  from  six  to  six  and  a  half  inches  (sometimes 
more)  in  length,  and  is  surrounded  by  erectile  tissue.  The  mucous- 
membrane  crypts  and  follicles  of  this  portion  of  the  urethra  have 
already  been  described.  The  calibre  of  the  penile  or  pendulous  urethra 
is  usually  from  27  to  30  French,  but  it  is  often  found  to  be  greater  than 
this  measurement.  The  penile  urethra  is  susceptible  of  considerable 
dilatability,  but  it  must  be  remembered  that  the  word  "calibre"  repre- 
sents normal  distention,  such  as  is  found  by  the  moderately  easy  passage 
♦of  instruments  or  by  the  stream  of  urine,  while  "dilatability"  means  a 
calibre  produced  by  unusual  or  excessive  distention  of  the  canal  by 
instruments. 

The  distal  portion  of  the  urethra  seated  in  the  glans  penis  is  called 
the  fossa  navicularis,  or  the  navicular  portion  of  the  urethra.  It  is  of 
spindle  shape,  and  at  its  middle  portion  its  calibre  is  30  to  33  F.  At 
its  point  of  junction  with  the  penile  urethra  the  calibre  is  from  about 
28  to  30  F.  The  calibre  of  the  meatus,  the  terminal  point  of  the  ure- 
thra externally,  is  from  21  to  28  F. ;  exceptionally,  however,  it  is  greater. 
A  schematic  representation  of  the  urethra  with  its  normal  contractions 
and  expansions  is  given  in  Fig.  12. 

To  recapitulate :  ^  The  calibre  of  the  urethra  is  not  uniform,  there 
being,  as  already  shown,  physiological  contractions  and  dilatations.  As 
a  general  average  the  following  figures  will  be  found  to  be  correct : 

Meatus,  7  to  9  m.  m 21  to  28  F. 

Fossa  navicularis,  10  to  11  in.  ra 30  to  33  F. 

Middle  of  pendulous  portion,  9  to  10  m.  m 27  to  30  F. 

Bulb,  11  to  Tim.  m 38  to  36  F. 

Membranous  urethra,  9  m.  m ;..■...  27  F. 

At  apex  of  prostate,  10  m.m 30  F. 

Middle  of  prostate,  15  m.m 45  F. 

Vesical  end  of  prostate,  11  m.  m 33  F. 

1  Dr.  Otis  (Practical  Clinical  Lectures,  etc.,  1883,  pp.  441-442)  states  that  there  is  a 
constant  relation  between  the  circumferential  measurement  of  the  flaccid  jienis  and  tiie 
calibre  of  the  urethra  in  the  healthy  condition.  He  says:  "When  the  circumference 
is  3  inches  the  urethra  has  a  normal  calibre  of  at  least  30  F. ;  if  3|,  it  will  be  32  F. ; 
if  3.}  =  34  F. :  if  32-  =  36  F. ;  if  4  inches  =  38  F. ;  and  if  4.V  =  40  or  more. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  PENIS,  ETC. 


49 


The  degree  of  mobility  of  different  portions  of  the  urethra  is  chiefly 
influenced  by  the  attachments  of  the  neighboring  fascia.  The  anterior 
part  of  the  penis  is  free,  and  capable,  in  a  flaccid  condition,  of  assuming 
almost  any  position ;  in  its  posterior  third,  however,  this  organ  is  con- 
nected with  the  symphysis  by  means  of  the  suspensory  ligament,  with 
the  ischiatic  and  pubic  rami  by  the  crura  of  the  corpora  cavernosa, 
and  with  the  anterior  layer  of  the  triangular  ligament  by  means  of  the 
bulb ;  the  spongy  urethra  may  therefore  be  said  to  be  fixed  in  pro- 
portion as  it  approaches  the  membranous  region.  The  membranous 
region  is  the  least  movable  of  all,  owing  to  its  firm  connection  w^ith  the 
pelvis  by  means  of  the  tw^o  layers  of  the  triangular  ligament.  The 
prostatic  urethra  is  susceptible  of  some  slight  change  of  position,  de- 
pendent upon  the  action  of  the  anterior  fibres  of  the  levator  ani,  the 
amount  of  urine  in  the  bladder,  and  the  passage  of  sounds  or  catheters. 

In  a  flaccid  condition  of  the  penis  the  urethra  has  two  curves — the 
first  confined  to  the  anterior,  the  second  to  the  deepest,  portion  of  the 
canal.  The  former  is  simply  due  to  the  dependent  position  of  the  ante- 
rior part  of  the  organ,  and  is  efilaced  in  a  state  of  erection  or  when  the 
penis  is  elevated  to  an  angle  of  about  60°  with  the  body.  The  latter 
is  called  the  subpubic  curve,  from  its  position  beneath  the  symphysis. 
Unless  some  degree  of  force  be  used  to  straighten  the  canal  this  curve 
is  permanent,  and  a  knowledge  of  its  direction  is  essential  -in  deter- 
mining the  proper  form  of  instruments  and  the  manner  of  their  intro- 
duction. 

The  subpubic  curve  commences  an  inch  and  a  half  anterior  to  the 
bulb  in  the  penile  urethra,  attains  its  lowest  point  when  the  body  is 


Fig.  12. 


Fig.  13. 


Fig.  14. 


Section  through  the  pre- 
puce and  glans. 


Just  behind  the  meatus. 


Through  prepuce  at  base  of 
glans. 


Fig.  15. 


Fig.  16. 


Fig.  17. 


Through  prepuce  and  corona 
glandi.s. 


Sections  just  behind  the  corona  ghmdis,  spongj-  and 
cavernous  bodies  well  shown. 


60  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

Fig.  18.  Fig.  19.  Fig.  20. 


Fig.  21. 


Fig,  22. 


Fig.  23. 


Figs.  18  to  23  show  sections  from  before  backward  through  the  penile  urethra.  The  pectiniform 
septum  is  complete  except  in  Fig.  19,  where  corpora  cavernosa  are  continuous  with  one 
another. 


Fig.  24. 


Fig.  25. 


Fig.  26. 


Through  bulbo-membranous  Through  apex  of  prostate.         Through  middle  of  prostate, 

junction,      urethra       sur-  capsule    of    prostate    well 

rounded  by  some  anterior  shown, 
fibres  of  the  compressor. 


Fig.  27, 


Fig.  28. 


Through  the  bladder  and  prostate,  behind  Just  behind  the  prostate,  through  the  bladder 

the  urethra.  and  seminal  vesicles. 


ANAT03IY  AND  PHYSIOLOGY  OF  THE  PENIS,  ETC.  51 

in  the  upright  position  nearly  opposite  the  anterior  layer  of  the  tri- 
angular ligament,  and  finally  ascends  through  the  membranous  and  pro- 
static regions.  According  to  the  observations  of  Mr.  Thompson  and 
Mr.  Briggs,  it  "  forms  an  arc  of  a  circle  three  inches  and  a  quarter  in 
diameter,  the  chord  of  the  arc  being  two  inches  and  three-quarters,  or 
rather  less  than  one-third  of  the  circumference."  Mr.  Thompson  states 
that  he  has  often  found  it  more  acute  in  spare  men,  and  in  the  corpu- 
lent more  obtuse — that  traction  of  the  abdominal  muscles  exercised 
through  the  suspensory  ligament  may  also  render  it  more  abrupt,  whence 
the  advantage  of  raising  the  shoulders  when  performing  catheterization 
upon  patients  in  the  recumbent  posture.  The  elevation  of  the  bladder 
above  the  pubes  in  children,  and  the  enlargement  of  the  prostate  so 
common  in  old  men,  also  effect  a  change  in  the  direction  of  the  sub- 
pubic curve  from  its  usual  adult  standard,  and  require,  therefore,  a 
corresponding  variation  in  the  form  of  instruments.  Swellings  and 
abscesses  about  the  lower  extremity  of  the  rectum,  large  hemorrhoidal 
tumors,  and  various  other  conditions  may  also  operate  in  a  greater  or 
less  degree  to  cause  some  change  in  the  direction  of  this  curve. 

The  urethra  is  far  from  uniform  as  regards  its  shape  and  conforma- 
tion in  its  various  positions.  This  is  well  shown  in  Figs.  12  to  26, 
taken  from  sections  of  the  frozen  penis  between  the  end  of  the  glans 
and  the  bladder.  The  canal  is  seen  to  be  a  vertical  slit  in  Figs.  12  to 
17.  This  vertical  condition  exists  as  far  as  the  junction  of  the  navicular 
with  the  penile  urethra.  In  the  penile  urethra  proper  the  canal  be- 
comes transverse,  and  so  remains  in  its  Avhole  extent  as  shown  in 
Figs.  18  to  23.  At  the  bulb  it  becomes  round,  and  so  remains  at  the 
bulbo-membraneous  junction  and  in  its  membranous  portion.  At  the 
apex  of  the  prostate  it  is  somewhat  changed,  as  shown  in  Fig.  25. 
In  the  middle  of  the  prostate  the  urethra  looks  like  an  inverted  Y — 
thus,  A  (see  Fig.  26) — between  the  arms  of  which  is  the  verumontanum 
containing  the  utriculus  masculinus.  At  the  bladder  the  urethro-vesi- 
cal  orifice  is  nearly  round,  the  circle  being  impinged  upon  by  the  uvula 
vesicse  at  its  lower  segment.  In  Fig.  27  the  very  beginning  of  the 
urethra  is  shown  in  the  depression  in  the  centre  of  the  base  of  the 
bladder.  This  is  the  posterior  surface  of  the  urethral  orifice,  its  ante- 
rior surface,  formed  by  the  prostate,  not  being  shown  in  the  section. 
The  two  dots  near  the  under  surface  of  the  prostate  indicate  the  ejacu- 
latory  ducts,  which  run  side  by  side.  Fig.  28  shows  a  section  behind 
the  prostate,  through  the  bladder  and  the  seminal  vesicles. 

The  seminal  vesicles  are  two  membranous  pouches  situated  at  the  base 
of  the  bladder,  between  it  and  the  rectum.  They  are  loosely  yet  firmly 
attached  to  the  bladder  on  their  upper  surface,  and  between  them  and 
the  rectum  is  a  layer  of  the  vesico-rectal  fascia.  Each  vesicle  is  some- 
what pyramidal  in  form,  measures  two  and  a  half  inches  in  length,  about 
half  an  inch  in  breadth,  and  a  quarter  to  a  third  of  an  inch  in  thickness. 
The  anterior  or  pointed  extremities  of  the  seminal  vesicle  are  situated 
within  a  finger's  breadth  of  each  other  on  each  side  of  the  median  line, 
just  at  the  base  of  the  prostate.  They  then  diverge  from  each  other  so 
as  to  form  the  letter  V  when  the  bladder  is  full.  The  trigone  is  the  space 
in  the  bladder  which  corresponds  with  the  V-shaped  space  at  its  base. 
Just  near  the  prostatic  end  of  each  vesicle,  on  their  inner  side,  they  are 


62 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


Fig.  29. 


joined  by  the  corresponding  vas  deferens,  and  they  fuse  together  and 

form  the  common  ejaculatory  ducts,  which 
tunnel  the  prostate  side  by  side  and  open 
on  the  lip  of  the  utriculus  masculinus  or 
into  its  cavity.  At  the  prostatic  end  of 
the  seminal  vesicles  and  the  vasa  deferentia 
these  structures  lie  together  so  closely  in 
juxtaposition  that  it  is  difficult,  if  not  im- 
possible, in  health  to  define  their  contours 
by  the  finger-tip  in  the  rectum,  and  even 
more  difficult  in  diseased  conditions.  This 
difficulty  is  much  increased  when  the  am- 
pullation  of  the  vasa  deferentia,  which  is 
frequently  found  here,  is  very  pronounced. 
(See  Fig.  29.) 

The  seminal  vesicles  have  been  described 
as  tubes  convoluted  like  little  sacculated 
bladders  and  as  racemose  glands.  Such 
opinions  are  erroneous.     The  seminal  ves- 

Showiug  the  relations  of  the  seminal  icles  are  really  blind-ended  tubes  with  di- 

vesicles,    vasa    deferentia,   ureters,  .      ,         ^      "^   .  .  mi  •      •        i        i 

prostate,  and  urethra.  vcrticula  01  vanous  sizes.      Inis  IS  Clearly 

shown  in  Fig.  30.  On  the  right-hand  side 
the  vesicle  is  seen  with  its  tubes  rendered  distinct,  but  in  natural  coapta- 
tion, by  the  removal  of  the  connective  tissue.  On  the  left  hand,  however, 
the  tubes  are  shown,  three  in  number,  after  being  dissected  apart.  The 
inner  tube  is  seen  to  have  a  decided  distal  enlargement ;  the  middle  tube 
is  seen  to  join  the  third  tube  at  right  angles.  These  two  tubes  bear  the 
same  relation  to  each  other  that  the  blade  of  a  jack-knife  does  to  its 
handle.  The  outer  enlarged  tube,  of  dog's-ear  shape,  is  called  the  handle 
of  the  jack-knife  and  the  middle  tube  its  blade.  ■  When  placed  in  natural 
coaptation  the  knife-blade  fits  snugly  in  the  concavity  existing  in  the 
handle.  It  is  necessary  to  understand  the  form  of  arrangement  of  the 
tubes  of  the  seminal  vesicles  for  reasons  stated  in  the  chapter  on  the  dis- 
eases of  these  structures. 

The  seminal  vesicles  have  three  coats — a  fibrous,  a  muscular,  and  a 
mucous  coat,  the  latter  covered  with  columnar  epithelium  and  studded  by 
various  small  tubular  glands.  The  seminal  vesicles  serve  as  reservoirs 
for  the  semen  ;  they  also  secrete  a  mucous  fluid  which  becomes  mixed  with 
the  semen,  It  is  well  to  remember  that  the  apex  of  the  prostate  is  about 
half  an  inch  or  more  from  the  anus,  and  that  its  base  is  fully  an  inch  and 
a  half  farther  back  and  upward ;  consequently,  the  finger-tip  must  cer- 
tainly be  within  the  rectum  for  at  least  an  inch  and  a  half  before  the 
vesicles  are  reached.  In  some  thin  subjects  this  is  accomplished  quite 
readily,  but  the  examination  is  more  difficult  and  the  results  are  more 
unsatisfactory  in  proportion  as  the  subject  is  fat  and  compactly  built. 

Near  the  base  of  the  seminal  vesicles  the  peritoneum  is  reflected  from 
the  anterior  surface  of  the  rectum  upon  the  bladder.  The  space  betAveen 
the  base  of  the  bladder,  with  the  attached  prostate  and  seminal  vesicles, 
and  the  rectum  is  filled  with  a  quite  dense  connective  tissue,  the  recto- 
vesical fascia,  which  is  very  dense  and  firm  at  the  prostate.  It  is  through 
this  space,  by  means  of  a  semicircular  incision  anterior  to  the  anus,  that 


ANAT03IY  AND  PHYSIOLOGY  OF  THE  PENIS,  ETC. 


53 


the  seminal  vesicles  are  reached  in  cases  of  abscess  pointing  toward  the 
rectum,  and  in  tuberculosis  of  these  organs. 

The  testicles  are  two  oval  glands  suspended  in  the  scrotum  by  the 
spermatic  cords.  These  glands  are  flattened  on  their  sides  and  hang 
obliquely,  the  upper  portion  being  directed  forward  and  outward,  the 
lower  border  backward  and  inward.  Around  the  superior  and  posterior 
surface  of  each  testis  is  a  crescentic-shaped  body  called  the  epididymis, 

Fig.  30. 


Showing  the  bladder  and  ureters,  the  ampuUated  end  of  the  vas  deferens,  seminal  vesicles, 
prostate,  and  membranous  urethra  :  a,  bladder ;  6, 6,  ureters ;  c,  c,  vasa  deferentia ;  d,  d,  seminal 
vesicle  ;  e,  prostate ;  /,  membranous  urethra ;  g,  corpora  cavernosa,  corpus  spongiosum,  and 
bulbous  portion  of  the  urethra. 

which  consists  of  three  segments,  the  upper  and  larger  one  being  the 
head,  also  called  the  globus  major,  the  middle  portion  the  body,  and  the 
inferior  portion  or  globus  minor. 

The  glandular  structure  of  the  testis  is  shown  in  Fig.  31  in  the  form 
of  conical-shaped  lobules  with  bases  at  the  circumference  of  the  organ  and 
apices  ending  in  the  mediastinum  testis.  These  lobules  are  enclosed  in 
fibrous  tissue  which  extends  between  the  mediastinum  and  the  tunica  albu- 
ginea,  or  proper  fibrous  tissue  of  the  testes.  These  lobules  are  made  up 
of  convoluted  seminiferous  tubes,  of  which  there  are  more  than  eight  hun- 


64 


GONOBBHCEA  AND  ITS  COMPLICATIONS. 


Fig.  31. 


Tunica  Vaginalis. 


Tunica  Albugii 


dred,  each  one  of  which  when  dissected  out  and  unravelled  measures  two 
and  a  half  feet.  These  lobules  contain  seminal  cells  and  spermatoblasts. 
In  the  connective-tissue  meshwork  which  surrounds  the  lobules  are  fine 

capillary  vessels  and  nerves.  At  the  me- 
diastinum the  tubules  bend  at  right  an- 
gles, and  these  form  thevasa  recta  (twenty 
or  thirty  in  number),  which  pass  verti- 
cally upward  and  perforate  the  tunica 
vaginalis.  x-Vs  these  minute  tubes  pass 
through  the  upper  part  of  the  tunica 
vaginalis  they  become  larger  and  less 
numerous  (fifteen  or  twenty),  and  are 
called  the  vasa  efi"erentia.  They  then 
become  much  enlarged  and  convoluted, 
and  form  cone-shaped  masses,  called  the 
coni  vasculosi,  which,  together  with  ves- 
sels, nerves,  and  connective  tissue,  con- 
stitute the  globus  major  of  the  epididy- 
mis. The  tubes  of  the  coni  vasculosi 
end  at  the  lower  part  of  the  globus  major 
in  one  tube,  which  becomes  intricately 
convoluted,  and  thus  forms  the  body  of 
the  epididymis  and  the  globus  minor. 
This  convoluted  tube  is  fully  twenty 
feet  in  length,  and  it  increases  in  cali- 
bre until  it  merges  in  the  vas  deferens. 
The  tunica  vaginalis  is  a  serous  pouch 
which  covers  the  testes  and  epididymis,  the  attached  portion  being  called 
the  visceral  layer  (tunica  vaginalis  propria),  and  its  reflection  upon  the 
scrotal  wall  the  parietal  layer  (tunica  vaginalis  reflexa).  Inflammation 
of  the  gland-substance  and  oedematous  hyperplasia  of  the  globus  major 
may  produce  dropsy  of  this  serous  pouch,  which  is  called  hydrocele. 

The  vas  deferens,  or  seminal  duct,  begins  at  the  lower  part  of  the 
globus  minor  and  runs  upward  along  the  inner  and  posterior  border  of 
the  testes.  It  is  here  accompanied  by  the  spermatic  artery,  the  artery 
of  the  vas  deferens,  and  the  cremasteric  artery.  Besides  these  vessels 
are  the  spermatic  veins,  coming  from  the  back  of  the  testes,  which  become 
convoluted  and  form  the  pampiniform  plexus.  All  these  vessels,  together 
with  a  rich  nervous  supply,  form  what  is  called  the  spermatic  cord,  which 
is  surrounded  by  a  distinct  fibrous  sheath.  At  the  internal  abdominal 
rings  the  vessels  join  their  several  trunks,  while  each  vas  deferens  descends 
into  the  pelvis,  crosses  the  external  iliac  artery,  curves  around  the  bladder 
on  the  outer  side  of  the  epigastric  artery  and  inner  side  of  the  ureter, 
backward  and  downward  to  its  base ;  there  it  usually  becomes  ampullated 
and  joins  the  duct  of  the  seminal  vesicles,  forming  the  common  ejacula- 
tory  duct.  Each  vas  deferens  is  from  eighteen  to  twenty -four  inches  long. 
The  testes  are  covered  by  the  scrotum,  a  musculo-cutaneous  pouch 
which  is  divided  into  two  parts  by  a  fibrous  septum.  This  cutaneous 
envelope  and  its  dartos  muscle,  together  with  the  external  spermatic  fas- 
cia, cremaster  muscle,  infundibuliform  (internal  spermatic)  fascia,  and  the 
tunica  vaginalis,  constitute  the  coverings  of  the  testis. 


Vertical  section  of  the  testis  and  epi- 
didymis (after  Gray). 


GONOBBHCEA  IN  THE  MALE.  55 

CHAPTEE  II. 

GONOKRHQEA  IN  THE  MALE. 

GoNORRHCEA,  the  most  frequent  of  all  venereal  diseases,  and  the  one 
essentially  of  sexual  origin,  is  a  virulent  process,  attended  by  much  sup- 
puration, which  attacks  chiefly  the  mucous  membrane  of  the  urethra,  male 
and  female,  and  the  parts  in  immediate  and  more  remote  anatomical 
relation.  The  mucous  membrane  of  the  eye  is  also  particularly  suscept- 
ible to  its  action.  There  is  no  doubt  that  the  rectal  and  anal  mucous 
membrane  may  be  attacked  by  this  process,  but  there  is  much  doubt 
about  the  existence  of  gonorrhoea  of  the  mouth  and  nose.  The  term 
"gonorrhoea,"  which  signifies  a  flow  of  sperm  (from  yovrj,  sperm,  and 
peu)^  to  flow),  although  etymologically  incorrect,  is  so  old,  has  so  long 
been  employed,  and  carries  with  it  so  much  clearness  and  precision  of 
meaning  to  the  medical  and  lay  mind,  that  it  is  well  to  retain  it  in  our 
nosology.  It  is  also  called  urethritis,  blenorrhagia,  blenorrhoea ;  chaude 
pisse  by  the  French ;  tripper  by  the  Germans ;  and  plain  clap  by  Eng- 
lish-speaking nations.  In  this  work  the  terms  gonorrhoea  and  urethritis 
will  be  used  interchangeably. 

It  is  claimed  by  Ricord  that  80  out  of  every  100  men  living  in  large 
cities  suffer  from  gonorrhoea  at  some  period  of  their  lives. 

Gonorrhoea  is  found  much  more  frequently  in  the  male  than  the 
female.  The  first  attack  is  usually  more  acute  and  severe  than  are  sub- 
sequent ones,  which  are  very  often  subacute  in  form  and  chronic  in 
course.  When  many  years  have  elapsed  between  two  infections,  the 
second  may  be  equally  as  severe  as  the  first. 

Gonorrhoea  is  mostly  found  in  young  men,  but  instances  of  children^ 
and  even  infants,  being  thus  affected  are  far  from  uncommon.  Toward 
puberty  it  is  very  often  found  in  the  male,  w  hile  between  the  twentieth 
and  thirtieth  years  its  frequency  of  occurrence  is  greatest.  From  the 
thirtieth  year  onward  its  occurrence  grows  progressively  less  frequent, 
but  it  is  seen  in  a  goodly  number  of  cases  of  middle-aged,  and  even 
of  old,  men.  Isaacs^  reports  the  case  of  a  man  one  hundred  and  three 
years  old  who  applied  for  treatment  of  a  florid  gonorrhoea.  This  par- 
ticularly virile  individual  had  suffered  from  chancroids  when  he  was 
one  hundred  years  old.  The  male  sex  derives  it  by  infection  from  the 
female,  and  vice  versd. 

In  the  vast  majority  of  cases  gonorrhoea  is  communicated  by  direct 
infection  in  coitus,  but  it  is  possible  that  it  may  be  contracted  by  medi- 
ate infection,  particularly  in  women.  The  pus  from  the  infected  geni- 
tals of  a  girl  or  woman  may  be  deposited  on  those  of  a  healthy  person 
by  means  of  the  fingers,  or  it  may  be  transported  upon  towels  and  syr- 
inges or  in  baths.  The  time-worn  explanation  of  the  origin  of  the 
trouble  by  contact  with  a  foul  privy  or  urinal  may  be  looked  upon  as  a 
euphemism  to  be  used  in  the  case  of  some  clerical,  venerable,  or  mar- 
ried transgressor.  In  very  many  cases  of  men  who  have  had  an  initial 
1  Med.  Record,  April  14,  1894,  p.  462. 


56  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

attack  of  gonorrhoea  acute  urethral  suppuration  may  be  solely  due  to 
sexual  and  alcoholic  excesses,  which  have  changed  a  chronic  and  dor- 
mant localized  inflammation  of  the  urethra  into  a  more  or  less  acute 
condition. 

Gonorrhoea  is  one  of  the  most  persistent  diseases  which  attack  mu- 
cous membranes.  It  invades  the  tissues  deeply,  and  as  a  consequence 
it  is  very  often  difficult  to  cure.  After  a  more  or  less  prolonged  chronic 
stage  it  often  settles  down  into  a  latent  and  dormant  condition  in  a  local- 
ized form,  and  may  thus  cause  no  symptoms  for  years.  Then,  again, 
this  condition  of  latency  may  be  frequently  varied  by  acute  attacks  of 
the  disorder. 

When  all  the  features,  complications,  and  sequelae  of  gonorrhoea  are 
taken  into  consideration,  it  will  be  seen  that  it  is  a  disease  of  no  insig- 
nificant character.  In  many  cases  it  passes  away  and  leaves  no  bad 
effects.  In  others  it  leads  to  the  development  in  the  male  of  such 
painful  complications  as  swelled  testicle  and  abscess  in  connection  with 
the  urethra.  In  the  female  it  may  lead  to  cystitis,  inflammation  of  the 
OS  uteri,  the  tubes,  the  ovaries,  and  even  to  peritonitis.  Its  long  dura- 
tion in  the  male  urethra  frequently  leads  to  stricture,  with  its  distressing 
and  often  fatal  results  from  bladder,  prostatic,  and  kidney  complications. 
By  the  action  of  the  toxines  which  the  gonorrhoeal  process  gives  forth, 
and  also  from  the  absorption  of  its  virulent  microbes  from  the  urethra 
into  the  circulation,  violent  and  painful  inflammations  of  joint-structures, 
joints,  tendinous  sheaths,  burs^,  fasciae,  and  fibrous  tissues  are  pro- 
duced. In  many  of  these  inflammations  gonorrhoea  seems  to  produce  a 
true  septicaemia  through  the  action  of  its  own  virulent  microbe.  In 
many  cases  it  is  very  probable  that  the  morbid  action  of  the  gonococcus 
prepares  the  tissue  for  the  invasion  of  pyogenic  microbes.  By  these 
combined  or  mixed  forms  of  infection  the  whole  organism  may  be  in- 
volved, and  severe  illness,  structural  impairment  of  parts,  invalidism, 
and  even  death,  may  be  produced.  By  reason  of  this  action  of  the 
gonococcus  alone  or  aided  by  that  of  other  pyogenic  microbes  the  eyes, 
the  heart  and  its  membranes,  the  coverings  of  the  spinal  cord  (and,  it 
is  also  claimed,  those  of  the  brain)  may  be  attacked,  and  serious,  even 
fatal,  results  may  follow. 

When  we  consider  the  vast  range  of  pathological  conditions  which 
gonorrhoea  may  cause  or  lead  to,  we  are  certainly  warranted  in  assert- 
ing that  it  is,  taken  as  a  whole,  one  of  the  most  formidable  and  far- 
reaching  infections  by  which   the  human  race  is   attacked. 

The  demonstration  of  the  fact  that  the  gonococcus  and  other  pyo- 
genic microbes  are  the  cause  of  urethral  suppuration  has  clearly  proved 
that  gonorrhoea  is  an  essentially  virulent  process. 


THE  GONOCOCCUS.  67 

CHAPTER  III. 

THE    GONOCOCCUS. 

The  gonococcus  is  reliably  revealed  to  the  eye  by  means  of  staining 
processes  ^  and  by  the  microscope  Avith  a  high  power  and  oil-immersion, 
using  at  least  a  ^l^'^^^h  lens.  It  is  a  relatively  large  micrococcus, 
nearly  always  appearing  as  a  diplococcus.  It  measures  0.8  to  1.6  micro- 
millimetres  in  length  and  0.6  to  0.8  micromillimetres 
in  breadth.    The  gonococci  are  usually  found  in  pairs.  Fig.  32. 

each  half  of  the  diplococcus  being  of  kidney  shape,  m  m,  g^  f%  (Mi 
and  the  two  thus  resemble  a  cofiFee-bean  or  a  French  'S'  'S'  ^  fl  f| 
roll.    Occurring  thus  in  pairs,  they  lie  close  together,   ,.     >,  ^        ^■^■^, 

.  o  ,i.'.Y  fe^'    Morphology  of  the  gono- 

their  liattened  surfaces  being  m  close  coaptation  and  coccus  (after  Bumm). 
their  outer  margins  convex.  Between  each  coccus 
is  a  very  narrow  split  which  shows  as  a  bright  line.  In  these  particulars 
the  gonococcus  resembles  other  diplococci.  In  its  multiplication  this 
diplococcus  divides  by  a  transverse  cleavage  or  at  right  angles  to  the 
median  fissure.  By  this  means  of  fission  each  pair  of  the  diplococcus 
is  converted  into  four  diplococci,  which  are  grouped  in  fours.  The 
mode  of  division  is  schematically  pictured  in  Fig.  32.  Beginning  at 
the  left  hand  of  the  figure,  the  line  of  cleavage  is  shown  to  be  more 
and  more  distinct  until  the  full  development  is  reached,  as  pictured  in 
the  right-hand  figure.  In  this  way  these  micro-organisms  increase  and 
multiply.  Other  diplococci,  however,  develop  in  a  similar  manner. 
From  this  method  of  transverse  fission  and  growth  originates  the  pecu- 
liar grouping  of  the  gonococcus  into  twos  and  fours  and  their  multiple 
derivatives.  It  must  be  remembered,  however,  that,  owing  to  their 
rapidity  of  growth,  we  sometimes  see  these  cocci  of  varying  sizes,  and 
not  infrequently  the  halves  are  not  quite  symmetrical  in  size. 

In  the  acute  stage  of  gonorrhoea  these  diplococci  are  found  in  greater 
or  less  number  encapsulated  in  masses  within  the  pus-cell.  When  numer- 
ous and  thus  seated  they  have  been  said  to  present  the  appearance  of  a 
swarm  of  bees.  Under  rather  low  powers  they  look  like  little  particles 
of  gunpowder.  They  may  be  so  numerous  within  a  pus-cell  as  to  rup- 
ture its  Avail.  Then  we  find  the  cocci  lying  free  in  the  serum,  scattered 
in  a  disordered  manner  betAveen  the  pus-cells,  but  even  then  presenting 
the  four  and  multiple-of-four  arrangement.  Early  in  the  infection  gono- 
cocci are  seen  seated  upon  epithelial  cells. 

Under  microscopical  examination  gonococci  are  readily  found  and 
recognized  in  the  pus  of  acute  gonorrhoea.  Then  the  clinical  features 
of  the  infection  and  the  microscopical  picture  of  the  discharge  and  its 
pus,  epithelium,  if  present,  and  diplococci,  taken  together,  are  so  striking 
and  unvarying  that  a  mistake  can  scarcely  occur.  But  in  later  stages 
of  true  gonorrhoea,  and  in  many  more  or  less  subacute  cases  of  urethral 

^  In  unstained  preparations  the  gonococcus  looks  like  a  minute  roundish  body,  which 
may  be  distinguished  from  the  surrounding  cells  and  their  nuclei  by  a  peculiar  clear 
pearl-like  sheen  and  its  quick  rotatory  motion. 


58  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

suppuration,  it  is  very  often  most  difficult,  and  sometimes  impossible,  to 
say  whether  the  microbe  is  the  gonococcus  or  some  other  form  of  diplo- 
coccus.  In  many  cases  the  crucial  test  rests  in  cultivations  and  inocu- 
lations. 

While,  however,  there  is  no  single  individual  sign  or  mode  of  distinc- 
tion of  the  gonococcus,  there  are  a  number  of  signs  which,  when  taken 
together,  offer  strong  presumptive  evidence  that  the  microbe  in  question 
is  the  one  just  named.     These,  as  given  by  Neisser  and  others,  are — 

1.  The  shape,  which  is,  as  we  have  seen,  roundly  oval,  with  its  median 
fissure  and  its  roll-like  or  coffee-bean  appearance,  and  its  lengthwise 
fissure.  Still,  as  Bumm  says,  many  pathogenic  and  non-pathogenic  dip- 
lococci  resemble  the  gonococcus  very  closely,  even  to  the  very  fine  point 
only  made  out  by  high  powers — namely,  a  slight  indentation  which  is 
sometimes  seen  in  the  contiguous  surfaces  of  both  hemispheres. 

2.  The  size :  they  are  large  diplococci,  and  in  their  development  are 
variable  and  resemble  other  diplococci. 

3.  The  grouping,  as  a  result  of  their  mode  of  division,  is  in  single 
pairs,  in  fours,  eights,  sixteens,  etc.     They  never  occur  in  chains. 

4.  Their  intracellular  position :  the  gonococci  are  found  in  heaps 
within  the  protoplasm  of  the  pus-cells,  and  also  scattered  between  the 
cells  in  varying  numbers.  Other  diplococci,  however,  are  also  found 
within  the  pus-cell.  Steinschneider  ^  emphasizes  the  fact  that  this  dispo- 
sition in  heaps  of  other  diplococci  is  so  irregular  and  different  from  that 
assumed  by  the  gonococcus  that  a  mistake  is  impossible. 

5.  Their  staining  properties  :  gonococci  are  readily  stained  by  aniline 
colors,  and  they  readily  lose  their  staining  by  Gram-Roux's^  method. 
This  quality  is  very  characteristic  of  the  gonococcus,  but  it  is  also  pos- 
sessed by  certain  other  diplococci,  by  streptococci,  and  by  staphylococci. 
Neisser  ^  himself  concedes  this  point,  and  says  the  intracellular  disposition 
of  diplococci  is  nearly  an  exclusive  property  of  the  gonococcus. 

In  this  connection  it  must  be  remembered  that  Legrain,  Bockhart, 
Zeissl,  Eraud,  and  Hugounenq  and  Hogge  have  found  diplococci  in  masses 
within  the  cells  in  specimens  of  urethral  secretions.  Consequently,  the 
student  must  be  cautious  in  drawing  conclusions.  The  intracellular 
grouping  of  micro-organisms  in  other  than  urethral  pus  has  been  found 
by  many  observers. 

The  truth  of  the  matter  is  this :  that  while  in  the  secretion  of  florid 
gonorrhoea  it  is  easy  to  recognize  the  gonococcus,  it  is  very  difficult  in 
chronic  and  subacute  cases  even  for  skilled  and  experienced  persons  to 
say  that  a  given  coccus  is  the  gonococcus  from  microscopic  study  alone. 
In  such  cases,  to  be  absolutely  positive,  cultures  must  be  made.  It  follows 
from  this  that  we  should  not  accept  most  of  the  statements  made  of  the 
discovery  of  the  gonococcus  in  chronic  urethral  affections. 

Methods  of  Staining-. — For  general  purposes  a  solution  of  methyl 
blue  is  all  that  is  needed  for  staining  gonococci,  but  fuchsine,  methyl 
violet,  gentian  violet,  and  victoria  blue  may  be  used.  The  technique  is 
as  follows :  Spread  by  means  of  a  platinum-wire  loop  some  of  the  pus, 
threads,  or  secretion  ^  on  a  cover-glass  in  a  very  thin  film,  or  place  a  drop 

^  Vide  infra.  ^  Vide  infra.  ^  Vide  infra. 

*  Neisser  and  Finger  recommend,  when  the  secretion  is  very  scanty,  that  an  injection 
of  sublimate,  1  :  10,000,  or  of  nitrate  of  silver,  1 :  2000,  shall  be  made  in  order  to  produce 


THE  GONOCOCCUS.  59 

of  the  secretion  in  the  centre  of  a  cover-glass,  and  then  place  another 
cover-glass  over  this.  Then  separate  the  two  by  sliding  them  over  each 
other,  not  by  pulling  them  apart.  In  this  way  two  evenly-spread  speci- 
mens are  obtained.  It  is  always  necessary  to  thoroughly  wash  the  glans 
penis  and  the  meatus  before  taking  the  secretion,  since  many  microbes  are 
seated  on  these  parts.  In  taking  secretions  from  the  female  genitals  scru- 
pulous care  should  be  exercised,  so  that  no  extraneous  or  accidental  micro- 
organisms are  gathered  up.  In  dispensary  work  the  secretion  from  the 
male  urethra  may  be  allowed  to  drop  upon  a  glass  slide,  and  it  is  then  to 
be  spread  out  over  its  surface  by  drawing  the  edge  of  a  similar  slide  over 
it.  The  specimen  may  be  allowed  to  dry  in  the  air  or  it  may  be  passed 
two  or  three  times  (the  right  side  up)  through  an  alcohol  or  gas  flame. 
The  dried  secretion  is  then  lightly  smeared  with  the  staining  fluid  by 
means  of  a  glass  rod. 

The  simplest  and  most  expeditious  method  of  staining  these  specimens 
is  to  put  a  drop  of  a  dilute  watery  solution  of  methyl  blue  upon  the  cover- 
glass,  allow  it  to  remain  two  or  three  minutes,  wash  off  with  water,  and 
then  examine  in  water.  This  may  be  allowed  to  dry,  and  then  it  may  be 
mounted  in  Canada  balsam.  By  this  method,  however,  the  gonococci  are 
not  shoAvn  so  clearly  as  by  others  to  be  mentioned. 

One  of  the  most  satisfactory  and  rapid  methods  of  examination  is  that 
recommended  by  Schiitz.^  This  is  founded  on  the  resistance  of  the  gono- 
coccus  to  acetic  acid  after  being  stained  with  methyl  blue.  After  the 
cover-glass  is  covered  with  a  thin  film  of  the  suspected  material  it  is 
passed  three  times  through  the  flame.  It  is  then  brought  in  contact  with 
a  saturated  solution  of  methyl  blue  in  5  per  cent,  carbolic-acid  water  for 
five  or  ten  minutes.  It  is  then  washed  with  water  and  placed,  for  a  time 
long  enough  to  count  one,  two,  three  slowly,  in  a  solution  of  five  drops  of 
acetic  acid  in  twenty  cubic  centimetres  of  distilled  water,  and  immediately 
washed  again  in  pure  water.  Everything  is  then  decolorized  except  the 
gonococci,  which  remain  distinctly  blue.  The  specimen  may  be  then 
examined  and  preserved,  or  at  this  stage  it  may  be  double  stained  with  a 
very  dilute  aqueous  solution  of  safranine.  This  second  staining  should 
be  very  slight,  the  cover-glass  being  washed  at  once  in  pure  water.  By 
this  process  the  gonococci  will  be  found  of  a  deep-blue  color,  the  epithelial 
cells  of  the  same  color,  while  the  pus-cells  and  their  nuclei  will  be  salmon- 
colored. 

Lanz  ^  proposes  the  following  method  of  staining,  which  makes  the 
detection  of  the  gonococcus  very  easy :  The  cover-glass  smeared  with  the 
gonorrhoeal  pus  is  dipped  for  half  a  minute  in  a  20  per  cent,  solution  of 
trichloracetic  acid,  then  washed,  and  dried  by  means  of  filtering-paper, 
then  gently  heated  in  an  alcohol  flame.  It  is  then  dipped  in  a  solution 
of  methyl  blue  for  from  two  to  five  minutes,  dried,  and  mounted  in  Canada 
balsam.  Double  coloration  may  be  obtained  by  eosin  staining.  The 
gonococci  are  stained  a  deep  blue,  in  marked  contrast  with  the  pale-blue 

a  decided  discharge.  This  procedure  may  be  practicable  in  hospitals,  but  it  should  not 
be  employed  in  private  practice,  unless  with  the  full  understanding  and  consent  of  the 
patient. 

^  "  Ein  Beitrag  zum  Nachweise  der  Gonococcen,"  Miinchen  mecl.  Wochenschrift,  xxxvi., 
No.  14,  1889. 

2  Beut.  med.  Wochenschrift,  1894,  No.  20,  p.  200. 


60  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

color  of  the  rest  of  the  celL  The  acid  renders  the  cell  and  its  nuclei 
transparent,  and  by  this  procedure  the  microbes  may  be  seen  in  the  sub- 
stance of  the  nuclei. 

Frankel's  ^  method  may  also  be  used.  This  consists  in  treating  the 
cover-glass  preparation  for  a  few  minutes  with  a  concentrated  alcoholic 
solution  of  eosin  (by  heating  the  staining  fluid).  The  surplus  of  the  dye 
is  absorbed  with  blotting-paper ;  the  specimen  is  at  once  placed  in  a  con- 
centrated alcoholic  methyl-blue  solution  (for  fifteen  seconds  at  most),  and 
then  it  is  to  be  washed  in  water.  The  cocci  will  appear  blue  on  a  red 
ground.  The  cellular  elements  of  the  blood  and  pus  have  absorbed  the 
eosin,  while  the  nuclei  and  micro-organisms  are  colored  blue. 

All  these  specimens  when  dried  may  be  preserved  in  Canada  balsam. 

Much  study  has  been,  and  is  being,  expended  upon  the  perfection  of 
such  means  of  coloring  gonococci  that  their  distinctions  shall  be  clearly 
and  absolutely  made  out.  Many  observers,  particularly  those  of  the 
Neisser  school,  place  great,  almost  implicit,  confidence  in  the  process 
known  as  the  Gram-Roux  ^  method.  The  procedure  is  as  follows ; 
Having  dried  the  specimen,  it  is  stained  with  methyl  blue  or  gentian 
violet;  then  it  is  submitted  for  two  or  three  minutes  to  the  action  of 
Gram's  solution  (iodine  1  part,  iodide  of  potassium  2  parts,  water  100  parts), 
which  possesses  the  property  of  fixing  the  aniline  colors  exclusively  on 
the  microbes,  and  not  on  the  anatomical  elements.  Then  the  specimen 
is  decolorized  in  absolute  alcohol,  washed  in  distilled  water,  and  then 
recolored  with  eosin.  The  micro-organisms  then  stand  out  again  clearly 
in  blue  or  in  violet,  while  the  epithelial  cells  or  leucocytes  offer  a  rose- 
colored  background.  Roux  says  that  he  learned  by  experiments  that 
Gram's  liquid  does  not  sufiiciently  and  firmly  fix  the  basic  aniline  colors 
in  gonococci,  but  that  as  soon  as  the  specimen  is  treated  with  absolute 
alcohol  these  cocci  and  the  anatomical  elements  become  very  difiicult  to 
recognize  with  the  microscope.  This  negative  fact  therefore  constitutes 
an  element  of  diagnosis,  since  other  micro-organisms  do  not  thus  become 
decolorized.  He  claims,  therefore,  that  when  the  presence  of  gonococci 
is  shown  by  aniline  dyes  and  upon  the  addition  of  Gram's  liquid  and 
alcohol  they  disappear,  it  is  certain  that  Neisser's  coccus  is  present.  On 
the  other  hand,  if  the  micro-organisms  remain  stained,  it  is  in  all  prob- 
ability not  the  gonococcus. 

This  method,  however,  when  put  to  the  crucial  test,  has  been  shown 
to  be  in  a  measure  fallible.  Lustgarten  and  Mannaberg,  as  we  shall 
see,  claim  that  one  or  several  species  of  diplococci  are  found  in  the  nor- 
mal urethra  which  completely  resemble  the  gonococcus  in  shape  and 
tinctorial  qualities,  especially  in  being  decolorized  by  Gram's  method. 
Steinschneider,^  Neisser's  disciple,  admits  that  Roux's  method  gives 
absolute  results  in  about  95  per  cent,  of  cases.     In  the  remaining  5  per 

1  Text-hook  of  Bacteriology,  p.  330,  New  York,  1891. 

'^  "Precede  technique  de  Diagnose  des  Gonococcus,"  Annales  des  Maladies  des  Org. 
Gen.-urin.,  1887,  p.  56. 

*  It  is  well  to  emphasize  the  fact,  brought  out  by  Hogge  {vide  infra),  that  out  of  the  86 
cases  examined  by  Steinschneider  only  28  were  those  of  chronic  gonorrha?a,  and  it  is  in 
these  that  mixed  and  saprophytic  infections  are  most  commonly  foimd.  The  reader  is 
referred  to  Hogge's  paper  for  some  sensible  critical  remarks  as  to  the  possibility  of 
errors  in  the  various  modifications  used  in  the  Gram-Koux  method.  If  his  suggestions 
are  followed,  the  results  will  certainlv  be  more  accurate. 


THE  GONOCOCCUS.  61 

cent.,  however,  the  diplococci  resembling  gonococci  have,  he  claims,  such 
a  markedly  different  arrangement  and  distribution  that  their  recognition 
is  easy.  Steinschneider  says  that  in  doubtful  cases  after  the  decolorizing 
process  he  stains  the  specimens  with  Bismarck  brown.  Then  "  at  once 
we  got  the  remarkable  results  that  in  all  cases  in  which  there  was  no  acute 
or  chronic  gonorrhoea  present  there  were  among  the  brown-stained  ana- 
tomical elements  only  few  bacteria,  few  diplococci,  especially,  which  were 
distinguished  by  the  dark-brown  staining.  If  gonorrhoea  was  present, 
there  Avere  found  clusters  or  individual  pairs  of  gonococci  which  had  the 
same  color  as  the  cells.  Never  did  these  diplococci  which  did  not  lose 
Gram's  staining  show  the  well-known  disposition  of  gonococci.  If  they 
lay  in  heaps,  which  was  rare,  their  disposition  was  so  irregular  and  so 
different  from  that  of  the  gonococci  that  confusion  was  impossible."  It 
will  be  seen  from  the  foregoing  that,  after  all,  the  staining  process  as  a 
means  of  diagnosticating  the  gonococcus  is  liable  to  lead  to  error  in  a 
goodly  proportion  of  cases.  No  trouble  will  be  experienced  in  studying 
the  secretion  of  acute  gonorrhoea  even  when  some  weeks  old.  But  the 
doubt  comes  in  in  subacute  and  chronic  cases,  just  the  ones  in  which  we 
are  anxious  to  determine  whether  the  long-drawn-out  inflammation  is 
really  kept  up  by  the  gonococcus,  and  whether  this  micro-organism  has, 
as  it  is  claimed  it  has,  an  indefinite  life  as  a  morbific  agent  in  the  male 
urethra. 

It  will  be  readily  seen  that  these  bacteriological  studies  of  urethral 
secretions  are  very  dif&cult,  intricate,  and  attended  at  every  step  Avith 
liability  to  doubt,  confusion,  and  error ;  consequently,  skepticism  and 
conservatism  are  warranted,  indeed  are  essential,  even  in  the  presence 
of  statements  made  by  experienced  and  skilled  observers. 

The  consensus  of  opinion  of  the  most  eminent  investigators  of  this 
subject  is  that  from  cultures  alone  can  we  get  absolutely  correct  know- 
ledge of  the  character  and  identity  of  micro-organisms.  In  this  way  the 
gonococcus  can  be  demonstrated  without  any  trouble,  and  confirmation 
of  its  existence  may  be  obtained  (if  a  consenting  case  can  be  found)  in 
experimental  inoculations  on  the  male  or  female  urethra.  It  must  be 
borne  in  mind  that  the  mucous  membranes  of  most  animals  are  immune 
to  the  virulent  action  of  the  gonococcus,  but  the  urethra  of  the  dog  can 
be  infected  with  cultures  made  in  an  acid  medium. 

This  micro-organism  outside  of  the  human  body  has  little  vitality. 
Its  culture  media  are  blood-serum,  and  blood-serum  and  agar-agar,  and 
urine  and  urea,  in  acid  solution.  As  we  shall  see,  Bumm  had  much 
trouble  in  cultivating  the  gonococcus,  but  Wertheim  has  lately  simplified 
the  matter  by  using  human  blood-serum  with  agar-agar  on  plates. 
Further  than  this,  Ghon  and  Schlagenhaufer  ^  have  simplified  the  method 
by  spreading  a  drop  of  human  blood  over  the  surface  of  the  agar  plate. 

My  advice  to  any  one  desiring  to  familiarize  himself  with  the  biology 
and  morphological  characters  and  nature  of  the  gonococcus,  and  of  other 
micro-organisms  of  the  male  and  female  genitals,  is  to  study  the  subject 
practically  in  a  pathological  laboratory. 

The  other  micro-organisms  which  can,  under  favorable  circumstances, 
produce  urethral  suppuration  are  some  varieties  of  the  staphylococci  and 
streptococci,  as  claimed  by  Bockhart. 

^  Wiener  klin.  Wochenschrift,  No.  39,  Aug.  24,  1893. 


62  GONOBBHCEA  AND  ITS  C03IPLICATI0NS. 

Our  knowledge  of  the  morphological  character,  life-history,  habitat, 
and  pathogenic  influence  of  these  micro-organisms  is,  as  yet,  very  slight 
indeed.  It  will  require  much  time,  skill,  and  patience  on  the  part  of 
many  investigators  to  place  this  subject  on  a  satisfactory  and  scientific 
basis. 


CHAPTER   IV. 

THE  PATHOGENIC  ACTION  OF  THE  GONOCOCCUS. 

The  experimental  inoculations  upon  the  human  urethra  by  Bumm, 
Wertheim,  Aufuso,  and  Finger  with  the  cultures  of  the  gonococcus  have 
clearly  demonstrated  the  virulent  action  of  that  diplococcus.  Let  us  now 
study  clinically  this  microbic  invasion  of  the  urethra  and  systematically 
examine  the  secretion  in  the  earliest  days  of  the  infection.  As  is  shown 
in  another  chapter  (p.  107),  gonorrhoea,  like  all  virulent  processes,  has  a 
period  of  incubation  of  varying  length,  its  shortest  being  two  days  and 
its  longest  fourteen  days,  though  even  longer  periods  are  claimed.  In  the 
light  of  clinical  study  alone  it  was  difiicult  to  understand  why  one  man's 
gonorrhoea  began  two  days  after  coitus,  while  that  of  others'  came  on  three, 
five,  and  on  intervening  days  up  to  the  fourteenth.  It  is  very  probable 
that  certain  unknown  conditions  inherent  to  the  tissues  of  the  penis  pre- 
dispose a  patient  to  gonorrhoeal  infection,  just  as  we  see  some  persons 
prone  to  tonsillar,  pharyngeal,  bronchial,  and  pulmonary  inflammations 
and  to  infectious  processes  of  the  skin.  Then,  again,  the  structure  and 
conformation  of  the  organ  may  present  conditions  of  predisposition. 
(See  chapter  on  Predisposing  Conditions,  etc.)  Microscopical  study,  how- 
ever, further  shows  that  the  number  of  the  gonococci  seems  to  be  an  ele- 
ment in  their  virulence,  and  that  acuteness  of  invasion  may  depend  on 
the  quantitative  rather  than  the  qualitative  element  of  the  gonococcus. 
It  is  possible,  however,  that  at  certain  times  and  under  unknown  con- 
ditions the  virulence  of  the  micro-organism  is  more  or  less  active.  The 
duration  of  exposure  to  the  infecting  secretion  in  prolonged  coitus,  with 
much  alcoholic  indulgence,  has  undoubtedly  much  to  do  in  many  cases 
with  the  acuteness  and  severity  of  the  attack. 

When  in  coitus  the  gonococci  are  deposited  in  the  urethra  or  on  the 
lips  of  the  meatus,  they  immediately  begin  to  proliferate,  and  in  due  time 
give  rise  to  a  scant  serous  secretion.  Clinical  and  microscopical  study 
shows  that  diff"erent  individuals  are  afi"ected  in  different  ways.  In  some 
the  attack,  as  shown  by  the  discharge,  comes  on  briskly  and  promptly, 
while  in  others  the  morbid  process  develops  slowly  and  insidiously,  and 
often  with  much  halting.  In  the  very  earliest  period  of  gonorrhoea  much 
can  be  learned  as  to  the  mode  of  invasion  of  the  disease,  and  as  to  the 
pathological  conditions  in  a  given  case,  by  the  microscopic  examination 


THE  PATHOGENIC  ACTION  OF  THE  GONOCOCCUS.  63 

of  the  secretion.  This  scientific  examination  should  be  made  in  every 
case,  since  from  its  results  indications  of  a  practical  nature  may  be 
derived.  Not  only  in  the  very  earliest  stage  does  the  microscope  give 
much  aid  and  broad  enlightenment  in  pathology  and  treatment,  but 
throughout  the  whole  course  of  gonorrhoea  its  teachings  are  invaluable. 

As  will  be  shown  farther  on,  the  number  of  gonococci  in  the  serous 
discharge  of  the  first  day  or  two  shows  very  great  differences  in  individual 
cases.  In  some  periods,  the  earlier  as  a  rule,  there  are  enormous  numbers 
of  gonococci  in  the  discharge,  while  during  the  latter  stages  of  the  attack 
there  are  frequently  so  few  of  them  that  but  one  or  two  pus-cells  can  be 
found  in  the  entire  field  containing  gonococci.  So  a  drop  of  discharge  at 
one  stage  of  the  attack  may  contain,  estimating  it  roughly,  but  two  or 
three  or  several  hundred  gonococci,  while  at  another  time  the  drop  holds 
enormous  quantities  of  the  cocci — a  million  or  more.  A  glance  at  Figs. 
35  and  36  will  illustrate  this  numerical  difference  of  the  cocci  in  two  dif- 
ferent specimens  of  gonorrhceal  discharge. 

Thus  when  gonorrhoea  is  contracted,  as  a  result  either  of  the  duration 
of  the  exposure  to  the  infecting  pus  or  according  to  the  stage  of  develop- 
ment of  discharge  in  the  donor,  the  number  of  gonococci  received  may 
vary  within  very  wide  limits.  This  numerical  variability,  then,  in  the 
gonococci  seems  in  a  measure  to  determine  the  period  of  incubation  and 
the  character  of  the  onset  of  the  discharge.  The  vulnerability  of  the 
tissues  and  the  conditions  favorable  to  inflammation  also  have  much  to  do 
with  the  promptitude  of  the  onset  of  the  inflammation. 

In  some  cases,  where  a  very  few  gonococci  embodied  in  the  pus-cells  are 
received,  the  discharge  does  not  become  visible  for  some  days,  although 
during  this  time  there  is  an  exudation,  but  it  is  so  scanty  and  colorless 
that  it  escapes  attention.  In  such  a  case  as  this  it  would  seem  that  so 
few  gonococci  entered  the  urethra  that  some  days  are  requisite  for  them 
to  proliferate  extensively  enough  to  produce  a  widespread  chemotaxis  or 
attraction  of  the  leucocytes  from  the  blood-vessels  of  the  urethral  mucosa, 
or  that  the  tissues  were  not  particularly  vulnerable.  After  the  gonococci 
have  proliferated  and  become  more  extensively  distributed  over  the  ure- 
thra, a  widely-spread  and  severe  exudative  inflammation  of  the  urethra 
takes  place  more  or  less  suddenly.  An  attack  of  gonorrhoea  would  be 
liable  to  begin  in  this  slow,  mild  way  if  the  infection  originated  from  a- 
similar  discharge,  such  as  fairly  old  gleet  or  declining  gonorrhoea,  in  which 
it  takes  considerable  searching  with  the  microscope  to  find  a  pus-cell  here 
and  there  containing  gonococci. 

In  other  cases  a  severe  discharge,  muco-purulent  from  the  beginning, 
occurs  suddenly  within  forty-eight  or  seventy-two  hours  after  the  exposure. 
In  such  a  case  as  this  we  may  suppose  that  a  very  large  number  of  gono- 
cocci enter  the  urethra  and  proliferate  extensively.  The  initial  cocci  are 
not  localized,  but  become  rapidly  distributed — perhaps  at  the  exposure — 
over  a  large  surface  of  the  urethra,  and  exert  chemotaxis,  or,  in  other 
words,  produce  inflammation  simultaneously  at  many  points  over  a  large 
segment  of  the  urethra.  A  glance  at  Fig.  37  will  show  how  the  great 
numbers  of  gonococci  swimming  about  free  in  the  serum  would  be  dis- 
tributed almost  immediately  over  a  large  tract  of  the  urethra  in  virtue 
of  its  capillary  attraction,  from  before  backward,  if  a  portion  of  such  a 
discharge  entered  the  meatus. 


64  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

Between  these  two  extreme  types  of  acute  and  mild  invasion  there  are 
all  sorts  of  intermediate  grades  of  the  incubation. 

Sloiv  Invasioji. — In  the  cases  of  long  incubation — where  there  seem 
to  be  but  few  gonococci  received  at  the  infection,  and  that  these  remain 
localized  for  a  few  days  before  proliferating  extensively  enough  to  spread 
over  a  considerable  part  of  the  urethra,  an  exudation  really  exists  during 
the  whole  period  of  the  incubation.  This  exudation  in  the  beginning  is 
almost  a  microscopic  element ;  it  is  exceedingly  limited  and  serous,  and 
so  generally  escapes  attention  that  there  is  seldom  an  opportunity  to  exam- 
ine it  microscopically.  After  two  or  three  or  several  days  this  scanty 
serous  exudation,  becoming  gradually  more  copious,  suddenly  changes  and 
becomes  a  purulent  discharge.  This  sudden  change  indicates  the  period 
when  the  gonococci  have  proliferated  and  become  extensively  enough  dis- 
tributed to  excite  general  chemotaxis.  (Compare  the  increase  of  the 
gonococci  in  Figs.  33  and  34.) 

In  the  very  beginning  of  the  prodromal  or  exudation  stage  ante- 
cedent to  the  onset  of  the  purulent  discharge  in  these  cases  of  slow  incu- 
bation there  is  simply  a  thin  or  sticky  moisture  of  the  walls  of  the  urethra. 
In  a  day  or  two  more  the  exudation  grows  more  material  and  a  trans- 
parent drop  the  size  of  two  or  three  pin-heads  may  be  forced  out  of  the 
meatus  by  gentle  pressure.  The  exudation  may  in  exceptional  cases  stay 
this  way  for  a  week.  Although  this  exudation  is  not  seen  during  the 
day,  it  appears  in  the  first  part  of  the  urine  as  scanty  lump-like  masses. 
The  discharge  is  best  seen  in  the  morning,  and  it  then  looks  very  much 
like  glycerin,  except  that  suspended  in  the  drop  are  some  minute  trans- 
lucent and  whitish  flocculi,  like  tiny  particles  of  rice-seeds  or  suet.     A 

Fig.  33. 


Gonorrhceal  discharge  in  the  early  da%s  of  infection  in  a  ease  of  long  incubation,  showing  pave- 
ment epithelial  clIK  on  -which  a  few  gonococci  are  seated,  and  a  few  pus-cells  which  as  yet 
contain  no  gonococci 

little  later  the  drop  becomes  more  copious,  appears  during  the  day,  and 
is  streaked  with  whitish-yellow  streaks ;  then,  perhaps  in  a  few  hours  or 
within  a  day,  the  drop  may  change  suddenly  and  radically,  when  it  be- 
comes entirely  yellow  and  creamy,  thick  and  copious,  and  takes  on  the 
characteristics  of  the  ordinary  purulent  discharge. 

The   structural  features  of  the   discharge   in   this   early  stage   of  its 
development  in  these  cases  of  long  incubation  are  as  follows :  The  exuda- 


THE  PATHOGENIC  ACTION  OF  THE  GONOCOCCUS. 


65 


tion  consists  largely  of  fluid  or  serum  containing  some  desquamated  epi- 
thelial cells,  and  later  on  only  a  scattered  pus-cell  here  and  there.  In 
the  early  stages  the  desquamated  epithelial  cells  predominate,  and  as  the 


Fig.  34. 


Showing  the  features  of  the  discharge  a  few  days  later  than  are  shown  in  Fig.  33.  The  epithelial 
cells  are  covered  by  an  increased  number  of  gouococci,  but  these  microbes  are  not  as  yet  con- 
tained in  the  substance  of  the  pus-cells,  which  are  rather  more  numerous. 


exudation  progresses  the  pus-cells   become  more  numerous.     (Compare 
Figs.  33  and  34.) ' 

It  is  the  desquamated  clusters  of  the  cells  lining  the  urethra  that 
produce  the  appearance  of  the  rice-like  or  suet-like  granules  in  the  clear 
drop.  Finally,  when  the  drop  suddenly  becomes  yellow,  the  epithelial 
cells  disappear  almost  entirely  or  are  overshadowed  by  the  enormous  num- 
bers of  pus-cells. 

^  The  case  which  furnished  Figs.  33,  34,  and  35  is  extremely  interesting  and  merits 
a  brief  recital :  Four  days  after  a  short  and  incomplete  coitus  the  patient  noticed  a  slight 
moisture,  with  some  translucent  particles,  at  the  meatus.  This  condition  continued  un- 
changed for  seven  days  (the  eleventh  day  after  exposure),  Avhen  the  secretion  amounted 
to  a  small  drop  in  the  morning,  and  was  perfectly  clear  and  contained  rice-like  particles. 
A  specimen  taken  at  this  time  presented  under  the  microscope  the  appearances  shoAvn  in 
Fig.  33.  There  we  see  a  few  cocci  at  the  edge  of  an  epithelial  cell,  but  none  in  the  few 
pus-cells  present.  Eight  days  after  this  (the  nineteenth  of  the  exposure)  a  slide  taken 
presented  the  appearances  shown  in  Fig.  34.  It  will  be  seen  that  tlie  gonococci  are  much 
more  numerous,  and  that  they  are  seated  on  the  epithelial  cells  and  at  their  edges.  They 
are  not  contained  in  the  pus-cells.  Eight  days  later  the  gonococci  were  found  in  the  pus- 
cells  and  the  epitlieliura  liad  disappeared.  In  Fig.  33  tliere  were  only  eiglit  gonococci, 
and  they  were  floating  free  in  the  serum.  In  Fig.  34,  taken  eight  days  later,  they  were 
more  numerous,  and  in  Fig.  35,  taken  eight  days  later,  we  see  a  cliaracteristic  picture  of 
confirmed  acute  gonorrhoea.  In  this  case,  therefore,  the  incubation  period  was  four  days 
and  tlie  duration  of  the  prodromal  stage,  or  stage  of  microbic  colonization,  was  twenty -seven 
days — a  most  unusual  occurrence.  In  all  probability  the  small  number  of  the  micro- 
organisms received  in  coitus  was  the  factor  in  the  slow  evolution  of  the  disease.  Perhaps 
the  existence  of  pavement  epithelium  in  the  fossa  navicularis  offered  a  barrier  to  the  inva- 
sion of  the  cocci.  This  patient  had  recovered  from  gonorrhoea  seven  months  before  the 
present  infection. 


66 


GONOBBHCEA  AND  ITS  COMPLICATIONS. 


The  gonococci  in  this  stage  of  scanty  exudation,  before  the  regular 
discharge,  may  not  be  found  at  all  by  the  ordinary  cover-glass  staining 


Fig.  35. 


Shows  the  features  of  the  discharge  in  confirmed  acute  gonorrhoea,  the  initial  and  preparatory- 
conditions  of  the  case  being  shown  in  Figs.  33  and  34.  The  epithelium  has  wholly  disappeared, 
and  only  pus-cells  containing  many  gonococci  now  appear  in  the  field. 

tests.     If  the  incubation  is  very  slow,  they  may  be  found  at  first  in  very 
limited  numbers,  entirely  free  in  the  serous  fluid,  later  on  about  the  edges 

Fig.  36. 


Gonorrhceal  discharge  obtained  a  few  hours  after  onset  of  disease,  containing  cylindrical  epithe- 
lium, pus-cells,  and  gonococci. 

or  on  the  surface  of  the  epithelial  cells,  and  finally  exclusively  in  the 
pus-cells.  It  is  very  interesting  to  study  the  spreading  of  the  gonococci 
over  the  surface  of  the  cell.  At  first  the  micro-organisms  may  be  seen 
only  on  the  edges  of  the  cell ;  then  they  gradually  extend  until  they 
cover  its  whole  surface,  perhaps  in  several  hours  or  perhaps  in  a  day 
or  two.     (See  Figs.  33  and  34.) 

It  is  important  to  remember  that  when  the  discharge  consists  only  of 
serum,  epithelial  cells,  and  gonococci,  the  latter  are  seated  on  the  cells  and 
they  also  float  free  in  the  serum.  This  condition  also  may  be  observed 
where  a  few  pus-corpuscles  have  become  mixed  in  the  discharge.  At  this 
time,  therefore,  the  micro-organisms  may  be  present  only  in  small  numbers 
in  the  pus-cells,  or  they  may  not  be  thus  placed  at  all.  Later  on,  when 
the  discharge  becomes  decidedly  purulent,  the  majority  of  the  gonococci 


THE  PATHOGENIC  ACTION  OF  THE  GONOCOCCUS.  67 

will  be  found  in  the  pus-cells,  and  very  few  will  be  free  and  scattered 
through  the  serous  fluid. 

The  behavior  of  gonococci  in  a  case  of  long  incubation  seems  to  be 
somewhat  as  follows :  The  gonococci  received  at  infection  are  too  few  to 
be  generally  distributed  over  the  urethra,  and  hence  the  chemotaxis  they 

Fig.  37. 


Showing  enormous  quantities  of  gonococci  in  pus-cells  and  floating  free. 

arouse  is  too  limited  to  appear  as  any  appreciable  exudation.  The  cocci 
seem  at  first  to  lie  free  on  the  surface  of  the  epithelium,  and  then  they 
work  their  way  down  between  the  surface  cells  to  the  deepest  layer  of 
urethral  lining  cells.  As  the  gonococci  thus  approach  the  capillaries 
beneath  the  epithelium,  chemotaxis  comes  into  play.  There  is  at  first 
a  slight  determination  of  leucocytes  from  the  blood-vessels,  accompanied 
by  some  serum  Avhich  passes  out  into  the  urethra,  and  synchronously  with 
this  there  is  a  desquamation  of  the  epithelium  lining  the  urethra. 

As  the  gonococci  become  more  and  more  numerous  and  are  distributed 
to  the  deeper  parts  of  the  urethra  in  virtue  of  its  capillary  attraction,  there 
comes  a  time  when  these  microbes  attract  the  leucocytes  from  a  consider- 
able territory  of  the  canal  simultaneously,  and  this  corresponds  to  the 
time  when  the  discharge  suddenly  becomes  purulent  and  abundant,  with 
the  gonococci  enclosed  in  the  pus-cell.     (See  Fig.  35.) 

The  gonococci  are  found  in  the  pus-cells,  not  because  the  cocci  them- 
selves actively  penetrate  the  protoplasm,  as  has  been  erroneously  stated, 
but  because  the  leucocytes  act  as  phagocytes.  The  leucocytes  enclose 
the  cocci  by  virtue  of  their  amoeboid  properties,  and  carry  them  out  of 
the  urethra  in  the  purulent  discharge.  It  is  the  pus-cell,  in  all  probability, 
which  carries  the  infecting  cocci  from  one  person  to  another,  and  probably 
very  few  individuals  are  infected  by  gonococci  floating  about  free  in  a 
discharge. 

Acute  Invasion. — The  character  and  onset  of  the  cases  of  acute  inva- 
sion may  now  be  considered.  In  these  cases  the  number  of  the  gonococci 
received  at  the  exposure  is  so  large,  their  proliferation  is  so  rapid,  or  they 
become  so  soon  distributed — very  likely  at  the  exposure — over  a  large 
surface  of  the  urethra,  that  the  discharge  may  be  sero-purulent  or  purulent 
from  the  beginning,  and  in  that  case  the  preliminary  scanty  serous  exu- 


68  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

dation  previously  described  is  very  evanescent  or  almost  entirely  absent. 
It  happens  very  seldom  indeed  that  in  these  cases  there  is  an  opportunity 
to  examine  microscopically  the  evanescent  serous  stage  of  such  a  dis- 
charge, but  still  there  is  a  stage  of  desquamation  of  the  urethral  epithe- 
lium in  advance  of  the  purulent  discharge.  This  is  well  shown  in  Fig.  36.^ 
The  desquamated  epithelium  appears  as  tiny  rice-colored  grains  in  a 
clear  exudation,  but  this  stage  of  desquamation  is  very  short  in  these 
acute  cases,  lasting  only  a  few  hours,  and  then  the  discharge  becomes 
purulent.  A  further  illustration  of  very  acute  invasion  with  myriads  of 
gonococci  is  typified  in  Fig.  37.^ 

^  The  case  from  which  Fig.  36  was  taken  illustrates  a  very  early  stage  of  the  discharge 
in  an  attack  of  acute  invasion.  This  patient  had  a  sero-purulent  discharge  from  the 
beginning  apparently  (incubation  four  days),  and  came  under  observation  a  few  hours 
(six  or  eight)  after  hrst  noticing  discharge.  The  case  (see  Fig.  36)  illustrates  especially 
well  how  even  in  acute  cases  there  is  a  desquamation  of  epithelium  from  the  urethra, 
although  it  is  so  transient  in  these  acute  cases  that  it  is  seldom  observed.  In  this  case 
the  urethra  appears  to  have  been  in  the  perfectly  normal  or  virgin  condition,  for  the  sur- 
face epithelial  cells  have  their  proper  cylindrical  shape.  There  are  very  many  gonococci 
in  this  specimen,  a  considerable  number  of  the  pus-cells  being  loaded  with  them.  A  very 
few  scattered  gonococci  were  found  free  in  the  serum  in  groups  of  twos  and  fours. 

In  this  case  the  urethra  was  probably  invaded  by  a  great  number  of  gonococci  at  the 
infection — either  the  man  having  exposed  himself  generously — or  there  were  many  cocci 
in  the  discharge  of  the  donor,  or  perliaps  both  conditions  were  combined.  The  initial 
extensive  number  and  distribution  of  the  cocci  provoked  a  rapid  acute  onset. 

^  Fig.  37  shows  a  very  unusual  feature  in  the  large  numbers  of  free  gonococci  sus- 
pended in  the  liquid  portion  of  the  discharge.  This  figure  was  not  selected  with  a  view 
to  exaggerate  this  feature,  but  is  taken  at  random  from  the  slide,  which  shows  quite  uni- 
formly the  conditions  thus  pictured.  The  case  was  that  of  a  man  who  had  had  gonorrhoea 
seven  years  before.  The  incubation  period  of  the  present  infection  was  five  days.  Two 
of  the  pus-cells  contain  forty-eight  gonococci,  one  of  them  eighteen,  and  the  other  forty- 
eight  gonococci,  while  ninety-eight  gonococci  were  counted  lying  free  in  the  serous  fluid 
of  the  same  field  (Leitz,  oil-immersion,  -^^  ocular,  4-tube,  length  15.5  mm.).  Estimat- 
ing that  one  drop  of  this  fairly  thin  discharge  could  be  spread  in  a  thin  film  over  ten 
cover-glasses  18  mm.  square,  such  a  droji  would  contain,  counting  roughly,  1,038,260  free 
gonococci  and  524,120  gonococci  enclosed  in  pus-cells  ;  and  this,  if  anything,  is  a  very  low 
rather  than  a  high  estimate.  This  gives  a  tangible  idea  of  the  number  of  gonococci 
occurring  sometimes  in  a  discharge.  A  drop  of  exudation,  as  in  this  case,  entering  a 
man's  urethra  would  carr}^  a  little  short  of  two  millions  of  gonococci. 

Apparently  in  this  case  the  gonococci  are  proliferating  in  enormous  numbers  over  the 
surface  of  the  urethra,  and  are  being  distributed  over  the  whole  surface  of  the  anterior, 
if  not  very  soon  into  the  posterior,  part  of  the  canal.  The  specimen  was  taken  from  the 
second  day  of  the  discharge,  and  chemotaxis,  or  the  attraction  of  the  leucocyte  by  the 
gonococci,  has  taken  place  fairly  voluminously,  but  the  proliferation  of  the  bacteria  has 
been  more  rapid  than  that  of  the  white  blood-cells,  which  takes  an  appreciable  amount  of 
time.  Thus  the  leucocytes  have  not  yet  appeared  in  sufficient  numtjers  at  this  particular 
stage  of  the  discharge  to  embody  the  cocci,  so  that  they  are  free  to  pass  to  new  portions  of 
the  urethra.  In  reflecting  over  this  latter  behavior  of  the  gonococcus,  proliferating  faster 
than  the  white  cells  can  embody  them,  and  passing  to  all  parts  of  tlie  urethra,  we  have 
some  sort  of  rational  basis  to  explain  the  different  grades  of  severity  so  well  marked  in 
gonorrhoea. 

It  is  very  seldom  that  just  such  a  picture  as  this,  showing  so  many  free  cocci,  is  ob- 
tained. Most  likely  these  enormous  numbers  of  gonococci  are  rather  a  transient  feature 
of  a  discharge,  for  a  very  extensive  observation  of  gonorrhoeal  discharge,  studied  in  tlie 
light  of  the  doctrine  of  chemotaxis,  shows  that  the  supjjly  of  white  blood-cells  is  so  exces- 
sive in  response  to  the  chemotactic  demand  of  the  gonococci  that  they  are  quite  generally 
engulfed  in  the  body  of  the  leucocyte. 

Probably  in  this  particular  case  a  few  hours  would  have  sufficed  to  bring  out  such  an 
increase  of  leucocytes  that  a  large  majority  of  the  free  gonococci  would  be  enclosed  in  the 
protoplasm  of  the  pus-cells. 

Another  interesting  feature  of  this  case  is  the  way  such  a  discharge  would  act  in  infect- 
ing another  urethra.  If  a  urethra  were  infected  with  such  a  discliarge,  the  resulting 
attack  would  certainly  be  acute  and  severe,  from  the  large  numlier  of  free  gonococci. 
The  urethra  being  endowed  with  a  species  of  capillary  attraction  from  before  backward, 


THE  PATHOGENIC  ACTION  OF  THE  GONOCOCCUS. 


69 


As  a  general  rule,  the  long  incubation  of  gonorrhoea  is  best  marked 
in  cases  where  the  urethra  has  been  the  seat  of,  or  damaged  by,  previous 
attacks,  while  the  very  acute  invasion  often  is  best  exhibited  in  the  virgin 
or  normal  urethra.  In  previous  protracted  or  multiple  gonorrhoeas  there 
is  a  tendency  toward  a  distinct  change  in  the  structure  of  the  urethral 
epithelium.  The  urethral  lining  in  places  becomes  thicker  and  the  sur- 
face cells  become  flattened.  Pavement  epithelium  then  replaces  the 
cylindrical  variety.  To  what  extent  this  change  in  the  urethral  epithe- 
lium determines  the  long  incubation  often  seen  in  patients  who  have  had 
many  previous  gonorrhoeas  is  a  rather  difficult  question  to  decide. 

Having  thus  far  studied  the  nature  of  the  discharge  in  the  very  earliest 
stages  of  both  the  slow  and  acute  invasions,  the  later  and  final  stages  may 
now  be  described. 

The  Purulent  Stage  of  the  Discharge. — When  the  discharge  has 
once  commenced  and  becomes  tangible  and  yellow,  so  that  the  patient 
notices  it,  its  structural  characters  are  very  uniform.  It  consists  almost 
entirely  of  pus-cells  and  serum.  The  pus-cells  of  gonorrhoea  are  larger 
than  those  of  any  other  form  of  suppuration.  Under  the  microscope  with 
a  moderate  power  the  pus-cells  can  be  seen  scattered  all  over  the  field, 
with  no  tendency  whatever  to  agglomeration  or  aggregation.     Occasion- 

FiG.  38. 


Showing  gonococci  in  the  pus-cells  of  acute  gonorrhoea ;  much  magnified. 


ally  in  the  beginning  of  the  purulent  stage  a  number  of  red  blood-cells 
appear,  and  finer  and  coarser  bands  or  sheets  of  fibrin.  Occasionally  also 
a  stray  rounded  or  oval  epithelial  cell  may  be  found  here  and  there.     A 

these  free  gonococci  would  lie  distributed  at  once  over  a  largo  surface,  lighting  ny)  inflam- 
mation at  many  points  simultaneously.  Tlie  older  idea,  tliat  gonorrlui'a  starts  in  at  the 
meatus,  lingers  in  the  fossa  navicularis,  and  then  trails  slowly  backward,  certainly  does 
not  explain  very  well  a  large  number  of  cases,  which  seem  rather  to  show  a  simultaneous 
invasion  of  several  portions  of  the  urethra. 


70  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

certain  proportion  of  tlie  pus-cells — say,  one  to  twenty  or  one  to  fifty — 
contains  from  two  to  fifty  or  eighty  gonococci  enclosed  in  their  cell-bodies. 

There  are  seldom  any  free  gonococci  except  in  the  earlier  stages  of 
the  purulent  period.  This  uniform  structure  of  the  purulent  stage  per- 
sists right  along  until  the  declining  stage,  and  a  good  idea  of  the  micro- 
scopic picture  in  this  stage  is  shown  in  Fig.  35,  and  under  a  higher  power 
in  Fig.  38. 

As  the  purulent  stage  declines  the  secretion  becomes  more  whitish 
from  the  admixture  of  mucus,  and  less  liquid.  Then  it  gradually  grows 
less  in  quantity  and  more  inspissated,  so  that  toward  the  end  of  the  acute 
stage  it  is  not  seen  as  a  secretion,  but  as  little  yellowish-white  clumps  or 
threads  in  the  urine.  Examination  of  the  secretion  of  this  stage  shows 
masses  of  pus-cells  held  together  somewhat  in  thread  form  by  mucus. 
This  condition  is  the  first  step  in  the  formation  of  the  gonorrhoeal  threads, 
or  tripper  faden. 

The  Declining  Stage. — Gleet. — Gonorrhoeal  Threads. — In  the  de- 
clining period,  or  after  the  discharge  has  persisted  as  a  gleet  for  some 
days  or  weeks,  it  still  consists  of  pus-cells,  less  thickly  aggregated,  how- 
ever, than  in  Fig.  35,  entangled  in  sheets  of  fibrin  or  mucus,  with  a  vari- 
able number  of  rounded  epithelial  cells.  In  this  stage  healing  of  the 
mucous  membrane  usually  begins.  The  hyperemia  gradually  grows  less, 
the  morbid  surface  becomes  contracted,  lessened  in  area,  and  a  tendency 
is  observed  to  render  the  surface  of  the  mucous  membrane  normal.  In 
this  process  exulcerations  and  eroded  spots,  caused  by  the  gonorrhoea, 
become  more  or  less  completely  covered  by  an  epithelial  coating.  As 
this  salutary  epithelial  proliferation  goes  on  there  is  much  desquama- 
tion, as  well  as  the  escape  of  serum  and  leucocytes  from  the  membrane. 
It  thus  happens  that  a  larger  or  smaller  number  of  epithelial  cells  are 
found  in  a  gleety  discharge.  With  the  appearance'  of  epithelial  scales  the 
reparative  process  may  be  said  to  really  begin,  and  as  the  case  progresses 
the  pus-cells  become  less  and  less  numerous,  while  the  epithelial  cells  in- 
crease in  number.  Then,  if  all  goes  well,  these  cells  gradually  grow  less 
numerous,  and  a  cure  results.  It  follows,  therefore,  when  in  a  declining!; 
gonorrhoea  pus-cells  persist  in  great  numbers,  while  epithelial  cells  are 
scanty,  that  there  is  slow  progress  toAvard  cure.  Then,  on  the  other  hand, 
when  frequent  examinations  show  that  the  pus-cells  are  disappearing  and 
that  the  epithelial  cells  preponderate,  it  is  evident  that  the  moi'bid  process 
is  ceasing.  As  in  the  early  stages,  so  in  the  later  ones,  the  microscope 
gives  us  great  aid  in  determining  the  character  and  extent  of  the  inflam- 
matory process.  In  these  later  stages  the  discharge  is  commonly  so 
scanty  that  it  does  not  escape  from  the  meatus,  but  it  is  carried  from  the 
canal  by  the  stream  of  urine.  This  discharge  is  then  seen  to  be  in  the 
form  of  clumps  rounded,  irregular,  or  crab-like,  in  the  form  of  flakes  of 
various  size  and  irregular  shapes,  and  in  the  form  of  threads  which  may 
be  long  and  very  thin  or  thick  or  short  and  stumpy.  The  threads  from 
either  the  anterior  or  posterior  portion  of  the  urethra  have  the  same  mi- 
croscopical structure  as  the  gleety  drop ;  they  are  composed  quite  con- 
siderably of  pus-cells  entangled  in  a  thick  fluid  exudation  containing 
fibrin  or  mucus  and  generally  a  variable  number  of  epithelial  cells. 

The  Question  of  the  Presence  of  the  Gonocoecus  in  Gleet  and  Threads. 
— This  is  an  exceedingly  important  subject,  since  it  introduces  the  ques- 


THE  PATHOGENIC  ACTION  OF  THE  GONOCOCCUS. 


71 


tion  of  late  and  remote  infection.  Many  clinicians  since  the  discovery  of 
the  gonococcus  seem  inclined  to  believe  that  this  micro-organism  stays 
somewhere  hidden  or  quiescent  in  the  urethra  as  long  as  the  gleet  or 
threads  remain,  and  that  it  is  the  direct  cause  of  the  gleet  or  threads. 
Others  go  still  further  and  make  it  appear  that  the  gonococcus  may  per- 
sist in  a  latent  way  for  a  long  time  after  the  chronic  discharge  or  gleet 
has  utterly  ceased,  and  that  under  appropriate  irritation  it  may  become 
active  and  aggressive  again.  These  observers — who  have,  moreover, 
quite  a  large  number  of  followers  in'  their  way  of  thinking — have  appar- 
ently come  to  their  conclusions  about  the  lengthy  or  indefinite  persistence 
of  the  gonococcus  by  calling  any  diplococci  which  they  see  about  the  size 
of  the  gonococcus  in  the  secretion  of  old  gleets,  gonococci.  As  we  have 
already  seen,  there  are  many  species  of  diplococci  very  much  like  the 
gonococcus  in  form  and  staining  qualities ;  consequently,  morphological 
identification  of  the  gonococcus  without  cultures  is  apt  to  be  fallacious. 
I  think  that  this  vieAv  of  the  extreme  persistence  of  the  gonococcus  in  the 
urethra  has  been  much  overdrawn,  and  those  who  hold  it  seem  to  over- 
look the  fact  that  there  is  abundant  damage  done  to  the  urethra  by  the 
gonococcus,  which  produces  an  exudative  inflammation  which  remains  long 
after  that  micro-organism  has  disappeared.  On  the  other  hand,  I  do  not 
state  positively  that  the  gonococci  promptly  disappear  in  the  declining 
stages — they  may  persist  for  some  time  in  the  gleety  discharge — but  after 
a  gleet  has  lasted  for  two  or  three  or  six  months  the  gonococci  are  in  all 
probability  in  most  cases  absent.^     To  decide  precisely  when  the  gonococci 


^  The  most  elaborate  study  of  the  frequency  of  occurrence  of  gonococci  in  chronic 
urethritis  is  that  of  Prof.  Goll  {Correspondenzblaitfilr  Schweitzer  Aerste,  1891,  vol.  xxi.  pp. 
25  et  seq. ),  but,  unfortunately,  his  results  were  all  obtained  from  the  microscope,  wliich 
we  have  shown  to  be  fallible  in  many  cases,  (ioll's  studies  were  carefully  made,  the 
secretion  in  each  case  being  examined  from  three  to  fourteen  different  times. 

The  following  table  will  show  the  dates  at  which  gonococci  were  found  in  1046  cases  : 


Duration  since  infection. 

Number  of 
cases. 

Gonococci 
found. 

Negative 
result. 

Percentage  of  occur- 
rence of  gonococci. 

4-5  weeks     

6  "          

7  "          ...... 

2  months 

3  " 

4  "        

5  "        

6  "        

7,  8,  9  months              .    . 

1  year   

li  years    ...        .        . 

3  "'.'.'.'.'.. 

4  "      

5  "      

6  and  more  years    .    .    . 

85 
54 
35 
75 
76 
62 
43 
55 

103 
83 
76 

135 
80 
37 
20 
22 

40 

21 

11 

15 

13 

13 

8 

8 

21 

12 

7 

7 

2 

45 
33 
24 
60 
63 
49 
35 
47 
87 
71 
69 
128 
78 
37 
20 
22 

■  47  per  cent. 
38       " 
31 

20       " 
17 
21 
18 

14       " 
19 
14 

9        " 

5        " 

2^      " 

Cases  examined  .    . 

1046 

178 

868 

In  these  studies  Goll  convinced  himself  that  in  some  young  healthy  men  the  gonococ- 
cus disappeared  for  good  in  three  weeks,  wliich  nuist  be  regarded  as  an  exceptional 
occurrence. 

A  perusal  of  the  tal)le  shows  that,  unless  mistakes  were  made  by  which  other  diplo- 
cocci were  regarded  as  the  gonococcus,  the  latter  organism  may  be  found  very  counnonly 


72  GONORBHCEA  AND  ITS  COJIPLICATIOXS. 

disappear  is  impossible  by  the  microscope  alone.  In  the  female  there 
seems  at  present  to  be  some  evidence — in  exceptional  cases,  however — in 
favor  of  the  long  persistence  and  dormant  condition  of  gonococci  in  the 
uterus  and  tubes. 

As  a  o;eneral  rule,  the  o:onococcus  crraduallv  ceases  in  the  srleetv  morn- 
ing  drop  and  in  the  urine  threads.  It  becomes  extinct  and  disappears 
out  of  the  urethra,  yet  the  gleet  and  threads  still  persist,  but  this  is 
because  of  certain  structural  changes  in  the  urethra  left  behind  by  the 
severe  exudative  inflammation  caused  by  the  gonococcus.  All  sorts  of 
bacteria  may  be  found  in  the  urine  threads  and  often  in  old  gleets,  and 
among  them  several  diplococci  which  resemble  or  look  almost  exactly  like 
the  gonococcus.  also  long  and  thin  and  short  and  thick  bacilli.  In  fact, 
by  the  microscope  alone  it  is  almost  impossible  to  positively  identify  the 
gonococcus  in  old  gleet  or  threads ;  consequently,  it  is  well  to  be  skeptical 
and  perhaps  incredulous  as  to  statements  of  authors  that  they  have  found 
this  microbe  under  these  conditions.  Unless  the  author  is  known  as  a 
conservative  and  skilled  observer,  or  there  is  inherent  evidence  of  abso- 
lute thoroughness,  carrying  conviction  in  his  essay,  his  conclusions  are 
not  entitled  to  stand  as  scientific  evidence.-' 

The  discharge  persists  after  the  extinction  of  the  gonococcus  because 
of  the  ulcers,  erosions,  small  round-cell  residues,  and  thickening  beneath 
the  epithelium  or  other  sequelae  incident  to  the  intense  exudative  inflam- 
mation aroused  by  the  gonococcus.  An  ulcer  or  exulceration,  especially 
in  a  long,  narrow,  closed  sinus  like  the  urethra,  will  continue  to  exude 
indefinitely  without  any  assistance  of  the  gonococcus. 

Chronic  Relapsing  Gonorrhcea. 

Patients  with  these  superficial  ulcers  or  other  sequeh'e,  such  as  a 
smouldering  inflammatory  condition  of  the  vessels  and  cells  of  the  part, 
left  behind  after  the  extinction  of  the  gonococcus.  may  become  the  sub- 
jects of  chronic  relapsing  urethritis  or  "latent"  gonorrhoea — termed 
latent  apparently  because  the  gonococcus  is  supposed  to  hibernate  some- 
where in  the  urethra,  and  then  become  active  again  with  appropriate 
stimulation.  The  real  explanation  seems  to  be  this :  The  gonococcus  is 
not  responsible  for  these  intermittent  attacks  continuing  long  after  the 
primary  attack,  but  the  erosions,  ulcers,  epithelial  deficiencies,  or  small 
round-cell  residues  (corresponding  to  the  granular  condition  of  the  mucous 
membrane),  which  have  never  been  perfectly  healed,  light  up  afresh  after 
debauchery  or  sexual  stimulation.     Yet  the  purulent  discharge  started  up 

up  to  the  ninth  month  of  infection  ;  that  during  the  second  year  it  occurs  in  a  goodly 
proportion  of  cases,  and  in  the  third  year  in  a  small  percentage  ;  and  that  it  is  not  found 
after  the  third  year.  The  truth  of  the  matter  is,  that  our  studies  in  this  direction  have 
hardly  commenced,  and  they  should  be  prosecuted  by  many  observers  on  many  patients 
in  the  light  of  our  newly-acquired  and  yet-to-be-acquired  knowledge  of  the  gonococcus 
and  its  biology.  It  will  be  a  long  time  before  dogmatic  statements  can  be  made  which 
will  stand  scientilic  scrutiny. 

'  In  the  light  of  this  position  it  is  interesting  to  know  that  Sahli  { Correspoiulensblaft  fiir 
Schweitzer  Aerzte,  1887,  p.  495)  says  that  he  had  not  once  failed  to  find  the  gonococcus  in 
the  numerous  male  patients  he  had  examined  even  after  a  long  duration  of  the  disease. 
Even  Fiirbinger,  who  is  a  careful  and  scientific  man  (Die  inneren  Krankheiten,  2d  ed.,  p. 
438),  speaks  of  the  disappearance  and  reappearance  of  gonococci  after  mechanical  and 
chemical  irritations  of  the  urethra. 


THE  PATHOGENIC  ACTION  OF  THE  CWNOCOCCUS. 


73 


in  this  way  contains  no  gonococci,  although  at  times  diplococci  of  one  kind 
or  another  may  be  found  looking  very  much  like  the  gonococcus  or  quite 
identical  "with  it,  so  far  as  form  and  staining  reactions  are  concerned. 

As  to  the  determination  of  the  gonococcus  in  all  these  stages  of  gon- 
orrhoea  by  the  microscope  alone  without  culture  methods,  it  should  be  said 
that  it  is  sometimes  exceedingly  difficult  to  identify  the  coccus  in  the 
earliest  and,  as  we  have  said  before,  particularly  in  the  later  gleety,  stages 
of  the  discharge.  In  the  active  purulent  stage,  however,  as  we  have 
seen,  the  identification  of  the  gonococcus  is  quite  reliable,  especially  when 
the  clinical  history  and  physical  signs  are  dovetailed  in  with  the  micro- 
scopical examination. 

We  now  come  to  the  study  of  the  pathological  products  of  urethral 
inflammation,   early  and  late. 

Gonorrhoeal  threads,  urethral  filaments,  also  called  trijyjJer  faden,  may 
be  divided  into  four  quite  distinct 

varieties.     First,  there  is  the  pus-  Fig.  39. 

thread  which  has  already  been 
alluded  to,  and  is  pictured  in  Fig. 
39.  It  is  a  thread  only  in  the 
sense  of  pus-cells  being  aggluti- 
nated with  each  other  or  strung 
together  by  means  of  mucin  as  a 
basement-substance.  It  may  be 
in  the  form  of  threads,  clumps, 
and  irregular  masses.  This  prod- 
uct is  observed  just  before  the 
appearance  of  epithelia  in  the 
threads.  The  second  is  the  gelat- 
inous thread.  The  third  is  a  firm 
thread,  consisting  of  pus,  mucus, 
round  and  epithelial  cells,  and 
indicative  of  a  well-developed 
chronic  exudative  process.  The 
fourth  form  of  thread  consists 
chiefly   of  epithelium,    Avith    very 

little  pus,  and  some  basement  mucin  to  hold  the  cell-elements  together. 
This  product  is  essentially  a  desquamation. 

The  gelatinous  threads  are  seen  most  commonly  toward  the  end  of  the 
acute  stage,  when  mucin  comes  to  be  secreted  and  acts  as  a  cement  sub- 
stance for  the  cellular  exudation.  These  gelatinous  threads  are  also  not 
uncommonly  seen  late  in  the  course  of  gonorrhoea  when  the  exudative 
process  still  lingers  in  the  submucous  connective  tissue  and  the  overlying 
membrane  is  in  a  catarrhal  condition.  These  gelatinous  threads  ai'e  some- 
times finer  than  the  finest  hair,  and  are  of  intermediate  sizes  until  the 
dimensions  of  a  knitting-needle  are  reached.  They  are  often  very  long 
(three,  four,  and  more  inches),  and  float  about  in  the  urine  in  graceful 
curves.  Then,  again,  they  are  thicker,  less  lengthy,  and  perhaps  of 
irregular  calibre.  They  are  usually  very  elusive,  and  are  with  difficulty 
captured  by  the  pipette  or  the  forceps,  and  when  caught  they  collapse  into 
a  little  gelatinous  mass.  In  this  form  of  thread  we  find  entangled  in  the 
cement  substance  pus-cells,  round-cells,  and  perhaps  some  large  flat  epi- 


Showing  a  thread-like  agglomeration  of  pus-cells 
held  together  by  mucin,  being  the  first  stage  in 
the  formation  of  the  thread. 


74 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


tlielial  cells.     This  form  of  thread  is  usually  seen  to  follow  the  pus-thread 
already  pictured  in  Fig.  39,  in  which  no  epithelium  is  yet  present,  and 


Fig.  40. 


Mucin,  pus,  and  epithelium. 
Fig.  41. 


Showing  gelatinous  thread  with  pus-cells,  round  hyaline  (iodophilous)  cells,  epithelial  cells  held 
together  by  mucin :  declining  stage  of  acute  gonorrhoea. 

which  is  symptomatic  of  the  turning-point  in  the-  acute  stage  of  the  dis- 
ease.    With  these  gelatinous  threads  there  is  frequently  such  an  amount 
-p  ,  A^  of  mucus  as  to  render  the  urine 

cloudy,  though  not  opaque,  and 
very  often  to  look  like  mucilage 
diluted  with  Avater,  or  new  cider. 
The  microscopical  appearances  are 
shown  in  Figs.  40  and  41. 

The  third  form  of  urethral  fila- 
ments consists  of  whitish-gray  and 
brownish-white  threads,  varying  in 
length  from  a  third  of  an  inch  to  an 
inch  and  more  in  length.  They 
may  be  thread-like,  thin,  and  deli- 
cate or  thick  and  stumpy.  Some 
have  a  distinct  head,  and  resemble 
a  comma,  and  are  said  to  come 
from  the  posterior  urethra.  Then, 
again,  they  present  branched  forms, 
and  some  resemble  crabs  in  shape. 
Indeed,  words  fail  to  describe  all  the 
shapes  assumed  by  these  urethral 
filaments.     Examined  under  the  microscope,  these  pathological  products 


Showing  secretion  of  late  declining  anterior 
gonorrhoea. 


THE  PATHOGENIC  ACTION  OF  THE  GONOCOCCUS. 


75 


Fig.  43. 


Showing  secretion  of  piosterior  urethritis  in 
chronic  stage. 


are  found  to  consist  of  round  cells,  hyaline  cells  readily  colored  with  iodine 
(iodophilous),  pus-cells,  epithelial  cells,  oval,  polygonal,  irregulat,  fusiform, 
and  caudate.     All  these  elements  are  held  together  in  the  most  complete 
disorder  as  to  arrangement  by  the 
basement  substance.     In  Fig.  42 
is  well  portrayed  the  appearance 
of  the  discharge  in  chronic  gon- 
orrhoea of  the  bulb,  and  its  study 
Avill  give  a  clear  idea  of  the  mi- 
croscopical picture. 

Attempts  have  been  made  with- 
out success  to  establish  sharply- 
marked  differences  in  the  micro- 
scopical pictures  of  the  discharge 
in  anterior  and  posterior  gonor- 
rhoea. The  truth  is,  that  in  the 
main  there  are  the  same  cellular 
elements  to  be  seen  in  the  dis- 
charg-e  from  the  anterior  urethra 
as  are  found  in  that  of  the  poste- 
rior urethra  in  chronic  gonorrhoea. 
Consequently,  in  many  cases  the 
microscope  affords  little  help  in 
determining  exactly  where  a  dis- 
charge comes  from,  but  it  generally  gives  a  good  idea  of  the  condition  of 
the  process.  In  some  cases,  however,  we  find  dead  spermatozoa  inex- 
tricably mixed  up  among  the  cell-groups,  and  thus  we  have  presumptive 
evidence  that  the  morbid  focus  is 
in  the  posterior  urethra.  But  even 
in  this  event  a  positive  conclusion 
cannot  be  reached  until  it  has  been 
proven  that  the  seminal  vesicles  are 
not  affected,  since  the  same  micro- 
scopical picture  may  be  presented 
in  seminal  vesiculitis.  In  Fig. 
43  the  appearances  of  the  dis- 
charge from  the  posterior  urethra 
are  Avell  shown.  There  is  much 
resemblance  to  the  picture  pre- 
sented by  the  discharge  from  the 
anterior  urethra  already  shown. 
(See  Fig.  42.)  But  it  will  be 
seen  that  there  are  many  sperma- 
tozoa scattered  and  in  clumps, 
and  that  the  round-cells  are  pres- 
ent in  rather  greater  numbers. 

These  appearances  of  the  mor- 
bid cellular  elements  in  anterior 

and  posterior  gonorrhoea  may  be  seen  months,  and  even  years,  after  the 
onset  of  the  infection.  In  other  words,  in  chronic  cases  the  morbid  pro- 
cess gives  rise  quite  uniformly  to  the  same  orders  of  pathological  products. 


Fig.  44. 


Showing  epithelinm  and  pus  from  a  localized 
morbid  area. 


76  GONORBHCEA   AND  ITS  COMPLICATIONS. 

The  scaly  threads  or  flakes  which  form  the  fourth  variety  are  less 
common  than  the  threads  just  described.  They  may  be  seen  in  the  form 
of  a  coarse  powder,  in  threads,  in  lumps,  and  flakes  of  whitish-gray  color. 
They  are  firm  in  structure,  and  readily  sink  to  the  bottom  of  the  glass. 
Examined  with  the  microscope,  these  flakes  show  a  quite  uniform  field  of 
flat  epithelium  in  various  shapes,  which  shows  stability  of  structure.  Many 
of  these  cells  are  nucleated,  and  not  infrequently  they  are  the  seat  of  fatty 
degeneration.  There  are  usually  some  pus-cells  intermixed  in  the  field. 
This  form  of  thread  or  flake  (well  shown  in  Fig.  44)  is  usually  the  prod- 
uct of  a  localized  inflammatory  process  in  the  anterior  urethra  as  far  down 
as  the  bulb.  It  is  usually  indicative  of  an  erosion  or  ulcer  in  which  the 
reparative  process  is  abortive,  and,  although  new  epithelium  is  formed,  the 
integrity  of  the  mucous  membrane  is  not  re-established.  On  finding  such 
a  microscopical  picture  one  is  warranted  in  making  an  endoscopic  exami- 
nation with  a  view  of  localizing  the  morbid  area. 

In  stricture  of  the  urethra  the  third  and  fourth  varieties  of  threads  are 
usually  found,  together  with  more  or  less  pus  and  mucus. 


CHAPTER  V. 

INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 

We  have  already  studied  the  pathogenic  action  of  the  gonococcus  in 
the  light  of  clinical  observation,  aided  by  the  microscopical  study  of  the 
gonorrhoeal  secretions. 

The  further  process  of  the  invasion  of  the  tissues  by  the  gonococcus 
may  now  be  considered.  Owing  to  the  great  difiiculty,  and  at  times 
impossibility,  of  obtaining  a  urethra  the  seat  of  active  gonococci-invasion, 
Bumm  studied  the  subject  upon  the  conjunctiva  of  infants  inoculated 
with  gonococci-containing  pus.  As  the  mucous  membrane  of  the  eye 
resembles  that  of  the  urethra,  and  as  the  two  mucous  membranes  react 
similarly  to  gonorrhoeal  infection,  it  is  fair  to  assume  that  the  morbid 
processes  and  appearances  are  similar  in  each  instance.  It  is  this  want 
of  pathological  material  on  my  own  part  which  forces  me  here  to  make 
use  of  Bumm's  observations  and  results. 

Having  gained  a  foothold  on  the  superficial  epithelial  layers,  and  there 
having  greatly  increased  in  numbers,  the  gonococci  penetrate  between  the 
epithelial  cells,  which  have  become  swollen  and  succulent,  into  the  soft 
protoplasm  substance.  It  is  interesting  to  note  that  in  the  infective  pro- 
cess the  cocci  themselves  are  the  active  agents  in  advancing  and  attack, 
and  that  they  are  not  enclosed  in  pus-cells.  Indeed,  active  participation 
of  the  pus-cell  is  not  observed.  The  spreading  of  the  micro-organisms 
onward  is  thought  by  Bumm  to  be  due  to  their  grooving  more  actively  on 
one  side — a  condition  caused  by  the  diff'erence  in  soil  and  probably  by  an 
increased  supply  of  oxygen.  In  all  cases  the  road  traversed  by  the  gono- 
cocci is  through  the  cement-substance  between  the  cells.     Sometimes  they 


PLATE  1. 


^-    '•.--- ^'"♦S 


•sg    't,  <-~«^" 


.?  —   >  *" 


'^t^ 
**^«» 


*^i- 


INVASION   OF  THE  TISSUES  BY  THE  GONOCOCCUS. 


INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS.  77 

squeeze  and  penetrate  by  their  files ;  then  again  they  advance  in  a  larger 
body,  and,  when  the  tissues  will  admit,  they  form  a  roundish  colony,  and 
from  that  stage  make  further  incursions  into  the  tissues.  When  they  have 
got  well  down  toward  the  subepithelial  connective-tissue  layer,  reaction 
on  the  part  of  the  tissues  occurs.^  Then  great  numbers  of  Avhite  blood- 
cells  escape  from  the  dilated  capillaries,  together  with  much  serum.  This 
stream  of  pus,  pouring  out,  breaks  through  the  epithelium  or  even  carries 
it  away  in  small  or  large  plates,  The  removal  of  the  epithelium  then 
permits  further  invasion  of  the  gonococci  even  to  the  papillary  layer,  but 
there  it  stops.  Pus-cells  filled  with  the  gonococci  may  now  be  seen,  but 
free  gonococci  are  much  more  numerous.  Coincidently  with  this  cocci- 
invasion  and  multiplication  the  inflammatory  process  increases  in  inten- 
sity, and  a  dense  round-cell  infiltration  is  formed  beneath  the  surface  of 
the  mucous  membrane.  This  is  the  transition  to  the  purulent  stage  of 
gonorrhoea.  In  some  cases  as  early  as  the  fourth  day  regeneration  of  the 
epithelium  begins  and  rapidly  progresses,  and  then  the  further  invasion 
of  the  micro-organism  may  be  stopped.  During  this  reparative  process 
the  pus-cells  escape  unhindered,  and  rows  and  clusters  of  gonococci  may 
be  harbored  between  the  cells  of  the  uppermost  layer  of  the  epithelial 
strata.  Under  some  circumstances  there  may  then  be  a  new  invasion  by 
the  gonococci.  An  outpouring  of  pus  destroys  more  or  less  of  the  epi- 
thelial layer,  and  this  opens  a  way  for  the  second  invasion.  This  condi- 
tion is  what  occurs  in  relapses  of  acute  and  tolerably  acute  gonorrhoea. 
The  cocci  may  develop  between  the  superficial  connective  tissue  and  the 
tunica  propria,  but  they  do  not  luxuriate.  It  seems  probable  that  they 
do  not  find  in  the  deep  parts  of  the  mucous  membrane  the  conditions 
necessary  for  development,  or  that  they  are  unable  to  withstand  the  influ- 
ence exercised  by  the  tissue-elements.^  They  are  most  at  home  in  the 
superficial  layers  of  the  connective  tissue  and  between  the  epithelial  cells. 

In  this  infective  process,  therefore,  we  see  a  violent  invasion  of  a 
mucous  membrane  by  large  masses  of  gonococci  which  penetrate  between 
the  cells.  There  is  always  to  be  observed  a  connection  between  the 
multiplication  and  activity  of  the  micro-organism  and  the  intensity  of  the 
inflammatory  process.  The  reaction  on  the  part  of  the  tissues  corresponds 
to  the  intensity  of  the  irritation  excited  in  the  soft  and  sensitive  epithe- 
lium. So  long  as  there  is  secretion  present  on  a  mucous  membrane,  the 
gonococci  may  remain  in  it  and  multiply,  for  it  oifers  a  favorable  culture- 
soil.  The  great  mass  of  gonococci  in  the  uppermost  strata  of  tissues 
perishes  there  from  simple  dissolution.  Final  healing  is  caused  not  so 
much  through  the  elimination  of  the  micro-organism  as  by  the  develop- 
ment of  a  protective  covering  of  squamous  epithelium  in  several  strata 
which  closes  up  all  gaps,  cracks,  and  inlets  to  further  invasion.  The 
infective  process  is,  therefore,  brought  to  an  end  by  the  energetic  devel- 
opment of  epithelium,  which  forms  a  barrier  which  the  gonococci  cannot 
break  throug-h. 

The  foregoing  description  will  be  rendered  much  clearer  and  more 
striking  by  a  study  of  the  figures  representing  microscopic  sections  of  the 
conjunctiva  (Plate  I.) : 

^  Chemotaxis. 

*  Bumm  states  that  gonoiTho?al  pus  injected  into  tlie  subcutaneous  connective  tissue 
produces  no  reaction,  and  that  the  gonococci  soon  disappear. 


78  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

In  Fig.  a  is  shown  a  section  through  the  conjunctival  fold  of  the  lower 
lid.  The  epithelial  layer  is  covered  with  an  exudation  which  consists  of 
fibrin  and  pus-cells,  and  contains  free  gonococci  and  others  enclosed  in 
pus-cells. 

In  Fig.  h  the  invasion  of  the  conjunctival  epithelium  by  colonies  of 
gonococci  is  shown. 

Fig.  c  shows  a  perpendicular  section  through  one  of  the  furrows  of  the 
fornix  conjunctivae  of  the  lower  lid.  The  conjunctival  epithelium  is 
invaded  by  gonococci.  It  is  desquamating,  and  is  infiltrated  with  the 
products  of  exudative  inflammation — serum,  fibrin,  red  blood-cells,  and 
pus-cells. 

Fig.  d  shows  the  ingrowths  of  large  superficial  colonies  of  gonococci  in 
the  epithelial  layer. 

In  Fig.  e  is  shown  a  vertical  section  through  the  conjunctiva  of  the 
lower  lid.  The  epithelium  has  been  completely  desquamated,  and  some 
of  the  earliest  colonies  of  gonococci  are  seen  penetrating  the  conjunctival 
connective  tissue. 

In  Fig.  /  is  shown  two  colonies  of  gonococci  penetrating  still  deeper 
into  the  subconjunctival  connective  tissue. 

In  Fig.  g  is  shown  the  gonococci  invading  the  superficial  portions  of 
a  papilla. 

In  Fig.  h  is  shown  proliferation  of  gonococci  in  the  superficial  (ede- 
matous part  of  an  intrapapillary  portion  of  the  conjunctival  epithelium. 

Fig.  i  shows  the  character  of  the  newly-formed  epithelium  (after  the 
cessation  of  the  gonococci-invasion),  Avhich  is  somewhat  changed  and  has 
more  the  type  of  squamous  epithelium.  On  the  surfiice  there  is  a  small 
cluster  of  gonococci. 

In  Fig.  j  is  shown  a  recurrent  invasion  of  newly- formed  epithelium  by 
gonococci. 

It  is  very  probable  that  when  gonorrhoea  is  caused  by  the  staphylo- 
coccus and  the  streptococcus  the  pathological  processes  and  changes  are 
similar  to  those  produced  by  the  gonococcus. 


CHAPTER    VL 


THE  PATHOLOGY  OF  CHEONIC  GONORRHCEA  AND  OF  STRICTURE 

OF  THE  URETHRA.^ 

As  we  have  already  seen,  gonorrhoea  does  not  produce  a  mere  catarrhal 
inflammation  of  the  urethra,  from  which  the  membrane  might  readily 
return  to  the  normal  condition,  but  in  addition  a  severe  exudative  inflam- 

^  For  a  more  technical  exposition  of  these  subjects  the  reader  is  referred  to  Wasser- 
mann  and  Hall^,  "  C Contribution  a  I'Anatomie  patholowique  des  Eetrecissements  de 
rUr^thre,"  Annales  des  Mai.  des  Organ.  Ge'n.-urin,  vol.  ix.,  1891,  pp.  143,  242,  295  et 
seq.  ;  also  Finger,  "Beitrilge  zur  Pathologischen  Anatomic  der  Blennorrh(Te  der  Miinn- 
lichen  Sexualorgane  (1,  C'hronisclie  Uretlu-al-blennorrhfi')  "  Ergiinzungsheft  zur  Archiv 
fur  Derm,  und  Syphilid,  1891,  pp.  1  et  seq.;  and  same  (2,  Chronisclie  Urethritis  posterior 
und  die  Chronische  prostatitis),  ibid.,  Ergiinzungsheft  fiir  1893,  pp.  27  et  seq. 


PATHOLOGY  OF  CHRONIC  GONOBRHCEA. 


79 


Fig.  45, 


/^.^y 


'A, 


1 1 


V 


i*^ 


'^^;hm: 


^ 


Showing  a  transverse  section  through  the  entire  urethral  canal  and  tunica  albuginea,  with 
round-cell  infiltration  around  urethra  and  mucous  follicles. 

mation  in  the  submucous  connective  tissue  results,  Avhich  has  a  tendency, 
if  the  process  persists  for  a  long  time,  to  damage  the  urethra  permanently. 
We  have,  therefore,  a  catarrhal  and  an  exudative  process  combined.     Such 

Fig.  46. 


lowing  a  segment  of  roof  of  urethra,  with  round-cell  infiltration  of  the  mucosa  and  tubular  ducts 
of  follicles  ;  higher  magnifying  power  than  in  Fig.  -15. 


80 


GONOBBHCEA  AND  ITS  COMPLICATIONS. 


an  exudative  inflammation  induced  by  the  gonococcus  is  attended  first 
with  a  desquamation  of  the  urethral  epithelium,  and  Avhen  this  epithelium 
is  restored  it  is  liable  to  be  more  or  less  thickened  and  to  have  a  different 
character  from  the  normal  epithelium  of  the  urethra.  In  other  words,  the 
normal  cylindrical  epithelium  of  the  urethra  becomes  destroyed  by  the 
gonorrhoeal  process,  and  is  on  healing  replaced  by  flat  pavement  epithe- 
lium. These  epithelial  proliferations  are  seen  by  the  endoscope  to  appear 
like  granular  and  warty  patches,  and  even  polypoid  growths.  When  old 
they  may  present  a  whitish,  opaque  appearance  resembling  cicatrices. 
Then,  again,  the  exudative  inflammation  attending  gonorrhoea  may  pro- 
duce ulcers  or  erosions,  and  frequently  induces  a  formation  of  connective 
tissue  in  the  walls  of  the  urethra.  The  mucous  glands  may  also  be  con- 
siderably changed.  Figs.  45  and  46  show  the  character  of  the  gonorrhoeal 
inflammation,  and  Figs.  47,  48,  and  49  illustrate  some  of  the  more  import- 
ant sequelae  of  chronic  gonorrhoea — namely,  stricture-formations. 

Figs.  45  and  46  were  taken  from  sections  of  the  urethra  of  a  subject  at 
Charity  Hospital  who  had  had  chronic  gonorrhoea  for  some  months.  In 
Fig.  45  the  topographical  distribution  of  the  inflammation  is  shown  in  a 

Fig.  47. 


Showing  an  exulceration  of  the  urethra,  with  round-cell  infiltration-bed  and  absence  of  epithe- 
lium ;  newly-formed  capillaries  in  red. 

section  through  the  entire  thickness  of  the  urethral  canal,  including  the 
tunica  albuginea.  The  whole  folded  lumen  of  the  urethra  is  surrounded 
by  a  deep  ring  of  small  round-cells  (2,  z\  Avhich  seem  mainly  to  have  come 
from  the  superficial  vessels  of  the  mucosa,  Avhile  a  part  of  them  may  be 
proliferated  connective-tissue  cells.  The  epithelial  lining  of  the  urethra 
is  desquamated,  and  is  entirely  absent  in  places  {x,  x\  while  in  other 
places  {y,  y)  it  is  still  in  proper  position,  although  infiltrated  with  pus- 
cells.  In  the  roof  of  the  urethra,  in  this  section,  the  ducts  of  the  mucous 
glands  at  various  depths  are  also  surrounded  by  a  heavy  infiltration  of 


PATHOLOGY  OF  CHRONIC  GONORBHCEA. 


81 


small  round-cells,  which  indicates  an  extension  of  the  inflammation  along 
the  mouths  of  the  glands  from  the  surface  of  the  urethra  {to,  w). 

Fig.  46  shows  the  invasion  of  the  urethra  by  the  gonorrhoeal  process 
still  more  plainly.     The  drawing  includes  the  whole  thickness  of  a  segment 


Fig.  48. 


Showing  a  section  through  a  superflcially-seated  stricture,  with  moderately  dense,  newly-formed 

connective  tissue. 

from  the  roof  of  the  urethra,  corresponding  to  the  rectangular  area  indi- 
cated by  p  q  in  Fig.  45.  With  this  higher  magnifying  power  in  Fig.  46 
the  infiltration  of  the  mucosa  and  tissue  surrounding  the  tubular  ducts  of 
the  mucous  glands  is  shown  in  detail.     With  the  exception  of  the  patches 


Fig.  49. 


,  /  i' 


Showing  a  section  through  a  firm  inodular  stricture,  the  connective  tissue  being  so  dense  as  to 

resemble  cicatricial  tissue. 

denoted  by  x  and  y,  the  epithelial  lining  of  the  urethra  is  absent,  so  that 
there  are  extensive  areas  of  erosion  of  the  infiltrated  mucosa. 

Lying  free  in  the  urethral  lumen  near  the  denuded  surface  is  a  flake 
of  the  gonorrhoeal  exudation  {z,  z,  Fig.  46).  This  flake  is  quite  identical 
in  structure  with  the  ordinary  gonorrhoeal  discharge  as  seen  on  a  cover- 

6 


82  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

glass,  and  consists  mainly  of  pus-cells  lying  in  a  fluid  or  granular  matrix. 
The  mucosa  just  beneath  what  is  left  of  the  epithelial  lining  is  very 
densely  crowded  with  small  round-cells  to  the  extent  shown  in  the  figure 
at  V,  V. 

In  the  same  way  the  ducts  of  the  mucous  glands  u,  w,  and  r,  and  in 
places  the  gland  acini  themselves  (t),  are  similarly  infiltrated  with  the 
small  round-cells.  The  ducts  w  and  r  have  their  lumina  partially  filled 
with  desquamated  cells  and  granular  material. 

These  figures  (45  and  46),  then,  serve  to  show  that  when  gonorrhoea 
has  become  chronic  it  must  necessarily  take  a  long  time  for  the  disease 
to  heal,  since  in  the  affected  regions  of  the  urethra  all  this  desquamated 
epithelium  must  be  restored,  and  the  infiltration  of  small  round-cells  be 
disposed  of  before  the  urethra  can  become  healthy  again. 

Among  the  most  important  sequelae  of  gonorrhoea  are  ulcers  or  erosions 
of  the  urethra,  which  are,  as  a  rule,  small  and  sharply  localized.  Fig. 
47  shows  a  longitudinally  situated  narrow  linear  ulcer  from  the  middle 
of  the  penile  urethra.  The  section  was  cut  transversely  through  the 
urethra.  As  far  as  the  structure  of  this  ulcer  is  concerned,  it  needs  but 
little  description,  for  it  does  not  differ  essentially  from  minute  ulcers 
elsewhere — in  the  skin  or  mucous  membranes  approaching  the  skin  in 
structure.  At  the  site  of  the  ulcer  the  epithelium  is  deficient ;  there  is  a 
fairly  circumscribed  collection  of  small  round-cells,  interspersed  with 
newly-formed  capillaries,  which  tend  to  pass  up  vertically  toward  the  sur- 
face.    In  a  word,  the  ulcer  has  a  bed  of  granulation  tissue. 

The  practical  importance  of  such  a  condition  of  the  urethra  is  that  it 
tends  to  persist  almost  indefinitely,  and  keep  up  a  discharge  which  appears 
as  a  scanty  gleet  or  a  discouragingly  prolonged  appearance  of  gonorrhceal 
threads. 

We  now  come  to  the  study  of  more  advanced  conditions  of  urethral 
inflammation  and  coarctation.  Further,  then,  the  exudative  inflammation 
is  of  great  surgical  importance,  for  the  reason  that  it  almost  inevitably 
tends,  if  not  properly  treated,  to  the  development  of  stricture  of  the 
urethra,  with  all  its  dangerous  sequelae.  Early  in  chronic  urethritis  the 
newly-formed  submucous-tissue  infiltration  is  still  soft  and  succulent,  and 
when  it  produces  very  decided  diminution  of  the  calibre  of  the  urethral 
canal,  it  may  be  then  called  "soft  stricture."  As  the  morbid  tissue  grows 
older,  and  connective-tissue  cells  take  the  place  of  the  small  round-cells, 
it  becomes  more  condensed,  and  then  the  stricture  can  no  longer  be  called 
soft,  and  the  term  "semi-fibrous"  may  be  applied  to  it.  Thus  in  the 
domain  of  chronic  anterior  urethritis  we  recognize  in  clinical  practice,  as 
ulterior  results,  the  soft  and  the  semi-fibrous  strictures. 

Figs.  48  and  49  illustrate  two  forms  of  stricture  of  the  urethra.  In 
Fig.  48  is  shown  one  of  the  forms  of  large-calibred  stricture,  Avhile  Fig. 
49  is  from  a  section  of  a  more  extensive  tight  stricture,  contracting  the 
urethra  to  a  considerable  degree.  These  figures  serve  not  only  as  a  text 
for  the  exposition  of  the  detailed  minute  anatomy  of  urethral  stricture, 
but  also  as  a  practical  demonstration  of  the  topographical  distribution  and 
general  structure  of  two  extreme  forms  of  strictures. 

Both  of  these  strictures  were  evident  to  gross  inspection.  In  Fig.  48 
is  a  section  of  the  stricture  shown  grossly  in  Fig.  117.  (See  chapter  on 
Stricture  of  the  Urethra.)     This  stricture  was  situated  in  about  the  middle 


PATHOLOGY  OF  CHRONIC  GONORRHCEA.  83 

of  the  anterior  urethra ;  it  lay  a  little  to  one  side  of  the  roof  of  the  ure- 
thra, and  looked  like  a  bit  of  coarse  cotton  thread  stretching  across  the 
surface  of  the  membrane  for  a  very  limited  distance — only  three  to  four 
millimetres.  The  urethra  was  perfectly  normal  both  above  and  below  the 
tiny  constricting  band  or  thread.  A  vertical  section  of  the  urethra  pass- 
ing transversely  through  this  little  band  presents  the  appearance  shown 
in  Fig.  48. 

This  stricture  is  very  superficial ;  in  fact,  most  of  it  is  raised  up  above 
the  surface  of  -the  urethra,  although  a  slight  amount  of  connective  tissue 
stretches  out  in  the  mucosa  on  either  side  of  the  centrally-elevated  nodule 
which  corresponded  to  the  thread-like  band  shown.  In  Fig.  48  the  stric- 
ture is  composed  of  fairly  dense  newly-formed  connective  tissue,  which, 
however,  lies  very  superficially :  the  wall  of  the  urethra  itself  is  but  very 
little  invaded  by  the  stricture.  This  is  a  good  illustration  of  the  least- 
developed  form  of  stricture.  This  band  or  ring  form  of  stricture  is  not 
common,  and  may  be  said  to  be  in  reality  rare.  In  this  case  but  one 
imperfect  band  was  present,  but  in  very  exceptional  instances  several 
bands  may  be  found,  which  may  exist  separately,  the  tissue  between  them 
being  healthy.  As  a  general  rule,  when  bands  of  stricture  exist,  the 
whole  expanse  of  mucous  membrane  on  which  they  appear  is  the  seat  of 
morbid  change.  Those  authors  who  lay  great  stress  upon  strictures  of 
large  calibre  teach  that  these  contractions  consist  of  separate  and  distinct 
bands.  This  statement  is  pure  assumption,  and  is  not  based  on  studies  in 
pathological  anatomy.  Therefore  it  is,  in  consequence,  incorrect,  the 
truth  of  the  matter  being  as  just  now  stated. 

Fig.  49  shows  a  much  more  extensively  developed  form  of  stricture. 
In  this  instance  the  lumen  of  the  urethra  was  considerably  narrowed — 
approximately  to  about  the  calibre  of  a  No.  9  or  10  sound  (French). 
This  stricture  formed  an  annular  ridge  extending  transversely  about  one- 
quarter  way  round  the  urethra  at  the  junction  of  the  membranous  with 
the  bulbous  portions.  In  the  vertical  section  (Fig.  49)  of  the  urethra 
passing  through  the  stricture  it  will  be  seen  that  the  stricture  is  due  to 
the  development  of  a  conical  lump  of  newly-formed  connective  tissue 
which  extends  deeply  into  the  wall  of  the  urethra,  so  as  to  involve  the 
membrane  very  extensively,  almost  down  to  the  albuginea.  This  mass 
of  connective  tissue  is  very  dense,  and  forms  a  fairly  rigid  body,  and 
altogether  it  has  the  structure  resembling  cicatricial  tissue.  The  inter- 
lacing strands  of  dense  fibrillated  fibres  composing  the  mass  pass  in 
several  directions :  many  of  them  pass  circularly  about  the  urethra,  while 
others  run  up  and  down  the  canal  for  a  short  distance.  Over  the  centre 
of  the  stricture  the  urethral  surface  is  elevated  in  a  conical  point,  while 
on  either  side  the  epithelium  is  somewhat  thickened.  At  the  right-hand 
side  of  the  drawing  the  mucosa  is  thickened,  and  some  newly-formed 
vessels  pass  up  vertically  toward  the  surface,  as  is  generally  the  case  in 
the  skin. 

This  latter  stricture  is  in  striking  contrast  to  the  previous  one  in  its 
lack  of  elasticity,  extensive  involvement  of  the  urethral  wall,  and  corre- 
spondingly greater  degree  of  narrowing  of  the  urethral  canal.  It  is 
merely  necessary  to  say  that  in  this  case  only  a  limited  portion  of  the 
lumen  of  the  urethra  was  involved,  and  it  is  here  portrayed  and  described 
in  order  that  the  pathological  condition  can  be  placed  in  contrast  with 


84  GONORRHOEA   AND  ITS  COMPLICATIONS. 

the  healthy  tissues  around  it.  In  cases  in  which  the  process  is  deeper 
and  denser  the  same  pathological  conditions  are  presented.  As  the  stric- 
ture increases  in  extent  and  depth  the  same  cicatricial  tissue  is  formed, 
going  down  as  far  as  the  tunica  albuginea,  and  even  involving  it  and  sur- 
rounding the  whole  lumen  of  the  urethra. 

This  form  of  stricture  is  known  in  clinical  practice  as  the  inodular 
stricture,  which,  when  fully  developed,  involves  a  greater  or  less  segment 
of  the  urethral  canal  in  its  totality. 

True  stricture  of  the  urethra,  then,  is  the  outcome  of  gonorrhoeal  in- 
flammation, which  results  in  a  cirrhotic  periurethritis  and  cavernitis. 

The  morbid  process  in  chronic  posterior  urethritis  is  essentially  the 
same  as  that  which  affects  the  anterior  urethra — namely,  a  small-cell 
exudative  inflammation  into  the  submucous  connective  tissue.  This 
small-cell  infiltration  may  be  superficial  and  only  involve  the  connective- 
tissue  layer,  or  it  may  extend  deeper  into  the  structural  parts  of  the 
prostatic  urethra.  In  the  superficial  form  of  infiltration  the  lesion  only 
involves  the  upper  layers  of  the  subepithelial  connective  tissue,  and  does 
not  result  in  much  condensation  of  the  membrane.  In  the  deeper  form 
the  whole  subepithelial  stratum  is  involved,  and  the  caput  gallinaginis, 
the  sinus  pocularis,  the  openings  of  the  ejaculatory  ducts,  and  the  glands 
of  the  posterior  urethra  may  also  be  more  or  less  implicated  in  the  cell- 
infiltration,  and  their  structure  and  function  more  or  less  damaged  and 
impaired.  All  these  structures  may  be  invaded  in  precisely  the  same 
manner  as  the  racemose  mucous  glands  of  the  anterior  urethra  are. 
These  pathological  changes  must  be  remembered  in  cases  of  spermat- 
orrhoea, prostatorrhoea,  and  in  functional  disturbances  of  the  general 
sexual  apparatus.  Where  this  cell-infiltration  is  very  extensive  and  deep 
the  prostatic  urethra  becomes  more  or  less  callous  and  dense.  The  pic- 
ture seen  by  the  naked  eye  of  chronic  posterior  urethritis  is  sometimes  a 
granular  condition  due  to  epithelial  thickening,  and  perhaps  a  slightly 
warty  condition  due  to  the  presence  of  minute  new  vessels  covered  with 
thickened  epithelium.  In  later  stages  the  caput  gallinaginis  is  seen  to  be 
enlarged  and  covered  by  callosities  formed  by  the  heaping  up  of  patho- 
logical epithelial  layers.  As  a  result  of  these  lesions  we  find  evidences 
of  a  persistent  desquamative  catarrh.  Owing  to  these  changes  the  dila- 
tability  of  the  prostatic  urethra  is  somewhat  impaired,  and  its  lumen  is 
perhaps  slightly  impinged  upon  by  the  epithelial  thickening  and  by  the 
increased  size  of  the  caput  gallinaginis;  but  there  is  no  such  condition 
(though  the  parts  may  have  even  become  cirrhotic)  of  stricture,  such  as  we 
find  in  the  anterior  urethra.  In  the  posterior  urethra  there  seems  to  be  a 
tendency  to  the  condensation  of  the  tissues,  without  much  decrease  in  the 
lumen  of  the  canal. 


THE  ETIOLOGY  OF  GONOBRHCEA.  85 

CHAPTER    VIL 

THE  ETIOLOGY  OF  GONOERHCEA. 

The  cause  and  origin  of  gonorrhoea  constitute  a  question  which  has 
almost  constantly  occupied  the  medical  mind  for  more  than  a  hundred 
years,  and  which  has  given  rise  to  many  animated  and  acrimonious  argu- 
ments and  disquisitions.  In  a  scientific  point  of  view  it  is  most  essential 
that  there  should  be  a  clear  and  full  understanding  of  this  vitally  import- 
ant subject,  which  is  commonly  treated  of  in  a  biassed  way  or  disposed  of 
too  briefly  and  magisterially.  No  subject  in  medicine  is  more  worthy  of 
careful,  unprejudiced  study,  and  for  that  reason  I  make  no  apologies  for 
this  exhaustive  presentation. 

So  often  in  practice  the  etiology  of  gonorrhoea  becomes  a  question 
which  involves  social,  marital,  and  domestic  relations,  and  so  often  upon 
its  correct  understanding  depend  the  happiness,  harmony,  honor,  and 
well-being  of  families,  that  a  clear  knowledge  of  it  is  absolutely  neces- 
sary. The  question  of  the  fidelity  and  loyalty  of  wife  and  husband,  lover 
and  mistress,  so  frequently  occurs,  resulting  from  some  purulent  discharge 
from  the  genitals  of  the  male  and  the  female,  that  it  is  one  of  the  funda- 
mental subjects  in  medicine  concerning  which  the  physician  should  have 
clear,  practical  views. 

There  is  no  longer  any  ground  for  claiming  that  gonorrhoea  is  simply 
a  catarrhal  inflammation.  It  has  been  clearly  and  fully  demonstrated 
that  it  is  a  typically  virulent  process,  and  that  its  essential  virus  resides 
in  the  action  of  one  microbe,  the  gonococcus,  and  that  other  micro-organ- 
isms also  act  as  virulent  agents  and  causes.  Though  these  facts  have 
been  proven  beyond  doubt  or  cavil,  there  are  yet  many  gaps  in  our  know- 
ledge as  to  how  gonorrhoea  originates  in  many  cases.  There  is  to-day 
an  easy-going,  self-satisfied  assertiveness  on  the  part  of  the  more  radical 
of  virulists  to  the  eff"ect  that  the  question  is  settled  and  the  case  closed. 
But  we  shall  see  in  the  progress  of  this  chapter  that,  though  much  has 
been  learned,  and  though  a  flood  of  light  has  been  thrown  on  the  subjects 
of  the  origin  and  nature  of  gonorrhoea,  there  still  remains  much  to  puzzle 
us,  much  yet  to  be  solved,  and  much  to  be  reconciled  by  patient  clinical 
observation,  supplemented  by  broad  studies  in  bacteriology  over  a  very 
wide  field. 

It  will  be  seen  farther  along  that,  although  the  virulent  nature  of 
gonorrhoea  has  been  demonstrated,  there  are  many  strong  and  vital  points 
in  the  doctrines  of  the  non-virulists  which  have  been  passed  over,  ignored, 
and  belittled  by  the  ultra-virulists.  I  shall  endeavor  to  present  our 
knowledge  on  this  subject  in  an  impartial  and  unbiassed  manner,  and 
shall  only  draw  such  conclusions  as  are  clearly  warranted  in  the  general 
survey.  To  this  end  a  statement  and  analysis  of  the  researches  and  views 
of  the  various  observers  who  have  contributed  to  this  subject  are  neces- 
sary. By  a  scientific  and  an  historical  study  we  may  put  ourselves  in 
possession  of  much  knowledge  which  has  until  now  not  been  collated  or 
formulated. 

For  many  years  the  opinion  was  held  by  the  advocates  of  its  virulent 


86  GONOBBHOEA  AND  ITS  COMPLICATIONS. 

origin,  though  it  lacked  demonstration,  that  gonorrhoea  was  caused  by  a 
virus  animatum  or  formed  ferment.  In  1837,  Donne  ^  claimed  that  an 
infusorium  called  by  him  the  trichomonas  vaginalis  was  found  in  vaginal 
pus,  and  that  it  was  the  cause  of  infection  in  coitus.  This  micro-organism 
is  a  habitat  of  the  normal  vagina,  and  has  no  pathogenic  influence. 
Jousseaume^  in  1862  claimed  that  the  alga  genitalia,  discovered  by  him, 
was  the  cause  of  gonorrhoea.  In  a  similar  strain,  Salisbury^  in  1868 
claimed  that  his  own  discovery,  the  fungus  which  he  called  crypta  gon- 
orrhoica,  was  the  origin  of  the  disease.  In  the  same  year  Hallier  claimed 
that  a  fungus  discovered  by  him,  and  called  the  coniothecium,  was  the 
true  materies  morhi.  As  a  matter  of  history  only,  it  may  be  mentioned 
that  Thiry  put  forward  the  claim  that  gonorrhoea  was  due  to  a  granular 
virus.  This  theory  was  largely  based  on  the  observation  of  granulations 
on  the  urethral  and  ocular  mucous  membranes  as  a  result  of  gonorrhoea. 
It  is  shown  elsewhere  that  these  granulations  are  pathological  results  of 
the  gonorrhoeal  process.  Thus  it  will  be  seen  that  no  real  pathogenic 
micro-organisms  had  been  found,  but  that  accidental  infusoria  and  inert 
cocci  had  been  seen,  and  were  by  some  looked  upon  as  pathogenic. 

In  1879,  Neisser  ^  published  a  short  and  modest  paper  which  marks 
an  epoch  in  the  history  of  gonorrhoea.  In  this  paper  he  claimed  that  by 
means  of  Koch's  staining  methods,  and  the  microscope,  using  a  lens  of 
high  power  and  oil-immersion,  he  had  found  in  the  gonorrhoeal  pus  of 
thirty-five  cases  of  from  three  days'  to  thirteen  weeks'  duration  a  micro- 
organism which  he  called  the  gonococcus.  He  claimed  that  in  each  case 
this  organism  was  found,  and  no  others,  and  that  it  was  not  found  in  the 
pus  derived  from  other  sources  nor  in  the  simple  leucorrhoeal  secretion. 
He  found  it  also  in  the  vaginal  discharge  of  two  young  girls  who  had  been 
assaulted  by  a  man  suffering  from  gonorrhoea,  in  the  pus  of  seven  cases 
of  ophthalmia  neonatorum  of  from  one  to  six  weeks'  duration,  and  in  two 
cases  of  gonorrhoeal  ophthalmia  in  adults. 

Neisser's  claims  were  soon  verified  and  supported  by  a  large  number 
of  observers,  notably  Weiss,^  Bokai,®  Welander,^  and  Bumm,^  who  found 
the  gonococcus  in  gonorrhoeal  pus  of  the  urethra.  In  like  manner,  Haab,^ 
Krause,^"  Kroner,"  Leopold  and  Wessels,^^and  Zweifel,^^and  others  endorsed 

^  Becherches  microscopiques  sur  la  Nature  des  Mucus,  Paris,  1837. 

^  "Des  V^getaux  parasites  de  1' Homme,"  These  de  Paris,  1862. 

^  "  Description  of  Two  New  Algoid  Vegetations,  one  of  which  appears  to  he  the  specific 
cause  of  Syphilis,  and  the  other  of  Gonorrhoea,"  Am.  Journ.  Med.  Sciences,  Jan.,  1868,  p.  17. 

*  "  Ueber  eine  der  Gonorrhoe  eigenthiimliche  Micrococcusform,"  Centralblatt  fur  die 
med.  Wissenschciften,  No.  28,  1879. 

5  "Le  Microbe  de  Pus  blennorliagique,"  Thhe  de  Nancy,  1880. 

^  "Ueber  das  Contagium  der  acuten  Blennorrhbe,"  Allgem.  med.  Cevtraheitung,  No.  74, 
1880. 

''"Quelque  K^cherches  sur  les  Microbes  pathog^nes  de  la  Blennorrhagie,"  Gazette 
medicate  de  Paris,  1884,  pp.  267  et  seq. 

8  Der  Micro-organi^mus  der  Gonnorrhoischen  Schleimhaut  Erkranhungen,  "  Gonococcus 
Neisser,"  AViesbaden,  1887. 

9  "  Der  iSIicrococcus  der  Blennorrhcea  Neonatorum,"  FeMschriff,  Wiesbaden,  1881. 

1"  "Die  Micrococcen  der  Blennorrhcea  Neonatorum,"  Centralblatt  fiir  praet.  AugenheU- 
kunde,  1882,  pp.  134  et  seq. 

"  "Zur  Aetiologie  der  Ophthalm.oblennorrha?a  Neonatorum,"  Archiv  fiir  Gynecologic, 
XXV.,  1884,  pp.  109  et  seq. 

^2  "Beitragzur  Aetiologie  und  Prophylaxe  der  Ophthalmoblennorrhoea  Neonat./'  ibid., 
vol.  xxiv.  pp.  92  et  seq. 

13  "  Zur  Aetiologie  der  Ophthalmoblennorrhoea  Neonator.,"  ibid.,  vol.  xxvi.  pp.  318etseq. 


THE  ETIOLOGY  OF  GONOBRHCEA.  87 

Neisser's  claim  that  the  gonococcus  was  the  materies  morhi  in  gonorrhoeal 
ophthalmia,  and  demonstrated  by  numerous  observations  and  confronta- 
tions that  the  eye-infection  of  the  many  children  reported  was  caused  by 
gonococci-containing  pus  Avhich  was  present  in  the  genital  tract  of  the 
mothers. 

Since  the  publication  of  Neisser's  original  essay  a  multitude  of  papers 
have  appeared  relating  to  the  gonococcus.  Many  of  these  papers  are  by 
able  men,  and  are  of  value  as  cumulative  evidence  only ;  but  still  more 
of  them  are  the  lucubrations  of  inexperienced  and  unskilful  physicians. 
It  is  well,  therefore,  to  ignore  much  that  has  been  written,  and  to  consider 
only  the  essays  which  we  may  term  magisterial. 

Neisser's  earlier  observations  were  wholly  microscopical,  but  in  a  sec- 
ond paper,  published  in  1882,  he  speaks  of  attempts  which  were  not  suc- 
cessful to  cultivate  the  gonococcus.  Claims  were  made  by  Bokai  (1880) 
and  Bockhart  (1883)  that  they  had  cultivated  the  gonococcus  and  had 
inoculated  it  with  success.  Bokai  claimed  that  with  the  product  of  his 
cultures  he  inoculated  the  urethrse  of  three  medical  students,  who  were 
thereby  infected  with  gonorrhoea.  Bockhart  inoculated  a  fourth  culture 
on  gelatin  into  the  urethra  of  a  paralytic,  in  Avhom  he  produced  urethritis, 
cystitis,  and  pyelitis.  The  man  died  ten  days  after  of  pneumonia.  It  has 
within  a  few  years  been  clearly  shown  that  the  gonococcus  can  only  be 
cultivated  upon  human  blood,  blood-serum  alone,  or  in  combination  with 
peptone-agar ;  consequently,  it  is  fair  to  assume  that  the  micro-organisms 
cultivated  by  Bokai  and  Bockhart  were  not  gonococci  at  all,  but  some 
form  of  pus-producing  cocci.  These  observations,  however,  have  much 
clinical  importance  in  the  fact  that  quite  early  in  the  history  of  the  bac- 
teriology of  urethral  discharges  they  showed  that  other  organisms  than 
the  gonococcus  can  produce  suppuration  in  the  urethra.  It  is  therefore 
necessary  to  emphasize  the  statement  that  no  reliance  whatever  can  be 
placed  on  cultures  obtained  with  any  other  media  than  those  just  men- 
tioned^namely,  human  blood  or  blood-serum  alone  or  in  combination 
with  agar-agar  or  peptone-agar.  Where  other  culture-media  have  been 
used  some  other  organism  than  the  gonococcus  has  been  cultivated. 
FrankeP  very  tersely  says  :  "  The  gonococcus  belongs  to  the  most  incar- 
nate parasites  inhabiting  the  human  body,  and  the  conditions  of  its  exist- 
ence outside  of  the  latter  are  at  any  rate  very  restricted." 

Up  to  the  year  1885  the  recognition  of  the  gonococcus  had  been  only 
made  by  means  of  the  microscope.  The  efforts  of  many  observers  to 
cultivate  the  micro-organism  had  failed  or  had  led  to  false  results,  as  we 
have  seen,  for  the  reason  that  the  proper  cultivating  medium  had  not 
been  used.  Neisser  himself  fell  into  error  when  he  claimed  that  he  had 
cultivated  a  coccus  on  flesh-peptone  gelatin,  which  was  the  gonococcus, 
but  which  was  in  all  probability  a  non-pathogenic  diplococcus.  The  first 
reliable  experiment  of  inoculating  the  human  subject  with  the  cultivated 
gonococcus  was  made  by  Bumm,  who  introduced  a  second  culture  into  the 
urethra  of  a  female  previously  healthy  as  to  her  genitals.  On  the  third 
day  a  burning  pain  was  felt  on  passing  water,  and  gonococci  were  found 
in  the  epithelium  of  the  urethra.  A  characteristic  gonorrhoea  followed, 
the  acute  stage  of  which  lasted  three  weeks.  Daily  examination  of  the 
discharge  showed  the  presence  of  gonococci.     Though  this  experiment 

^  Text-book  of  Bacteriology,  New  York,  1891,  pp.  330  et  seq. 


88  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

seemed  striking  in  result,  it  was  not  convincing,  for  the  reason  that  only 
a  second  culture  had  been  used. 

Fliigge^  expressed  himself  as  follows  regarding  this  experiment:  "In 
this  instance,  notwithstanding  the  fact  that  no  pus-cells  were  found  in  the 
culture  on  microscopical  examination,  we  cannot  entirely  put  aside  the 
objection  that  perhaps  the  cocci  in  the  urethral  discharge  were  simply 
carried  over,  especially  as  the  first  transference  upon  the  artificial  culture- 
medium  was  made  with  relatively  large  masses."  To  settle  all  doubt, 
Bumm  made  a  second  experiment,  and  in  it  used  the  twentieth  culture 
of  the  gonococcus  on  human  blood-serum,  which  he  had  impregnated  with 
the  pus  of  gonorrhoeal  ophthalmia.  The  patient  was  also  a  woman, 
healthy  as  to  her  genitals.  The  infecting  culture  was  placed  in  her 
urethra,  care  having  been  taken  that  no  other  infection  could  occur.  In 
about  two  days  the  urethral  mucous  membrane  was  seen  to  be  red,  and 
from  it  a  small  quantity  of  cloudy  serous  fluid  exuded,  which  under  the 
microscope  was  seen  to  contain  gonococci  and  epithelial  and  pus-cells.  A 
typical  gonorrhoea  was  produced.  This,  then,  is  the  first  satisfactory  and 
unimpeachable  experiment  by  culture,  which  proved  the  gonococcus  to  be 
the  pathogenic  agent  in  gonorrhoeal  infection.  Owing  to  the  great  care 
and  skill  necessary,  and  the  great  difficulty  experienced  in  cultivating  the 
gonococcus,  many  observers  have  failed  in  their  efforts  to  thus  isolate  it. 

Aufuso^  sterilized  and  coagulated  the  fluid  taken  from  an  inflamed 
knee-joint  and  inoculated  it  with  active  gonorrhoeal  pus.  Cultures  were 
successfully  made,  and  from  the  tenth  generation  he  inoculated  the  urethra 
of  a  healthy  man,  using  a  portion  the  size  of  a  pinhead.  In  two  days  a 
muco-purulent  discharge  appeared,  which  was  the  forerunner  of  acute 
gonorrhoea.  In  the  secretion  characteristic  diplococci  (gonococci)  were 
found.      Cultures  on  gelatin  remained  sterile. 

Wertheim,^  however,  has  lately  added  much  to  the  question  of  the 
pathogenic  nature  of  the  gonococcus  and  has  made  some  very  important 
advances  in  its  prompt  and  ready  cultivation,  which  have  been  accepted  by 
Bumm  as  reliable  and  confirmed  by  Gebhard.^  Taking  the  pus  of  gonor- 
rhoeal salpingitis,  this  observer  has  cultivated  it  according  to  his  method, 
and  with  the  product  has  by  inoculation  into  the  human  urethra  produced 
gonorrhoea  in  five  cases.  Thus  we  have  ample  proof  of  the  virulence  of 
the  gonococcus  when  produced  by  cultures.  It  will,  therefore,  be  seen 
that  the  gonococcus  thrives  with  equal  luxuriance  and  acts  with  equal 
virulence  in  the  conjunctival  and  urethral  mucous  membranes.  The 
observations  of  the  ophthalmological  investigators  already  mentioned  have 
clearly  shown  that  gonococci-containing  pus  from  the  mother's  genitals 
causes,  under  favorable  circumstances,  virulent  ophthalmia  in  the  eyes  of 
their  new-born  children. 

In  clinical  practice  Welander^  studied  twenty-five  cases  of  men  suf- 
fering from  gonorrhoea  in  confrontation  with  the  women  from  whom  they 
derived  the  infection,  and  in  each  instance  found  the  gonococcus  in  the 

^  Die  Mikro-organismen,  2d  ed. ,  p.  1 58. 

^  Riforma  Medka,  1891,  anno  vii.,  vol.  i.  pp.  328  et  seq. 

^  "Die  Ascendirende  Gonorrhoea  beim  Weibe,  etc.,"  Archiv  filr  GynakoL,  1892,  vol. 
xlii.  pp.  1-86,  and  ' '  Zur  Lehre  von  der  Gonorrlioe,"  Verhandl.  chr  Deutsch.  Gesselsch.  fur 
Gynaek.,  Leipzig,  1892,  iv.  pp.  340  et  seq. 

*  "  Der  Gonococcus  Neisser  auf  der  Platte  und  Reinculture,"  Berl.  klin.  Wochenschrift, 
1892,  No.  11.  5  Op.  cit. 


THE  ETIOLOGY  OF  GONOBBHCEA.  89 

secretions  of  both  sexes.  Such  uniformity  of  result,  however,  it  must  be 
admitted,  is  little  less  than  marvellous.  This  observer  also  introduced 
gonococci-containing  pus  into  the  urethrse  of  three  men.  The  result  was 
gonorrhoea  in  its  typical  form  in  two  days,  in  the  secretion  of  which 
gonococci  were  found.  Bumm  also  speaks  of  a  case  in  Rinecker's  clinic 
in  which  gonococci-containing  pus  Avas  introduced  into  the  human  urethra, 
with  the  effect  of  promptly  producing  typical  gonorrhoea. 

The  foregoing  evidence  is  further  supported  by  innumerable  observa- 
tions made  by  very  many  observers,  Avho  constantly  found  gonococci  in 
the  pus  of  true  acute  gonorrhoea. 

There  is  further  certain  negative  evidence  which  demands  our  atten- 
tion, since  it  is  both  interesting  and  important.  Thus,  Kroner  and  Zwei- 
fel,  who  by  clinical  observation  and  inoculation  had  demonstrated  that 
pus  and  lochia  containing  gonococci  always  produced  typical  gonorrhoeal 
ophthalmia,  invariably  observed  negative  results  when  they  inoculated 
the  conjunctiva  with  vaginal  secretions  free  from  gonococci.^  The  expe- 
rience of  Welander,  Leopold  and  Wessels,  and  Bumm  confirmed  that  of 
Kroner  and  Zweifel.  Bumm  in  a  series  of  experiments  {a)  with  the  cer- 
vical secretion  free  from  gonococci  after  the  subsidence  of  gonorrhoea,  (&) 
with  the  secretion  free  from  gonococci  of  chronic  gonorrhoea,  and  (c)  with 
gonorrhoeal  secretion  in  which  the  gonococci  had  perished,  also  obtained 
negative  results  by  inoculating  the  eye. 

Neisser^  in  his  latest  essay,  reaffirming  his  belief  in  the  virulence  of 
the  gonococcus  and  its  causative  relation  to  the  gonorrhoeal  process,  lays 
stress  upon  the  negative  facts  brought  out  by  Sternberg,^  Lundstrom,* 
Chameron  and  Constantino  Paul,^  and  others.  These  observers,  without 
any  preconceived  prejudices  and  with  the  object  of  producing  gonorrhoea, 
inoculated  into  the  human  urethra  in  a  number  of  cases  non-specific  cocci 
which  they  had  cultivated  upon  media  upon  which  the  gonococcus  Avill 

^  This  absolute  uniformity  of  negative  result  is  so  striking  that  it  is  apt  to  beget  doubt 
in  one's  mind.  This  is  particularly  the  case  when  we  consider  the  results  obtained  by  my 
colleague,  Dr.  J.  A.  Andrews,  whom  I  know  to  be  an  accurate  and  skilled  observer. 
Andrews  says  (art.  "Gonorrhoeal  Ophthalmia,"  A  System  of  GenUo-urinary  Diseases,  etc., 
vol.  i.  p.  224)  :  "The  writer  has  examined  the  secretion  from  the  vagina  of  the  mothers 
of  eighty-eight  infants  in  which  ophthalmia  developed  from  fifty  to  seventy-two  hours 
after  birth.  The  gonococcus  was  found  in  two  only  of  tliese  cases  in  the  mother  and  child, 
the  one  infant  being  infected  at  birth,  and  the  other  six  days  after  birth  through  careless- 
ness of  the  mother.  The  typical  clinical  picture  of  gonorrhoeal  conjimctivitis  was  absent 
in  eighty-six  cases  ;  nevertheless,  one  eye  was  lost  in  five  infants  and  both  eyes  in  one 
infant,  the  disease  being  non -gonorrhoeal."  Andrews  further  on  says  that  his  microscop- 
ical studies  have  convinced  him  that  in  the  majority  of  cases  ophtlialmia  neonatorum  is 
not  of  a  gonorrhoeal  nature.  Thus  we  see  that  the  result  of  clinical  observation  is  not  in 
accord  with  the  result  of  experimentation  in  this  matter.  Therefore  in  this  particular 
instance,  and  in  all  essays  at  experimentation  on  the  subject  of  urethral  suppuration,  we 
must  not  be  too  much  carried  away  with  the  results  claimed  for  experiments,  the  majority 
of  whicli  have  been  made  by  men  who  are  champions  and  zealots  of  the  gonococcus  doc- 
trine. We  shall  see  farther  on  that  scientific  clinical  observation,  aided  by  unimpeach- 
able microscopic  skill,  leads  to  conclusions  which  are  more  or  less,  and  in  some  cases 
wholly,  at  variance  with  some  of  the  claims  of  the  gonococcus  champions. 

^  "Ueber  die  Bedeutung  des  Gonococcen  fiir  Diagnose  und  Therapie,"  Verhandlungen 
der  Deuischen  Dermatoiogischen  Gesellschaff,  Vienna,  1889,  pp.  133  et  seq. 

3  "The  Micrococcus  of  Gonorrhoeal"  Pus,  etc.,"  Med.  News,  .Jan.  20,  1883,  pp.  67  et 
seq.,  and  "Further  Experiments  with  the  Micrococcus  of  Gonorrhceal  Pus,  etc.,"  ibid., 
Oct.  18,  1884,  pp.  426  et  seq. 

*  "Studier  ofver  Gonococcus,"  Inaug.  Dissert.,  Helsingfors,  1885. 

^  "  Du  Traitement  de  la  Blennorrhagie  consider^e  comme  Affection  parasitaire,"  These 
de  Paris,  1884. 


90  GONORRBCEA  AND  ITS  COMPLICATIONS. 

not  thrive.  The  experiments  were  made  as  early  as  1884,  when  it  was 
not  known  that  the  gonococci  could  only  be  cultivated  on  human  blood- 
serum.  Consequently,  the  culture-products  they  obtained  were  not  gono- 
cocci at  all,  but  some  harmless  microbe.  Though  these  cultures  of  sup- 
posed gonococci  were  introduced  freely  into  the  urethra,  no  result  whatever 
was  produced  in  any  case.  Neisser  further  makes  the  important  statement 
that  he  has  studied  the  action  of  various  cocci  cultivated  from  gonorrhoeal 
pus  upon  the  human  urethra,  and  that  he  has  obtained  absolutely  negative 
results. 

Welander's  experiments  also  presented  some  striking  results.  He 
introduced  into  the  urethra  of  five  men  the  fetid  pus  of  balanitis  which 
contained  indifferent  microbes,  also  leucorrhoeal  secretion  containing  a 
multitude  of  different  micro-organisms,  yet  in  no  instance  was  any  patho- 
logical reaction  induced.  He  took  the  vaginal  secretion  of  a  fourteen- 
year-old  virgin  containing  epithelial  cells,  spherical  and  bacilliform 
microbes,  and  introduced  it  into  the  urethrse  of  three  men,  without  indu- 
cing any  reaction  whatever.  Again,  he  introduced  fetid  purulent  vaginal 
discharge,  containing  large  quantities  of  microbes,  into  the  urethrae  of 
three  other  men,  with  an  absolutely  negative  result.  From  three  women 
whose  urethral  secretion  contained  gonococci,  but  whose  vaginal  secretions 
were  free  from  these  organisms,  he  took  a  considerable  quantity  of  this 
vaginal  secretion  and  introduced  it  into  the  urethrse  of  three  healthy  men, 
without  any  effect  whatever.  From  the  urethra  of  one  of  these  women, 
who  was  menstruating  at  the  time,  he  took  a  small  quantity  of  the  secre- 
tion and  introduced  it  into  the  urethra  of  a  healthy  man.  The  result  was 
the  rapid  induction  of  a  true  gonorrhoea,  as  shown  by  the  symptoms  and 
the  presence  of  gonococci  in  the  pus.  A  small  quantity  of  the  urethral 
secretion  of  three  women,  in  which  gonococci  were  present,  was  introduced 
into  the  urethrae  of  two  of  the  men  who  had  previously  been  unsuccessfully 
experimented  upon  with  the  pus  not  containing  gonococci,  with  the  result 
of  producing  gonorrhoea  promptly. 

Summing  up  the  knowledge  thus  far  presented,  which  may  be  called 
the  creed  of  the  gonococci-advocates,  it  is  claimed  that  the  following  propo- 
sitions are  worthy  of  acceptance  : 

1.  The  demonstration  of  the  gonococcus  by  the  microscope  in  gonor- 
rhoeal pus. 

2.  Its  cultivation  and  its  production  by  means  of  experimental  inocu- 
lation of  gonorrhoea  in  the  human  urethra. 

3.  The  development  of  gonorrhoea  experimentally  in  the  human  subject 
by  the  introduction  into  the  urethra  of  gonococci-containing  pus  from 
males  and  females. 

4.  Certain  negative  evidence  which  seems  to,  and  it  is  claimed  does, 
prove  that  secretions  not  containing  gonococci  will  not  produce  gonorrhoea. 

5.  A  number  of  indifferent  microbes  obtained  by  cultivation  and 
falsely  regarded  as  gonococci  produced  no  pathological  result. 

6.  Various  purulent  secretions  taken  from  men  and  Avomen  not  con- 
taining gonococci  did  not,  when  experimented  with,  produce  gonorrhoea. 

7.  It  must  not  be  forgotten  that  certain  microbes,  supposed  to  have 
been,  but  which  certainly  were  not,  gonococci,  in  the  hands  of  Bokai  and 
Bockhart  produced  violent  suppuration  resembling  true  gonorrhoea  in 
experiments  on  the  human  subjects.      This  last  point  has  been  almost 


THE  ETIOLOGY  OF  GONORRHOEA.  91 

ignored,  but  certainly  passed  over,  by  Neisser  and  his  followers ;  but  it 
will  require  our  attention  and  further  elaboration  again  a  little  farther  on. 
Bumm,  as  a  result  of  his  studies  (and  his  views  are  accepted  in  full  by 
Neisser  and  many  others),  thinks  that  in  the  present  state  of  medical 
science  he  is  warranted  in  presenting  the  following  postulates : 

1.  When  no  disinfecting  treatment  has  been  used  gonococci  are  to  be 
found  in  the  secretion  of  every  gonorrhoeal  mucous-membrane  inflamma- 
tion. 

2.  Secretions  free  from  gonococci  behave  as  non-infectious  toward 
mucous  membranes. 

3.  A  secretion  containing  gonococci  causes  gonorrhoeal  inflammation 
in  susceptible  mucous  membranes  with  absolute  certainty  even  when  used 
in  small  quantity.  He  further  claims  that  the  presence  of  Neisser' s  gono- 
cocci in  a  secretion  proves,  under  all  circumstances  and  m  all  certainty, 
both  the  infectious  origin  of  the  disease  of  the  mucous  membrane  and  of 
the  secretion  poured  forth,  and  that,  conversely,  a  secretion  free  of  gono- 
■cocci,  whatever  he  its  origin,  has  no  virulent  properties. 

The  foregoing  gives  a  full  and  impartial  statement  of  the  position  of 
Neisser  and  his  followers.  It  will  be  seen  that  their  claims  are  far-reaching, 
and  that  they  are  made  with  an  absolutism  which  is  peculiar  to  most  new 
departures  which  break  into  an  era  of  doubt  and  uncertainty.  Until  1879 
we  had  groped  in  the  dark,  unaided  even  by  a  ray  of  truly  scientific  light, 
as  to  the  essential  nature  of  the  gonorrhoeal  process.  Having  found  the 
gonococcus,  Neisser  and  his  followers  proceeded  in  the  most  magisterial 
manner  to  claim  that  it,  and  it  alone,  was  the  pathogenic  agent  in  the 
causation  of  gonorrhoea,  and  that  in  it  resided  its  virulence.  It  was  the 
same  tendency  of  the  human  mind  which  actuated  Ricord  when,  more  than 
forty  years  previously,  he  had  claimed  with  vehemence,  in  season  and  out 
of  season,  that  gonorrhoea  was  a  simple  catarrhal  process  absolutely  with- 
out virulence  or  specificity.  Gonorrhoea  had  so  long  been  confounded 
with  syphilis — which  is,  of  course,  a  virulent  disease — that  when  Ricord 
established  the  non-identity  and  non-interdependence  of  the  two  diseases, 
he  very  promptly  and  truculently  proceeded  to  deny  for  gonorrhoea  any 
virulent  principle  whatever,  and  to  relegate  it  to  the  group  of  simple 
catarrhs.  In  like  manner,  but  in  an  opposite  direction,  Neisser  and  his 
followers,  as  soon  as  the  gonococcus  was  revealed  to  them,  put  up  the 
claim,  which  has  been  stated,  that  in  the  gonococcus  alone  resided  the 
virulence  of  true  gonorrhoea.  But  absolute  statements,  particularly  on 
subjects  as  yet  not  long  and  broadly  discussed,  luckily  always  incite  in 
the  minds  of  some  doubt,  skepticism,  and  conservatism,  which  lead  to 
further  study  and  examination,  and  in  the  end  to  broader  views  and  posi- 
tions nearer  the  truth.  This,  naturally,  is  what  has  occurred  in  the 
matter  of  the  gonococcus  question.  Neisser's  far-reaching  claims  and 
assumptions  have  led  to  a  broad  investigation  of  the  Avhole  subject  of  the 
etiology  of  gonorrhoeal  discharges  by  many  observers.  As  a  result,  it  will 
be  seen  that  while  Neisser's  main  proposition  as  to  the  relation  of  the 
gonococcus  to  acute  gonorrhoea  is  true  in  a  large  majority  of  cases,  it  may 
have  its  exceptions.  It  has  also  been  further  very  clearly  shown  that 
other  micro-organisms  may  be  the  pathogenic  agents  in  urethral  suppura- 
tions. It  is  well,  therefore,  not  to  be  led  by  the  writings  of  Neisser, 
Bumm,  and  others  into  a  feeling  that  the  question  is  fully  and  finally 


92  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

settled,  but  to  examine  into  and  ponder  over  the  facts  which  have  been 
brought  out  by  those  who  deny,  in  part  or  in  whole,  the  absolute  specificity 
of  the  gonococcus.  The  question  of  the  etiology  of  gonorrhoea  is  to-day, 
as  we  have  said  before,  far  from  being  on  an  absolutely  definite  and  set- 
tled basis,  and  very  much  careful  and  extended  study  is  yet  needed  to 
broaden  our  knowledge,  to  clear  away  doubt  and  confusion,  to  reconcile 
inconsistencies,  and  to  fill  very  many  important  gaps. 

The  bolt  which  struck  in  the  camp  of  the  gonococcus-adherents,  and 
did  the  most  damage,  was  the  paper  of  Lustgarten  and  Mannaberg,^  which 
may  be  said  to  have  produced  consternation.  These  observers  show  that 
in  the  normal  urethra  a  variety  of  micro-organisms  grow.  Most  of  these 
microbes  are  harmless  parasites  or  saprophytes.  There  are  three,  how- 
ever, which,  the  authors  think,  deserve  especial  attention.  They  are — 1, 
a  pyogenic  coccus,  the  staphylococcus  aureus ;  2,  a  bacillus  resembling 
the  tubercle  bacillus,  and  probably  identical  with  the  smegma  bacillus ; 
and  3,  one  or  several  species  of  diplococci,  which  resemble  completely 
Neisser's  gonococcus  in  shape  and  tinctorial  qualities,  especially  in  being 
decolorized  by  (jrram's  method. 

The  establishment  of  the  fact  that  in  healthy  urethras  micro-organisms 
known  to  have  a  pathogenetic  power  lurk  and  lie  dormant  is  of  great 
importance  in  further  perfecting  our  knowledge  and  in  removing  obscuri- 
ties from  many  seemingly  queer  or  anomalous  cases.  Besides  these  pyo- 
genic bacteria  there  are  several,  if  not  many,  others  which  are  thought  to 
be  innocuous,  but  which  may,  perhaps,  under  favorable  circumstances, 
become  harmful.  Lustgarten  and  Mannaberg's  observations  led  to  the 
study  of  this  question  by  several  other  observers,  who  have,  in  the  main, 
confirmed  their  statements.  Thus,  Steinschneider,^  a  pupil  of  Neisser, 
made  an  exhaustive  study  of  the  bacteriology  of  the  urethra  in  a  normal 
state,  and  also  in  subjects  suffering  from  acute  and  chronic  gonorrhoea. 

Fig.  50. 


tf^ 


Showing  on  the  left  half  some  groups  of  gonococci  obtained,  by  culture,  and  on  the  right  half  some 
groups  of  a  so-called  pseudo-gonococcus  cultivated  from  a  specimen  derived  from  a  normal 
urethra  virgin  to  gonorrhoea  (cultures  by  Dr.  Henry  Heiman  in  the  pathological  laboratory  of 
the  College  of  Physicians  and  Surgeons,"N.  Y.j. 

As  a  result,  he  found  virulent  and  inert  organisms  in  healthy  urethras, 
and  also,  like  Bumm,  various  other  organisms  in  gonorrhoeal  pus  besides 
the  gonococci.     He  concedes  that  a  diplococcus,  or,  as  it  may  be  termed, 

^  "Ueber  die  Mikro-organismen  der  Normalen  Mannlichen  Urethra,  etc.,"  Viertel- 
jahresschrift  filr  Derm,  unci  Syph  His,  1 887,  pp.  90o  et  seq. 

^  "  Ueber  Seine  in  Verbindung  mit  Dr.  Galewsky  vorgenommenen  Untersucliungen 
liber  Gonococcen  und  Diplococcen  in  der  Harnrohre,"  Verhandlungen  der  Deutsch.  Der- 
matol. GeseUschafi  zu  Prague,  1889,  pp.  159  et  seq. 


THE  ETIOLOGY  OF  GONORRHOEA.  93 

pseuclo-gonococcus,  which  in  a  measure  resembles  the  gonococcus,  is  found, 
and  may  lead  to  a  possibility  of  doubt  and  error  in  about  5  per  cent,  of 
cases.  This  statement,  coming  direct  from  Neisser's  laboratory,  is  cer- 
tainly very  significant. 

In  this  connection  Fig.  50  is  worthy  of  attentive  study.  On  the  left- 
hand  side  of  the  figure  the  true  gonococcus  is  seen,  while  on  the  right- 
hand  side  a  larger,  but  very  similar,  diplococcus,  arranged  in  groups  of 
twos  and  fours,  is  portrayed.  A  comparison  of  these  two  orders  of  diplo- 
cocci  shoAvs  no  visible  difi'erence  except  in  size.  It  can  be  readily  seen, 
therefore,  that  unless  a  person  is  thoroughly  skilled  in  bacteriology  he 
may  easily  fall  into  error  in  the  identification  of  these  micro-organisms. 

There  is  still  further  evidence,  however,  in  the  same  direction  and 
strain.^  A  number  of  capable  men  have  separately  studied  this  question, 
and  have  shown  conclusively  that  many  micro-organisms  are  found  in  the 
healthy  urethra,  most  of  which  are  non-pathogenetic.  There  is  consider- 
able unanimity  of  statement  that  microbes  very  closely  resembling  the 
gonococcus,  and  very  difficult  to  distinguish  from  it,  are  quite  constantly 
found.  Then,  again,  it  is  very  clearly  proved  that  such  micro-organisms 
as  the  staphylococci  and  streptococci,  whose  virulence  under  favorable 
conditions  is  well  known,  have  been  frequently  found  in  the  normal 
urethra.  The  net  results  of  the  studies  thus  far  made  into  the  bacteriol- 
ogy of  the  normal  and  diseased  urethra  go  to  show  that  the  gonococcus  is 
the  most  constant  and  potent  morbific  agent  in  the  production  of  urethral 
inflammations,  but  that  other  micro-organisms  also  play  an  active  role  in 
this  direction.  We  have  knowledge  enough  concerning  some  of  these 
pyogenic  microbes  to  warrant  the  statement  that  they  can,  and  do  under 
favorable  conditions,  produce  urethral  suppuration. 

In  the  course  of  time  it  may  be  proved  that  certain  micro-organisms 
found  in  the  urethra,  which  are  now  regarded  as  harmless  saprophytes, 
may  also,  under  certain  conditions,  be  capable  of  producing  inflammatory 
changes.  At  present  precise  statements  as  to  the  pathogenic  agent  or 
agents  in  other  than  gonococci-produced  urethral  suppurations  cannot  be 
made.  It  will  require  much  patient  and  accurate  study  by  many  observers 
to  place  this  subject  upon  a  clear  scientific  basis.  All  that  we  can  do 
now  is  to  place  on  record  the  experience  thus  far  developed  and  the  views 
derived  from  such  experience. 

To  Aubert^  is  certainly  due  the  credit  of  having  first  definitely  called 
attention  to  the  fact  that  urethral  discharges  are  caused  by  other  micro- 
organisms than  the  gonococcus.     He  made  a  series  of  observations  which 

^  This  may  be  found  in  the  following  essays :  Giovannrni  :  "  Die  Microparasiten  der 
mannlichen  Ham rohren trippers,"  Centralbl.f.  d.  med.  Wissenschaft,  1886,  No.  48  ;  Legrain  : 
"  Les  Associations  microbiennes  de  1' Ur^thre,"  Annates  des  Maladies  des  Organes  Genito- 
urinaires,  1889,  pp.  141  et  seq. ;  Petit  et  Wassermann  :  "  Micro-organismes  de  1' Urethra 
de  I'Homme,"  same  journal,  1891,  pp.  378  et  seq. ;  Eovsing :  "  Die  Blasenentzundungen  ihre 
Aetiologie,  etc.,  Berlin,  1890,  pp.  60  et  seq.;  Hall^,  "De  I'lnfection  urinaire,"  Ann.  des 
Mai.  des  Org.  G^n.-urin.,  Feb.,  1892;  Keymond  :  "Cystites  survenues  chez  des  Malades 
n'ayant  jamais  ete  Sondes,"  ibid.,  Oct.,  1893,  pp.  734  et  seq.  Several  observers  found 
many  micro-organisms  quite  uniformly  ;  some  differ  from  others  as  to  the  nature  and 
character  of  certain  microbes,  but  all  are  fairly  well  in  accord  with  the  statement  given 
in  the  text.  (Vide  supra.)  The  fact  is,  that  we  have  only  just  begun  tlie  study  of  the 
bacteriology  of  the  healthy  and  diseased  urethra,  and  that  no  absolute  statements  or  any 
generalization  whatever  can  yet  be  made. 

^  "De  1' Urethrites  bact^riennes,"  Lyon  Medical,  1884,  xlvi.  pp.  337  et  seq. 


94  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

convinced  him  that  besides  ordinary  gonorrhoea  there  are  certain  urethral 
discharges  characterized  by  the  presence  of  bacteria  which  differ  markedly 
from  the  gonococcus,  and  which  may  be  complicated  by  epididymitis  and 
cystitis.  He  speaks  of  having  found  in  three  cases  a  small  oval  and 
elongated  coccus  and  bacillus.  He  is  not  certain  whether  this  form  of 
gonorrhoea  is  a  type  or  an  accidental  condition  due  to  what  we  now  call 
mixed  infection.  The  value  of  Aubert's  work  resides  in  the  broad  possi- 
bilities which  it  suggests,  rather  than  in  the  definiteness  of  its  statement. 

Further  light  is  thrown  on  the  subject  by  a  lengthy  paper  by  Bock- 
hart/  in  which  he  describes  and  pictures  certain  micro-organisms  which 
he  found  in  urethral  pus  and  by  cultivation  during  the  study  of  fifteen 
cases.  Bockhart  concludes  that  there  is  a  benign  acute  pseudo-gonor- 
rhoeal  urethritis  which  results  from  infection  by  bacteria  of  the  vagina, 
among  which  most  prominent  are  a  small  staphylococcus  and  an  ovoid 
streptococcus.  In  its  clinical  course  this  form  of  gonorrhoea  resembles 
that  which  is  elsewhere  described  as  simple  urethritis. 

Zeissl,^  in  an  extended  study  of  this  question,  examined  the  pus  of 
seven  cases  of  urethral  suppuration,  non-gonorrhoeal  in  origin,  and  found 
diplococci  resembling  gonococci  and  other  micro-organisms.  Zeissl's 
paper  is  interesting  and  valuable  in  the  fact  that  the  various  microscopic 
pictures  are  clearly  reproduced. 

Further  evidence  as  to  the  origin  of  urethral  suppurations  in  pus  free 
from  gonococci,  and  as  to  the  existence  of  diplococci  resembling  gonococci, 
is  furnished  by  a  number  of  observers.  Thus,  Rauzier^  details  three 
cases  of  so-called  gonorrhoea  in  the  secretion  of  which  no  gonococci  were 
found,  but  a  larger  diplococcus  was  present,  which  resembled  the  former. 

Legrain  *  reports  the  case  of  a  medical  student  who  had  urethritis,  in 
the  pus  of  which  the  presence  of  the  micrococcus  cereus  albus  of  Passet 
was  found.  The  woman  with  whom  the  man  had  cohabited  was  consid- 
ered healthy,  but  she  had  previously  suffered  from  retro-uterine  phlegmon. 
In  this  case  the  supposition  is  warranted  that  perhaps  infection  was  caused 
by  urethral  inflammation  which  developed  the  pathogenic  power  of  a 
saprophyte.  Legrain  ^  further  details  the  case  of  a  man  free  from  venereal 
disease  or  vegetations  who,  while  convalescing  from  typhoid  fever,  was 
attacked  by  urethral  suppuration,  at  one  time  slightly  sanguinolent,  which 
involved  the  posterior  urethra.  In  the  pus  of  this  case  the  micrococcus 
pyogenes  aureus  and  several  other  micrococci  were  found. 

Castex  ^  reports  the  case  of  a  perfectly  healthy  boy  who,  having  reten- 
tion of  urine  following  an  operation  on  the  knee,  was  catheterized,  per- 
haps carelessly.     A  slight  sluggish  purulent  urethritis  was  produced,  in 

^"Ueber  die  pseudo-gonorrhoische  Entziindung  der  Harnrohi-e  und  des  Xeben- 
hodens,"  3Ionatshefte  fiir  Prakt.  Dermatohgie,  1886,  pp.  134  et  seq. 

''  "  Ueber  die  Diplococcus  Neisser's  und  seine  Beziehung  zum  Tripperprozess,"  Wiener 
klinik,  Nov.  and  Decern.,  1886. 

*  "Le  Gonocoque  et  la  Duality  des  Urethrites,"  Gazette  med.  de  Montpelier,  Nos.  7 
and  8,  1888. 

*  "Contribution  a  la  Diagnose  du  Gonococcus,"  Annales  des  Maladies  des  Organ.  Gen.- 
urin.,  1888,  pp.  523  et  seq.,  and  "Contribution  a  1' Etude  de  I'Etiologie  des  Urethrites 
non-blennorrhagiques,"  ibid.,  1889,  pp.  337  et  seq. 

^  "Urethrite  survenue  chez  un  Convalescent  de  Fi^vre  typhoide,"  ibid.,  1889,  pp. 
291  et  seq. 

*  "Urethrite  sans  Gonocoque,"  Gaz.  hebd.  de  Med.  et  de  Chir.,  2d  Series,  vol.  xxiv. 
p.  358,  1887. 


THE  ETIOLOGY  OF  GONORRHCEA.  95 

the  secretion  of  which  a  staphylococcus  was  found  and  further  cultivated. 
Somewhat  similar  in  nature  is  the  case  reported  by  De  Amicis.^  This 
observer  injected  ammonia  into  the  male  urethra  (being  a  repetition  of 
the  classic  experiment  of  Swediaur),  which  produced  suppuration,  in  the 
pus  of  which  diplococci  resembling  gonococci  were  found.  These  diplo- 
cocci  were  larger  than  gonococci,  and  were  not  found  in  the  pus-cells. 
De  Amicis  further  claims  that  he  took  pus  from  a  child  suffering  from 
vulvo-vaginitis  which  was  not  due  to  gonorrhoeal  infection  and  inoculated 
with  it  the  male  urethra.  The  result  was  typical  gonorrhoea,  in  the  pus 
of  which  micrococci  resembling  gonococci  were  found.  The  experiment 
of  Martin^  is  corroborative  of  the  result  obtained  by  De  Amicis.  Martin 
took  the  secretion  of  a  child  which  was  suffering  from  declining  vulvo- 
vaginitis. Though  when  first  observed  the  pus  contained  gonococci,  it 
was  free  from  the  microbe  at  the  time  of  the  experiment.  Some  of  the 
secretion  was  placed  three-quarters  of  an  inch  deep  into  the  urethra  of  a 
consenting  hospital  patient.  In  four  days  the  prodromal  symptoms  of 
gonorrhoea  were  noted,  and  on  the  sixth  day  there  was  a  profuse  purulent 
and  bloody  discharge.  Examination  of  this  secretion  on  the  tenth  day 
showed  large  numbers  of  gonococci.  Later  on  the  man  suffered  from  pos- 
terior urethritis. 

Eraud  ^  has  for  some  years  studied  the  question  of  the  specificity  of 
the  gonococcus.  As  a  result,  he  seeks  to  prove  that  the  gonococcus  is 
probably  an  inoffensive  guest  of  the  normal  urethra.  He  thinks  that  the 
specificity  of  the  gonococcus  is  not  yet  proven — that  it  may  be  a  harmless 
saprophyte  of  the  normal  urethra  capable  of  transformation  under  condi- 
tions not  yet  made  clear.  His  researches  have  been  carried  on  with 
secretions  of  patients  suffering  from  gonorrhoea,  prostatitis,  and  orchitis, 
and  on  secretions  from  the  healthy  urethrse  of  infants  six  days  old,  from 
young  children,  and  adolescents  virgin  to  gonorrhoea.  He  concludes — 1. 
There  exists  in  the  urethrse  of  healthy  men  a  staphylococcus  which  is 
capable  of  producing  orchitis ;  2.  This  microbe  is  found  in  children  and 
infants;  3.  This  saprophyte  presents  the  same  characters  as  the  microbe 
of  orchitis  and  gonorrhoeal  prostatitis ;  4.  There  is  reason  for  supposing, 
if  not  for  concluding,  that  all  these  microbes  are  one  and  the  same  para- 
sites living  as  saprophytes  in  the  normal  urethra,  and  capable  under 
unknown  conditions  of  giving  rise  to  the  gonorrhoeal  process.  These 
observations  have  been  further  put  to  the  test  and  studied  by  Prof. 
Hugounenq,*  who  endorses  Eraucl's  conclusions. 

In  this  connection  it  is  well  to  consider  the  statement  of  Prof  Straus,^ 
whose  knowledge  and  skill  in  bacteriology  are  well  known.  Straus  reports 
the  case  of  a  boy  sixteen  years  old  who  never  had  coitus,  but  who  was  a 
confirmed  masturbator.     This  boy  was  attacked  with  urethritis  showing 

^  "De  la  Nature  parasitaire  de  la  Blennorrhagie,"  Lyon  Medical,  Aug.  2,  1884,  pp. 
1075  et  seq. 

^  "Vulvo-vaginitis  in  Children,"  Joui'nal  of  Cutaneous  and  Gen.-urin.  Disea,^es,  Nov., 
1892,  pp.  415  et  seq. 

^  "l)es  Kaisons  qui  semblent  militer  en  faveur  de  la  non-specificit^  du  Gonocoque, 
etc.,"  Bulletin  de  la  Societe  fran^aise  de  Derm,  et  de  Syph.,  vol.  ii.,  1891,  pp.  231  et  seq. 

*  "Sur  un  Microbe  pathog^ne  de  I'Orchite  blennorrhagique,"  Annates  des  Maladies 
des  Organes  Ginito-urinaires,  Juin,  1893,  p.  465. 

*  "Presence  du  Gonococcus  de  Neisser  dans  un  Ecoulement  urethral  survenu  sans 
rapports  sexuels,"  Archiv.  de  Med.  exper.  et  d'Anatomie  path.,  1889,  i.  pp.  326  et  seq. 


96  GONORBHCEA  AND  ITS  COMPLICATIONS. 

acute  symptoms.  On  four  occasions,  at  intervals  of  time,  Straus  found 
in  the  urethral  pus  gonococci  in  the  pus-corpuscles  and  on  the  epithelial 
cells.  He  thinks  this  case  is  important  as  regards  the  view  held  by  many, 
that  gonorrhoea  may  be  contracted  without  sexual  exposure  or  contagion 
as  a  result  of  great  irritation  of  the  urethra.  Straus  advances  the  propo- 
sition that  perhaps  the  gonococcus  is  a  normal  and  inoffensive  guest  of  the 
urethral  canal,  and  that  under  the  influence  of  irritation  it  becomes  patho- 
genic. He  thinks  there  may  be  a  similarity  in  the  action  of  the  gonococ- 
cus to  that  of  the  pneumococcus  of  Frankel,  which  usually  remains  dor- 
mant in  the  mouth  and  air-passages  until  some  favoring  causes  call  into 
play  its  virulent  action. 

I  have  myself  studied  the  bacteriology  of  urethral  pus  very  extensively, 
and  I  am  thoroughly  convinced  that  urethral  suppuration  is  produced  by 
other  microbes  than  the  gonococcus.  I  have  seen  cases  of  mild  gonorrhoea 
in  the  secretion  of  Avhich  I  have  found  the  staphylococcus  and  a  small 
streptococcus.  In  many  of  these  cases  the  clinical  picture  of  simple  or 
mild  urethritis  was  present,  but  I  have  seen  three  instances  in  which  the 
suppuration  and  subjective  symptoms  were  such  that  a  diagnosis  of  viru- 
lent gonorrhoea  was  warranted.  These  cases,  moreover,  ran  a  rebellious 
course,  and  one  case  was  complicated  by  severe  typical  posterior  urethritis 
and  epididymitis.  Careful  examination  of  the  pus  showed  an  absence  of 
the  gonococcus  and  the  presence  of  a  streptococcus.  A  patient  attending 
at  my  college  clinic  presented  the  typical  symptoms,  objective  and  sub- 
jective, of  acute  gonorrhoea.  In  the  pus  taken  from  this  man's  urethra 
Dr.  Van  Gieson  found  by  the  microscope  the  streptococcus  pyogenes, 
which  he  was  able  to  cultivate  on  human  serum-agar  and  on  glycerin- 
agar.  No  experimental  inoculations  were  made,  for  the  reason  that  the 
cultures  died  so  quickly.  Other  observers,  Bockhart,  De  Amicis,  and 
Aubert,  have  also  noted  the  occurrence  of  seemingly  virulent  gonorrhoea 
in  the  pus  of  which  no  gonococci  could  be  found,  but,  on  the  contrary,  a 
streptococcus  or  a  staphylococcus.  We  have  already  seen  that  the  injec- 
tion of  ammonia  (De  Amicis)  may  cause  urethral  suppuration  in  the  pus 
of  which  a  microbe  C9,n  be  found,  and  the  same  result  sometimes  follows 
the  passage  of  a  sound.  In  the  pus  of  a  case  seen  by  me  of  a  urethral 
discharge  induced  by  intemperate  endoscopy  at  the  hands  of  one  of  its 
enthusiasts  (an  anterior  and  posterior  urethritis  of  severe  type,  but  of 
short  duration,  having  been  produced).  Prof.  Prudden  found  by  the  micro- 
scope and  by  cultivation  micrococcus  urese  in  large  quantities.  Few  men 
aifected  with  true  gonorrhoea  suffered  more  than  this  patient  did,  who  had 
had  no  urethral  inflammation  for  many  years  previously.  I  have  in  many 
other  cases  of  traumatic  urethritis  found  cocci  other  than  the  gonococci.^ 

^  In  these  cases  it  is  most  probable  that  the  trauma  of  the  urethra  produces  a  hyper- 
emia and  succulence  of  the  cells  which  are  favorable  to  the  morbid  activity  of  its  sapro- 
phytic microbes  and  guests.  An  organism  which  was  harmless  becomes  potential  and 
pathogenic,  and  a  suppurative  inflammation  is  indiiced.  It  is  not  unreasonable  also  to 
suppose  that  morbific  microbes  may  be  introduced  into  the  urethra  upon  unclean  instru- 
ments. Legrain  ("Des  Urethrites  non-blennorrhagiques,"  Annales  des  Maladies  des  Org. 
Genito-urinaires,  1889,  pp.  337  et  seq. )  states  that  he  carefully  introduced  a  bougie  smeared 
with  the  second  culture  of  the  micrococcus  pyogenes  aureus  into  the  bladder  and  produced 
no  result.  A  week  later  he  repeated  the  same  experiment,  using  slight  violence,  and  as 
a  result  a  mild  and  ephemeral  form  of  suppuration  was  produced  in  thirty-six  liours.  He 
failed  in  a  similar  manreuvre  when  he  used  tlie  micrococcus  pyogenes  albus.  Legrain 
recalls  the  fact  that  Voillemier  introduced   into  the  urethra  of  two  patients  a  bougie 


THE  ETIOLOGY  OF  GONORRHCEA.  97 

As  further  bearing  on  this  subject  it  is  well  to  give  the  results  of  some 
very  careful  observations  made  by  Hogge  ^  under  Guy  on' s  auspices  in  the 
Necker  Hospital  laboratory.  Hogge  in  two  cases  very  clearly  shows  the 
difficulties  and  drawbacks  experienced  in  examining  chronic  urethral  dis- 
charges and  pus  from  the  bladder  and  in  distinguishing  the  microbes  there 
found  from  the  gonococcus.  The  first  case  was  that  of  a  man  aged  sixty- 
five  who  never  had  had  gonorrhoea,  but  who  had  a  purulent  secretion  follow- 
ing the  introduction  of  a  sound.  This  pus  contained  a  diplococcus  found 
in  the  cell-substance  and  scattered  over  the  field,  which  resembled  in  its 
various  features  the  gonococcus.  It  was  also  decolorized  by  Gram's 
method.  It  could  be  cultivated  on  gelatin,  agar-agar,  and  in  bouillon. 
The  second  case  Avas  one  of  cystitis  following  operation  for  a  bladder  neo- 
plasm in  a  patient  who  had  gonorrhoea  tAventy  years  before.  In  the  urin- 
ary sediment  a  similar  microbe  was  found,  which  could  be  cultivated  on 
the  media  just  mentioned.  The  author  shows  that  in  chronic  discharges 
there  are  microbes  which  by  their  form,  size,  intracellular  position,  their 
mode  of  grouping,  their  number,  their  mode  of  coloration  and  decolora- 
tion, resemble  the  gonococcus.  These  microbes  can  be  cultivated  on  gel- 
atin, agar-agar,  and  bouillon,  whereas  the  gonococcus  Avill  not  grow  on 
these  media.  Consequently,  in  such  chronic  cases  we  cannot  affirm  that 
a  certain  microbe  is  the  gonococcus,  and  can  only  ascertain  its  real  nature 
by  cultivation.  In  this  connection  it  is  well  to  remember  that  in  the  nor- 
mal urethra  Lustgarten  and  Mannaberg  found  a  coccus  resembling  the 
gonococcus. 

As  a  result  of  the  accumulated  knowledge  upon  this  Avhole  subject  up 
to  1889,  Neisser^  has  had  to  concede  that  it  is  possible,  under  certain 
circumstances,  that  other  micro-organisms  than  the  gonococcus  may  cause 
purulent  urethritis.  But  he  strenuously  contends  that  these  forms  of 
urethritis  are  all  clinically  absolutely  different  from  true  gonorrhoea.  He 
states  in  this  paper  (1889)  that  since  1879  every  case  of  urethritis  in  his 
private,  polyclinic,  and  clinical  practice  has  been  examined  for  the  gono- 
coccus, and  that  only  two  cases  of  purulent  urethritis,  appearing  in  an 
acute  form  and  caused,  as  it  seemed,  by  infection,  have  been  observed 
Avhich  did  not  positively  show  the  gonococcus.  In  these  cases,  moreover, 
no  pseudo-gonococci  were  found. 

In  his  latest  paper,  however,  Neisser^  concedes  that  it  is  often  exceed- 
ingly difficult  to  establish  the  diff"erence  betAveen  gonococci  and  similar 
diplococci.  Then  he  details  the  case  of  a  man  who  several  years  before 
his  marriage  had  gonorrhoea  and  double  epididymitis,  and  who,  after 
frequent  coitus  with  his  Avife,  had  a  profuse  acute  purulent  discharge. 
Yet  on  examination  of  the  pus  no  microbes  of  any  kind  could  be  found. 
He  further  cites  the  case  of  a  man  Avho  for  nine  years  had  cohabited  only 

smeared  with  the  pus  of  an  abscess  of  the  tliigh  and  of  a  cold  abscess  of  the  glands  of  the 
neck,  and  that  no  reaction  followed  in  either  case,  though  the  bougie  remained  in  situ  two 
hours.  In  these  cases  it  seems  to  me  very  probable  that  an  old  pus,  poor  in  microbes  or 
whose  microbes  were  in  a  state  of  decadence,  was  used,  and  that  mechanical  violence  was 
not  produced. 

1  "  Gonocoques  et  Pseudo-gonocoques,"  Annales  des  Mulad.  des  Org.  G^nito-urin.,  April, 
1893,  pp.  281  et  seq. 

^  "Ueberdie  Bedentung  der  Gonococcen  fiir  Diagnose  und  Therapie,"  Verhandl.  der 
Devt.  Dermat.  Gemlhchaft  Gehalten  znr  Prag,  Vienna,  1889,  pp.  133  et  seq. 

^  "Welchen  Werth  hat  die  Mikroscopische  Gonococcenuntersuchung  ?"  Deui.  med. 
Wochenschrift,  Nos.  29  and  30,  1893. 


98  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

with  his  wife,  yet  who  came  to  him  with  a  urethritis  which  from  its  symp- 
toms he  would  have  been  led  to  pronounce  gonorrhoeal.  He  could  find 
no  gonococci  in  the  secretion,  but,  on  the  contrary,  numerous  small  diplo- 
cocci.  This  attack  was  cured,  but  five  or  six  days  after  each  intercourse 
with  his  wife  the  patient  was  similarly  attacked.  The  foregoing  very 
clearly  proves  that  Neisser  to-day  does  not  consider  his  first  position  as 
firm  as  he  in  earlier  years  thought  it  to  be. 

The  results  obtained  by  Neisser  (and  his  followers  are  equally  as  rad- 
ical in  their  statements)  are  certainly  startling,  and  from  their  uniformity 
of  success  as  to  the  gonococcus  they  beget  a  spirit  of  skepticism  in  con- 
servative minds.  Seeing  that  a  number  of  disinterested  observers — and 
myself  included — in  much  shorter  periods  of  research  than  ten  years  have 
found  in  numerous  cases  other  micro-organisms  than  gonococci  in  acute 
gonorrhoea,  the  suspicion  is  warranted  that  a  rigorous  differentiation  was 
not  practised  by  Neisser  and  others.'  When  such  dogmatic  statements 
are  made  as  emanate  from  the  ardent  advocates  of  the  gonococcus,  par- 
ticularly the  one  that  this  microbe  is  the  sole  and  essential  morbific  agent 
in  acute  gonorrhoea,  there  should  be  ample  evidence  offered  that  full  and 
sufficient  care  has  been  taken  in  establishing  the  presence  of  the  gono- 
coccus in  the  vast  number  of  cases  claimed,  and  also  that  the  presence  of 
other  pathogenic  microbes  has  been  looked  for  and  not  found.  Thus  far, 
this  certainly  has  not  been  done,  and  it  is  safe  to  say  that  the  question 
can  never  be  settled  by  microscopic  examination  alone.  Cultures  of 
urethral  pus  in  very  many  cases  and  by  many  men  Avorking  separately 
are  absolutely  necessary  toward  a  solution  of  this  question.  Then,  again, 
much  experimental  inoculation  will  be  required  to  confirm  the  knowledge 
gained  by  the  study  of  the  cultures. 

Reviewing,  therefore,  the  question  of  the  pathogenesis  of  gonorrhoea 
and  of  miscellaneous  urethral  discharges  in  the  light  of  our  present  know- 
ledge and  in  a  judicial  spirit,  we  are  warranted  in  drawing  certain  con- 
clusions and  of  stating  certain  assumptions  which  may  fairly  be  drawn 
from  facts  and  statements  now  in  our  possession : 

,1.  In  a  large  proportion — perhaps  in  a  large  majority — of  cases  of 
acute  purulent  gonorrhoea  or  urethritis  the  pathogenic  agent  is  the  gono- 
coccus. (Bumm,  it  will  be  remembered  (vide  supra),  claims  that  in  every 
case  it  is  found.) 

2.  In  a  small  proportion  of  cases  of  acute  purulent  gonorrhoea  or 
urethritis  the  infecting  agent  or  agents  seem  to  be,  in  the  absence  of  the 
gonococcus,  one  or  more  of  the  pyogenic  microbes,  the  staphylococcus 
and  the  streptococcus,  and  perhaps  others  whose  virulency  is  not  yet 
demonstrated.  (Bumm  claims  that  secretions  free  from  gonococci  are 
non-infectious.) 

3.  In  many  cases  of  mild  urethritis  in  virgin  subjects,  and  in  those 
who  have  had  true  gonorrhoea  some  time  before,  these  micro-organisms 

^  I  have  several  times  been  struck  by  the  looseness  of  statement  of  the  ultra-ardent 
advocates  of  the  gonococcus,  and  by  their  easy-going,  routine  methods  of  microscopical 
examination.  They  rarely  ever  fail  to  see  this  microbe  in  any  specimen  which  they 
examine,  even  when  taken  at  haphazard.  With  great  celerity  they  dry  and  stain  the 
secretion,  place  it  under  the  lens,  and  in  an  instant  claim  that  they  see  the  gonococcus. 
The  case  is  then  settled  for  them.  Thus  tliey  continue  in  case  after  case.  I  suspect 
that  if  the  truth  were  really  kno^vn  regarding  statements  and  liistories  of  cases,  in  fully  80 
per  cent,  the  gonococcus  was  not  really  found,  although  it  was  claimed  to  be  clearly  seen. 


THE  ETIOLOGY  OF  GONORRHCEA,  99 

and  others  more  or  less  well  known  to  us  are  in  all  probability  the  causes 
of  urethral  suppuration,  the  tissues  being  rendered  by  coitus  favorable  to 
their  pathogenic  action. 

4.  Some  cases  of  mild  or  more  severe  relapsing  gonorrhoea,  with  abun- 
dant purulent  secretion,  may  be  due  to  the  renewed  activity  of  gonococci, 
which  may  have  remained  latent  and  dormant  in  the  urethra,  but  which, 
under  favoring  circumstances,  had  again  taken  on  their  virulent  action. 
In  some  of  these  cases  the  symptoms  are  much  less  severe  than  in  the  first 
attack.  The  inference,  then,  is  that  the  tissues  are  less  susceptible  or 
that  the  virulence  of  the  gonococcus  has  become  attenuated. 

5.  Many  cases  of  more  or  less  severe  relapse  after  true  gonorrhoea  are 
not  due  to  the  gonococcus,  but  to  the  other  less  virulent  microbes.  Then, 
again,  the  hypersemia  left  after  an  attack  of  gonorrhoea  may  increase  to 
an  active  purulent  inflammation  as  a  result  of  stimulation  or  sexual  ex- 
cesses, microbic  action  being  entirely  absent.  This  is  probably  the  con- 
dition in  most  cases  of  acute  or  mild  urethritis  in  which  neither  gonococci 
nor  other  micro-organisms  are  to  be  found. 

6.  It  is  clearly  proved  by  clinical  observation  and  experimental  inocu- 
lation that  pus  or  any  secretion  {e.  g.  the  lochia)  containing  gonococci 
may,  and  does,  produce  a  virulent  suppuration  in  susceptible  mucous 
membranes,  most  commonly  of  the  urethra  and  of  the  eyes. 

7.  The  observations  of  Lustgarten  and  Mannaberg,  of  Steinschneider 
and  Galewsky,  and  of  others  already  mentioned,  go  to  show  that  patho- 
genic and  non-pathogenic  micro-organisms  are  found  as  inoffensive  inhab- 
itants of  the  normal  urethra.  There  is  sufficient  evidence  in  our  posses- 
sion to-day  to  warratit  the  belief  that  under  the  favoring  conditions  of 
sexual  excitement  and  excess  these  micro-organisms  become  hostile  and 
virulent  and  give  rise  to  urethral  suppurations  of  both  mild  and  severe 
types. 

8.  The  statement  is  further  warranted  that  these  saprophytic  agents 
may  cause  a  purulent  inflammation  in  a  urethra  congested,  ulcerated,  or 
infiltrated  as  a  result  of  a  previous  gonococcus  inflammation.  There  is  no 
doubt  whatever  that  many  cases  of  relapse  of  gonorrhoea  are  not  caused 
by  a  renewed  gonococcus-infection  nor  by  the  relighting  into  activity  of 
latent  hibernating  gonococci,  but  that  they  are  due  to  the  morbid  action 
of  the  less  virulent  microbes,  denizens  of  both  healthy  and  damaged 
urethrge. 

9.  The  advocates  of  the  gonococcus  theory  go  too  far  when  they  claim 
that  this  micro-organism  so  frequently  remains  dormant  and  hiding  in 
the  urethra  after  the  cessation  of  a  true  gonorrhoea.  The  gonococcus  is 
essentially  a  virulent  agent  and  a  disturber  of  the  peace,  and  for  reasons 
and  from  facts  to  be  given  later  it  is  fair  to  assume  that  it  disappears 
from  the  urethra  upon  the  final  cure  of  true  gonorrhoea.  It  is  the  excep- 
tion, rather  than  the  rule,  that  it  should  remain  dormant  in  the  urethra 
for  a  long  time. 

10.  Most  of  the  cases  of  gonorrhoea  or  urethritis  which  are  the  result 
of  chemical  or  mechanical  irritation  or  violence  are  in  all  probability  due 
to  the  morbific  action  of  a  number  of  micro-organisms  so  constantly  found 
in  normal  and  chronically  and  very  subacutely  inflamed  urethrae.  This 
statement  is  very  clearly  proved  by  the  evidence  of  Legrain,  De  Amicis, 
Castex,  myself,  and  others.     In  some  cases  these  chemical  and  mechanical 


100  GONORRHCEA  AND  ITS  COMPLICATIONS. 

irritants  provoke  an  exacerbation  of  the  virulence  of  the  gonococcus.  In 
these  cases,  however,  it  is  probable  that  the  virulent  urethritis  is  not  yet 
at  an  end  or  that  the  gonococcus  had  not  yet  thoroughly  disappeared. 

11.  The  studies  of  Eraud,  Hugounenq,  and  D'Arlhac  are  worthy  of 
thought  and  investigation,  since  they  put  the  gonococcus  question  in  a 
new  light.  They  think  that  this  micro-organism  is  a  denizen  of  the 
normal  and  diseased  urethra,  and  that  under  favorable  conditions  it  takes 
on  virulent  action.  It  will  be  seen  a  little  farther  on  that  it  is  frequently 
very  difficult,  and  in  many  cases  impossible,  to  find  gonococci  in  the 
secretions  of  a  woman  with  whom  a  man  suffering  from  true  gonorrhoea 
has  had  coitus.  Many  cases  seem  to  prove  that  the  infection  of  the  man 
(he  even  having  a  healthy  urethra)  is  due  to  causes  inherent  in  himself. 
Neisser  and  his  followers  in  a  magisterial  manner  claim  that  gonococcus- 
infection  in  the  male  urethra  in  a  virgin  subject  always  is  derived  from  a 
secretion  of  the  female  consort  containing  gonococci.  We  shall  see,  later 
on,  that  this  view  is  at  variance  in  many  cases  with  clinical  facts,  and 
that  Eraud's  proposition  may  in  the  end  lead  to  a  partial  or  full  explana- 
tion of  the  subject.  There  are,  however,  very  many  cases  (as  we  have 
seen)  of  gonorrhoea  which  were  derived  from  a  similar  process  in  the  female. 

12.  The  term  "  pseudo-gonococci  "  does  not  apply  to  any  particular 
micro-organism,  but  it  is  being  applied  rather  loosely  to  any  and  all 
microbes  capable  of  producing  urethral  suppuration. 

The  net  outcome  of  all  this  knowledge  is,  that  gonorrhoea  is  a  disease 
induced  by  micro-organisms,  the  condition  of  the  affected  mucous  mem- 
branes being  such  as  to  favor  their  pathogenic  action.  It  is  therefore  a 
virulent  disease,  its  chief  pathogenic  agent  being  the 'gonococcus.  Other 
micro-organisms  also  give  rise  to  urethral  suppuration,  sometimes  as  violent 
and  as  much  complicated  as  true  gonorrhoea.  In  these  rather  unusual 
<3ases  nothing  but  microscopical  examination  can  determine  that  the 
morbid  process  is  not  caused  by  the  gonococcus.  The  suppurations 
caused  by  a  number  of  pus-producing  microbes,  some  of  which  have  been 
called  pseudo-gonococci,  are  usually  milder  in  character  and  shorter  in 
duration  than  the  gonococcus-infection.  They  are  simply  cases  of  a 
milder  form  of  urethral   infection. 

These  views  are  less  radical  and  sweeping  than  those  of  Neisser's 
school,  which  are  well  summed  up  in  the  following  quotation  from  Finger,^ 
who  says :  "  Blennorrhoea  (gonorrhoea)  is  a  virulent  process  whose  virus 
is  the  gonococcus,  and  we  therefore  recognize  only  one  condition  as  neces- 
sary to  the  production  of  blennorrhagic  urethritis  as  of  all  blennorrhagic 
affections — namely,  the  conveyance  of  gonococci  in  any  vehicle,  which 
usually,  but  not  always,  consists  of  mucus  or  pus  derived  from  another 
blennorrhagic  affection.  Blennorrhagic  urethritis  can  only  develop  by 
inoculation  with  gonococci.  Its  chief  source  is  the  transmission  of  hlen- 
norrhagic  pus  from  the  female  sexual  organs,  and  therefore  coitus  with  a 
woman  suffering  from  blennorrhoea  of  the  sexual  organs  is  the  main  source 

of    blennorrhagic    urethritis    in    the   male Blennorrhoea    of   the 

sexual  organs  in  the  female  is  therefore  the  most  important  source  of 
blennoi'rhagic  urethritis  in  the  male,  and  coitus  is  the  means  of  infec- 
tion." 

^  Die  Blennorrhoe  der  Sexualorgane  und  Hire  Compllcationen,  2d  ed.,  Leipzig  und  Wien, 
1891,  p.  37. 


THE  ETIOLOGY  OF  GONORBHCEA.  '      101 

The  practical  outcome  of  this  doctrine  is  that  whenever  a  man  has  a 
purulent  discharge  in  which  gonococci  are  to  be  found  the  conclusion  is 
surely  and  logically  warranted  that  he  derived  the  infection  from  a  woman 
similarly  infected.  In  other  words,  this  theory  of  the  ultra-adherents  of 
gonococci-virulism  proclaims  in  its  essence  that  gonorrhoea  originates  only 
in  gonorrhoea.^  The  general  acceptance  of  this  doctrine  can  only  result, 
in  very  many  cases,  in  suspicion,  rude  and  violent  recrimination,  estrange- 
ment, unhappiness,  dishonor,  and  even  suits  for  divorce  in  families  and 
in  society  between  males  and  females,  husbands  and  wives,  lovers  and 
mistresses,  between  whom  there  may  not  be  any  breach  of  fidelity  or  lack 
of  loyalty  whatever.  Such  a  doctrine  is  brutal  in  the  extreme,  and  is 
largely  the  outcome  of  too  great  reliance  being  placed  upon  the  results 
furnished  by  the  microscope.  It  is  another  instance  of  the  absolutism  of 
thought  which  so  often  pervades  the  human  mind  when  light  is  suddenly 
thrown  on  a  hitherto  dark  subject.  To  enthusiasts  the  subject  then 
seems  clear  and  settled ;  any  doubts,  uncertainties,  inconsistencies,  and 
gaps  in  knowledge  are  by  them  ignored  or  passed  over  unconsidered. 

There  can  be  no  doubt  that  many  men  contract  gonorrhoea  from  women 
suflFering  from  a  specific  gonococcus-infection  of  some  part  of  their  genital 
tract,  and,  on  the  other  hand,  women  are  infected  by  men  similarly  infected 
in  their  urethra.  But  there  is  met  Avith,  particularly  in  private  practice 
even  among  nice  people,  a  class  of  cases  in  which  men  contract  gonorrhoea 
from  women  who  claim  to  be  and  seem  to  be  perfectly  healthy.  The  latter 
state  that  they  never  had  the  classical  symptoms  of  gonorrhoea,  and  prior 
to  the  infecting  coitus  and  after  it  considered  themselves  perfectly  healthy. 
On  this  subject  we  have  some  very  strong  evidence  which  to-day  by  the 
Neisser  school  is  looked  upon  as  false  and  obsolete.  No  one  certainly 
studied  this  question  more  intelligently  and  for  a  longer  time  than  Ricord, 
and  yet  to-day  his  vievrs  Avith  many  go  for  naught.  Let  us  look  at  these 
old  views  and  see  whether  there  is  not  at  least  some  truth  in  them.  Ricord^ 
says  :  "  When  we  investigate  with  the  greatest  care  the  determining  causes 
of  the  most  characteristic  gonorrhoea,  we  are  forced  to  admit  that  the  gon- 
orrhoea! virus  is  absent  in  the  majority  of  cases.  There  is  nothing  more 
common  than  to  find  that  women  who  have  occasioned  the  most  intense, 
the  most  persistent  gonorrhoeas,  accompanied  with  the  most  characteristic 
gonorrhceal  complications,  were  only  afi"ected  with  uterine  catarrh,  some- 
times hardly  purulent.  Quite  often  the  menstrual  flux  appears  to  have 
been  the  sole  cause  of  the  disease.  In  a  great  number  of  cases  we  can 
discover  nothing  unless  perhaps  errors  in  diet,  excess  in  sexual  intercourse, 
the  use  of  certain  drinks  or  of  certain  articles  of  food.  Hence  the  frequent 
belief  of  patients,  which  is  often  correct,  that  they  have  contracted  their 
clap  from  a  perfectly  healthy  woman.  Upon  this  point  I  am  assuredly 
familiar  with  all  sources  of  error,  and  I  have  the  pretension  to  say  that  no 
one  is  more  guarded  than  myself  against  the  various  forms  of  deceit  which 
beset  the  path  of  the  observer ;  yet  I  confidently  maintain  the  following 
proposition  :  ivomen  frequently  give  gonorrhoea  ivitltout  having  it  them- 
selves.    When  one  studies  gonorrhoea  without  prejudice,  without  precon- 

'  In  his  edition  of  1888,  Finger  went  so  far  as  to  say,  "It  is  an  evident  condition  sine 
qud  non  that  the  woman  from  wliom  a  man  acquires  blennorrhagic  urethritis  must  herself 
suffer  from  blennorrhtea."     He  omits  this  sentence  in  the  1891  edition. 

^  Lettres  sur  la  Syphilis,  3d  ed.,  1863,  pp.  46  and  47. 


102  OONORBHCEA  AND  ITS  COMPLICATIONS. 

ceived  notions,  he  is  forced  to  admit  that  it  originates  from  causes  that 
give  rise  to  inflammation  of  other  mucous  membranes."  ^ 

On  this  subject  Fournier^  remarks:  "With  the  purpose  of  elucidating 
this  difficult  question  of  the  origin  of  gonorrhoea  I  have  made  during  many 
years  a  great  number  of  eonfro7itations  of  patients,  to  whom  I  believe  I  have 
given  the  most  minute  attention.  More  than  sixty  times  I  have  examined 
women  from  whom  true  gonorrhoeas  have  been  contracted  under  conditions 
which  could  scarcely  leave  any  doubt  as  to  the  origin  of  the  disease.  Now, 
from  this  study  I  am  convinced  that  the  opinion  of  my  master  (Ricord)  is 
the  only  true  one,  and  the  only  one  which  conforms  to  the  facts  of  daily 
observation,  Ricord  says  frequently  women  give  gonorrhoea  without  hav- 
ing it :  in  my  opinion  he  should  have  said  7nost  frequently.  For  one  gon- 
orrhoea which  results  from  contagion  (in  the  precise  sense  of  the  word), 
there  are  three  at  least  in  which  contagion  plays  no  part.  According  to 
my  observation,  a  man  is  more  often  responsible  for  his  gonorrhoea  than 
than  the  woman  from  whom  he  seems  to  have  contracted  it :  he  gives  him- 
self gonorrhoea  more  frequently  than  he  receives  it."^ 

^  It  is  never  amiss  to  quote  Kicord's  remarks,  for  they  always  show  a  profound  know- 
ledge of  human  nature  and  of  medicine.  His  recipe  for  conti-acting  gonorrhoea  is  graphic, 
comprehensive,  and  suggestive.  He  says  :  "  Select  some  woman  of  a  pale,  lymphatic 
temperament — a  blonde  is  better  than  a  brunette — and  the  more  whites  she  has  the  better. 
Take  her  out  to  dine  ;  order  oysters  first,  and  don't  forget  asparagus  afterward.  Drink 
often  and  freely :  white  wines,  champagne,  coffee,  liqueurs, — they  are  all  good.  After 
dinner  dance  a  while,  and  have  your  friend  dance  with  you.  Get  well  heated  during  the 
evening,  and  quench  your  thirst  without  stint  with  beer.  At  night  play  your  part  val- 
iantly :  two  or  three  times  would  not  be  too  much,  but  more  would  be  better.  The  next 
morning  do  not  forget  to  take  a  prolonged  hot  bath  ;  moreover,  do  not  omit  an  injection. 
This  programme  having  been  conscientiously  followed  out,  if  you  don't  have  a  clap,  some 
good  deity  must  have  saved  you." 

^  Art.  "  Blennorrhagie,"  Nouveau  Dictionnaire  de  Med.  et  de  Chirurqie  pratique,  vol.  v., 
1866,  pp.  152  et  seq. 

^  This  statement  merits  even  more  emphasis  than  is  given  to  it  in  the  text,  since  the 
conditions  underlying  the  question  are  to-day  better  understood.  Now,  we  know  posi- 
tively that  in  normal  urethrse  there  are  many  and  varied  hibernating  and  harmless 
micro-organisms  which  under  conditions  of  irritation  of  the  tissues  become  active  and 
pyogenic.  We  further  know  that  very  many  men  have  chronically-damaged  urethne, 
due  to  local  ex  ulcerations,  thickening,  and  hyperemia,  subacute  inflammation  of  follicles 
and  crypts,  granular  and  papillomatous  conditions,  ulcers,  warts,  polypoid  growths,  and 
even  stricture — conditions  ever  ready  to  fall  into  inflammation.  Now,  these  may  exist 
with  no  symptoms  and  little  if  any  perceptible  discharge.  In  these  cases  of  damaged 
urethrse  there  is  good  evidence  in  hand  that  saprophytic  microbes  may  also  be  present  in 
innocent  inactivity.  Now,  with  these  facts  in  mind  it  is  easy  to  understand  why  the  fol- 
lowing conditions,  agents,  stimulants,  and  excitants  produce  purulent  discharges  in  men : 
1,  protracted  and  repeated  coitus,  with  perhaps  much  alcoholic  excess,  masturbation,  and 
priapism  with  much  excitement ;  2,  spicy  food,  alcoholics,  beer  and  ale,  cantharides, 
arsenic,  the  terebinthinates,  asparagus,  iodide  and  bromide  of  potassium  (these  act  as 
irritants  through  the  urine) ;  3,  strong  injections,  chiefly  ammonia,  nitrate  of  silver,  per- 
manganate of  potassium,  bichloride  of  mercury,  etc  ;  4,  careless  passage  of  sounds  and 
catheters,  horseback  riding,  bicycling,  football,  and  all  violent  exercises,  prolonged  walk- 
ing, and  games. 

Many  authors,  notably  Guyon  ("Sur  les  Urethrites  blennorrhagiques,"  Annales  des 
Maladies  des  Organ.  G^n.-urin.,  vol.  i.,  1883,  pp.  333  et  seq.),  lay  great  stress  upon  certain 
diatheses  as  being  the  (at  least)  underlying  causes  of  gonorrliwa.  These  are  gout,  the 
plethoric  condition,  rheumatism,  and  tuberculosis.  This,  of  course,  is  debatable  ground. 
There  are  certainly  some  persons  more  prone  to  infections  of  various  kinds  than  otliers : 
the  tissues  of  these  persons,  we  may  say,  offer  fertile  culture-grounds  to  micro-organisms. 
Therefore  it  is,  I  think,  more  correct  to  consider  that  the  diatheses  or  morbid  conditions 
are  underlying  and  predisposing  rather  than  exciting  causes  of  gonorrhoeal  infection  or 
of  urethral  suppuration.  There  can  be  no  reasonable  doubt  that  in  early  syphilis  the 
urethrse  of  men,  and  sometimes  of  women,  are  prone  to  become  the  seat  of  a  suppurative 


THE  ETIOLOGY  OF  GONORBH(EA.  103 

In  a  like  strain  wrote  my  deceased  colleague,  Dr.  Bumstead,  who  was 
ever  an  intelligent,  painstaking,  and  alert  observer.  He  says  :  "  Of  one 
thing  I  am  ahsolutely  certain :  that  gonorrhoea  in  the  male  may  proceed 
from  intercourse  Avith  a  woman  with  whom  coitus  has  for  months,  or  even 
years,  been  practised  with  safety,  and  this,  too,  without  any  change  in  the 
condition  of  her  genital  organs  perceptible  to  the  most  minute  examina- 
tion with  the  speculum.  I  am  continually  meeting  cases  in  Avhich  one  or 
more  men  have  cohabited  with  impunity  with  a  woman  before  and  after 
the  time  Avhen  she  has  occasioned  gonorrhoea  in  another  person,  or,  less 
frequently,  in  which  the  same  man,  after  visiting  a  woman  for  a  long 
period  with  safety,  is  attacked  with  gonorrhoea  without  any  disease  appear- 
ing in  her,  and  after  recovery  resumes  his  intercourse  with  her  and  expe- 
riences no  further  trouble.  The  frequency  of  such  cases  leaves  no  doubt 
in  my  mind  that  gonorrhoea  is  often  due  to  accidental  causes,  and  not  to 
direct  contagion." 

These  opinions,^  emanating  from  three  of  the  most  learned  and  expe- 
rienced men  in  the  study  of  venereal  diseases,  are  certainly  worthy  of 
attention,  and  I  think  that  their  correctness  in  the  main  will  be  found  to 
be  in  consonance  with  the  prevailing  knowledge  of  gonorrhoeal  infection. 
There  can  be  no  doubt  whatever  that  in  many  cases  men,  even  those  pre- 
viously virgin  to  the  disease,  contract  true  gonorrhoea,  presenting  typical 
gonococci,  from  women  Avho  never  had  gonorrhoea  and  in  whom  the  most 
careful  and  rigorous  examination  failed  to  reveal  the  gonococcus.  I  have 
had  this  experience  many  times,  and  I  am  fully  alive  to  all  sources  of 
error  and  to  all  the  tricks  and  deceitful  practices  of  patients.  Here  are 
three  instances :  A  gentleman  virgin  to  gonorrhoea  has  had  coitus  with  a 
girl  aged  eighteen  for  a  year.  He  was  the  only  man  she  had  ever  cohab- 
ited with,  and  she  had  never  suffered  from  gonorrhoea  or  leucorrhoea. 
Tour  days  after  a  prolonged  and  exciting  coitus,  stimulated  by  much  wine, 
he  developed  severe  gonorrhoea  with  abundant  typical  gonococci.  I 
examined  the  woman  the  day  after  the  development  of  his  trouble  and 
the  fifth  after  the  coitus.     By  the  speculum  I  saw  that  the  vulva  and 

process.  The  reason  is  very  simple :  the  tissues  of  syphilitics  (the  infection  being  active) 
are  very  prone  to  be  attacked  by  pyogenic  micro-organisms  if  any  traumatism  or  irrita- 
tion is  inflicted  upon  them.  Horteloup  lays  great  stress  {Legons  sur  I'  Uretkrite  chronique, 
1892)  upon  herpetism  as  an  underlying  cause  of  chronic  gonorrhoea.  He  defines  herpe- 
tism  as  a  vasomotor  and  trophic  neurosis,  but  it  is  hard  to  understand  what  morbid 
entity  he  means. 

^  In  this  connection  it  is  well  to  consider  the  results  of  De  Luca's  experiments  ("  Con- 
tribuzione  alia  Patologia  ed  alia  Clinica  del  Catarrho  venereo  nella  Donna,"  Giornale 
Interned,  delte  Scienze  Med.,  nuova  serie,  Naples,  1880) :  1.  He  injected  the  purulent  ute- 
rine .secretion  of  a  patient  into  her  urethra,  and  produced  typical  gonorrhoea.  2.  Later 
on,  when  less  purulent,  the  same  secretion  was  injected  into  the  urethra  of  a  prostitute, 
with  no  result.  3.  Sero-epithelial  secretion  of  uterine  catarrh  injected  into  the  urethra 
of  a  prostitute ;  no  result.  4.  The  previous  case  of  mild  uterine  catarrh  was  rendered 
purulent  by  introducing  a  sound  dipped  in  ammonia  into  the  cervix  ;  the  resulting  i)uru-. 
lent  secretion,  when  injected  into  the  urethra  of  a  prostitute,  produced  typical  gonorrlKva. 

5.  Purulent  sputum,  with  vibratile  epithelium,  from  a  case  of  bronchitis  and  malaria  was 
introduced  into  the  urethra  of  a  woman,  and  produced  an  active  purulent  inflammation. 

6.  Secretion  from  tliis  artificial  urethritis  introduced  into  the  urethra  of  another  woman 
produced  typical  gonorrhcea.  7.  Laudable  pus  from  a  small  abscess  of  the  eyebrow  in  a 
syphilitic  subject  wlien  introduced  into  the  female  urethra  produced  a  subacute  urethritis. 
8.  Secretion  from  pervious  subjects  introduced  into  tlie  la-ethra  of  another  woman  pro- 
duced a  similar  result.  It  is  unfortunate  that  the  bacteriology  of  these  cases  was  not 
studied.  It  i.s,  however,  most  probable  that  these  urethral  suppurations  were  caused  by 
pyogenic  microbes. 


104  OONOBRHCEA  AND  ITS  COMPLICATIONS. 

vagina  were  a  little  redder  than  usual,  but  free  from  pus  (no  injections  or 
preparatory  cleansing  having  been  used),  and  that  a  little  glairy  whitish 
mucus  escaped  from  the  os.  I  examined  many  specimens  of  the  secretions 
of  all  the  genital  parts,  taken  on  a  sterilized  platinum-wire  loop,  and 
found  many  cocci  and  bacilli,  but  absolutely  no  gonococci.^  Nothing  in 
the  way  of  treatment  was  done  for  this  girl,  yet  she  is  healthy  to-day, 
having  resumed  coitus  with  her  lover  on  his  recovery  from  his  ten-weeks' 
tribulation.  I  have  in  six  other  similar  cases  made  similar  examinations 
and  arrived  at  the  same  results. 

Here  is  another  case  worthy  of  thought,  for  I  can  vouch  for  the  cor- 
rectness of  the  statements  concerning  it :  A  man,  whom  I  cured  of  gonor- 
rhoea twenty-five  years  before,  came  to  me,  having  been  perfectly  well  in 
the  mean  time,  with  a  second  typical  attack,  a  year  or  so  ago,  in  the  dis- 
charge of  which  gonococci  were  abundant.  He  had  had  coitus  only  with 
his  wife  for  many  years,  and  she  was  confined  to  her  bed  as  a  result  of 
self-produced  miscarriage.  Her  symptoms  were  those  of  pelvic  peritonitis. 
Microscopic  examination  of  the  secretions  showed  no  gonococci  whatever. 
In  the  vaginal  secretion  I  found  numerous  varieties  of  microbes ;  in  the 
urethra  nothing  could  be  found,  but  in  the  pus  which  exuded  from  the  os 
uteri  both  streptococci  and  staphylococci  were  abundant.  It  certainly 
cannot  be  claimed  that  gonococci  remained  latent  in  this  man's  urethra 
for  twenty-five  years,  and  it  is  clear  that  his  infection  was  derived  from 
his  wife.  She  had  many  cocci  in  the  vagina  and  os,  but  no  gonococci, 
which  her  husband  had.  A  similar  instructive  case  is  as  follows  :  A  gen- 
tleman had  typical  gonorrhoea  in  all  particulars  (his  fii-st  attack,  which 
was  followed  by  severe  posterior  urethritis).  Gonococci  were  frequently 
found  in  his  discharge.  He  had  had  intercourse  with  a  lady  who  never 
had  had  any  affection  of  the  genital  apparatus,  but  who  had  suffered  from 
a  retro-uterine  phlegmon  for  some  time,  during  which  he  had  coitus  with 
her.     In  her  vaginal  pus  many  microbes  were  present,  but  no  gonococci. 

These  and  several  other  cases  were  carefully  watched  and  studied,  and 
in  none  of  the  women  could  gonococci  be  found,  while  all  the  men  presented 
typical  gonorrhoea  with  gonococci-containing  pus.  Cases  like  these  make 
one  at  least  skeptical  at  Finger's  statement,  "  that  direct  transmission  of 
of  the  gonococci-containing  vehicle  is  necessary  to  infection."  I  claim 
that  in  the  present  state  of  our  knowledge  such  magisterial  statements  as 
this  (which  is  the  tenet  of  the  gonococcus  school)  are  not  warranted. 
There  has  not  been  sufficient  study  of  the  healthy  and  morbid  vaginal 
secretions  to  warrant  such  a  sweeping  and  specific  statement.  Since  in 
these  cases  of  healthy  and  diseased  female  genital  apparatus  it  is  possible 
for  men  to  contract  gonorrhoea,  the  questions  arise.  Was  the  infecting 
agent  a  parasite  of  the  normal  urethra  which  became  metamorphosed  into 
the  gonococcus  ?  or,  Was  the  agent  derived  from  the  female  genitals  ? 
We  know  really  so  little,  if  anything,  of  the  biology  of  the  gonococcus 
before  it  is  found  in  the  pus  of  the  male,  and  from  that  experimented 
with,  that  I  think  we  should  be  slow  in  making  absolute  statements  con- 
cerning it.  That  it  is  frequently  found  in  the  female  genitals,  where  it  is 
often  a  source  of  infection  to  man,  no  one  can  doubt.     But,  on  the  other 

^  Now  that  the  culture  of  the  gonococcus  is  more  readily  accomplished,  and  may  be 
more  generally  practised,  this  test  as  to  the  nature  of  the  secretions  in  suspected  subjects 
may  be  used  in  addition  to  the  microscope. 


THE  ETIOLOGY  OF  CWNORRHCEA.  105 

hand,  in  a  vast  number  of  women  giving  gonorrhoea  it  cannot  be  found. 
My  studies  very  clearly  convince  me  that  we  shall  never  arrive  at  abso- 
lutely precise  knowledge  of  the  etiology  of  gonorrhoea  until  all  the  microbes 
of  the  female  genitals  have  been  studied  with  the  microscope,  by  means 
of  cultures,  and  by  experimental  inoculation.  Further  than  this,  we  must 
have  similar  knowledge  of  the  microbes  of  the  normal  and  diseased  male 
urethra.  I  am  absolutely  of  the  opinion  that  our  present  limited  know- 
ledge of  the  bacteriology  of  the  male  and  female  genitals  does  not  warrant 
our  throwing  aside  as  obsolete  and  untrue  the  results  of  accurate  and  pains- 
taking clinical  observation  of  such  men  as  Ricord,  Fournier,  Bumstead, 
and  many  others.  The  Neisser  school  claim,  first,  that  faulty  observation 
led  these  observers  to  fail  to  see  gonorrhoea,  and  to  consider  the  process  a 
catarrhal  one,  because  the  symptoms  were  not  those  of  florid  gonorrhoea ; 
second,  that  they  are  worthless,  because  they  were  made  before  the  gono- 
coccus  era  ;  and  third,  that  through  error,  lack  of  thoroughness  of  exam- 
ination, and  perhaps  by  reason  of  the  deceit  and  misrepresentations  of  the 
women,  localized  spots,  patches,  or  follicles  of  gonorrhoea!  inflammation  in 
the  urethra,  in  urethral  and  juxta-urethral  follicles,  in  vulvar  follicles, 
Bartholin's  glands,  and  in  the  os  uteri  escaped  observation,  and  were  the 
seats  from  which  infection  was  derived.  In  the  cases  above  reported  and 
in  others  I  kept  in  mind  the  pitfalls  of  error  and  false  judgment ;  I  was 
prepared  for  deceit  and  falsehood,  yet  I  failed  to  find  gonococci  in  the 
secretion  of  women  from  whom  men  virgin  to  gonorrhoea  contracted  typ- 
ical blooming  infections.  That  the  gonococcus  is  found  in  acute  gonor- 
rhoea of  the  male,  and  is  seemingly  the  morbific  agent,  I  have  already 
cheerfully  conceded.  But  where,  in  very  many  cases,  does  it  come  from  ? 
Is  it  a  metamorphosed  and  virulent  microbe  which  has  originated  in  a 
harmless  denizen  of  the  normal  or  diseased  urethra?  or  is  it  a  torpid 
inhabitant  of  the  vagina,  unrecognizable  in  that  stage  as  the  gonococcus, 
but  which  under  sexual  excitement  and  alcoholic  stimulation  becomes  a 
formidable  agent  with  intensely  virulent  properties  ?  I  have  in  my  read- 
ing seen  it  stated  that  man  is  the  natural  incubator  of  gonorrhoea.  Is  it 
possible  that  the  male  ui'ethral  mucous  membrane  is  the  tissue  most  suit- 
able to  the  nurture,  fructification,  and  maturity  of  this  peculiarly  virulent 
microbe  ? 

Many  authors  speak  of  a  virulent  form  of  gonorrhoea — and  I  have  seen 
many  such  instances — which  is  sometimes  contracted  by  men  from  women 
in  coitus  during  or  just  after  the  menstrual  process.  These  menstrual 
gonorrhceas  in  most  cases  present  the  typical  clinical  picture  of  florid 
gonorrhoea,  and  they  may  pursue  the  same  course  and  be  attended  by  the 
same  complications.  Many  of  these  women  never  had  gonorrhoea ;  some 
are  absolutely  free  from  all  genital  abnormalities ;  others  may  have  some 
abnormal  but  simple,  non-specific  condition,  yet  at  the  menstrual  epoch 
they  become  poisonous.  Can  it  be  that  the  hyperaemia  and  bloody  fluid 
for  a  time  vitalize  the  usually  inoff"ensive  microbes  Avhicli  are  present  in 
all  vaginae,  and  endow  them  with  virulent  principles.  We  cannot  to-day 
answer  this  question,  but  we  can  say  that  during  menstruation  some  per- 
fectly pure  and  healthy  women  at  times  give  men  typical  gonorrhoea. 

It  is  further  claimed  that  the  secretions  from  the  cavity  of  the  uterus, 

•from  the  swollen  and  exulcerated  cervix,  from  laceration  of  the  cervix 

and  perineum,  those  due  to  uncleanliness  of  the  vulva  and  vagina,  and 


106  QONOBBHCEA  AND  ITS  COMPLICATIONS. 

arising  from  chronic  simple  inflammation  of  these  parts,  may  give  rise  to 
gonorrhoea.  In  such  cases  the  Neisser  school  will  claim  that  there  are 
gonococci  in  the  pus  or  that  the  resulting  infections  in  the  men  are  simple 
urethritis.  Yet  let  any  one  study  these  cases  without  bias  or  prejudice, 
and  he  will  find  that  many  times  the  gonococcus  is  absent  from  the  female 
discharge,  Avhile  the  male  has  typical  gonococci-urethritis.^ 

The  trend  of  all  this  is  that  this  subject  of  the  etiology  of  gonorrhoea 
is  yet  in  an  unsettled  state,  and  that  opinions  should  be  formed  in  all 
cases  with  care  and  reserve.  It  is  possible  for  a  man  to  have  a  urethral 
discharge  containing  true  gonococci  which  he  contracted  from  a  woman 
who  never  had  gonorrhoea.  According  to  doctrines  now  largely  prevail- 
ing, the  gonococcus  in  the  male  is  presumptive  evidence  of  guilt  of  the 
woman.  Such  a  doctrine  is  too  absolute,  and  even  cruel,  and  may  be  the 
cause  of  much  unhappiness,  suffering,  and  misery.  This  question  often 
involves  the  virtue  of  wives  and  the  loyalty  of  mistresses,  and  demands 
our  earnest  attention.  Dr.  Bumstead,  in  a  passage  which  shows  very 
conspicuously  the  kindly  nature  of  the  man  and  the  broad  conservatism 
of  the  physician,  says  on  this  subject :  "  The  importance  of  this  truth 
whenever  a  physician  in  the  exercise  of  his  profession  incurs  the  great 
responsibility  of  passing  judgment  upon  the  virtue  of  a  woman,  and  thus 
affecting  her  reputation  and  happiness  (and  often  that  of  many  others 
with  whom  she  is  connected)  for  life,  cannot  be  overrated.  In  all  such 
cases  the  accused  should  receive  the  benefit  of  any  doubt  which  may  exist, 
and  the  physician  Avho  withholds  it  from  her  out  of  a  morbid  fear  that  he 
may  be  imposed  upon,  and  thus  runs  the  risk  of  convicting  an  innocent 
person,  is  unworthy  of  his  calling.  His  province  is  to  decide  from  the 
symptoms,  taken  in  connection  with  the  known  facts  of  the  case,  and 
unless  these  are  sufficient  to  establish  guilt  beyond  the  shadow  of  a  doubt 
humanity  demands  at  least  a  verdict  of  '  not  proven.'  "  ^ 

^  This  statement  is  strikingly  supported  by  a  very  important  case  which  is  just  now 
under  my  care  :  A  young  man  who  had  never  had  gonorrhoea  had  connection  with  his 
mistress,  a  strong  and  healthy  girl,  who  likewise  never  had  gonorrhoea,  under  the  condi- 
tions of  prolonged  excitement  and  liberal  alcoholics.  In  three  days  he  experienced  the 
typical  signs  of  incipient  gonorrhoea,  which  developed  in  a  florid  manner,  the  secretion 
showing  numerous  gonococci.  I  carefully  and  thoroughly  examined  the  woman,  and 
found  no  inflammation  about  her  genitals  and  no  gonococci  whatever.  Violating  all  the 
directions  given  him,  the  man  in  the  fourth  week  of  his  gonorrhoea  ventured  to  have 
coitus  with  this  woman,  he  then  noticing  only  a  slight  amount  of  discharge  in  the  morning. 
By  this  act  he  was  rendered  much  worse.  Four  days  after  this  coitus  the  young  woman, 
who  had  been  perfectly  well  in  the  interval,  complained  of  pain  on  urination,  and  three 
days  after  this  I  found  her  with  a  profuse  purulent  discharge  from  tlie  urethra  and  acute 
vulvitis.  Gonococci  in  abundance  were  found  in  the  urethral  and  vulvar  pus.  In  this 
case  the  man  certainly  was  the  incubator  of  the  gonorrhoea,  which  he  gave  to  his  consort. 

^  The  justice  and  force  of  the  foregoing  remarks  are  well  brought  out  by  the  following 
cases  :  A  married  man,  twenty -six  years  old,  returned  after  a  month's  absence  and  cohab- 
ited with  his  wife.  In  two  days  he  noticed  the  usual  symptoms  of  acute  gonorrho?a,  and 
consulted  a  physician,  who  informed  him  that  he  was  suffering  from  that  disease.  To  the 
patient's  remaik  that  he  had  only  had  connection  with  his  o^^^l  wife,  the  physician  replied 
that  gonorrhoea  came  from  gonorrhoea — ergo,  the  wife  liad  that  disorder.  The  patient 
being  incredulous,  the  physician  fortified  his  position  by  quoting  from  the  work  of  a 
prominent  author  from  whose  teachings  he  had  gained  his  belief.  Such  was  the  patient's 
anger  that  he  immediately  confronted  his  wife,  who  was  at  the  full  table  of  a  large 
boarding-house,  and  in  vile  and  blasphemous  language  accused  her  of  infidelity  and  of 
giving  him  a  foul  disease.  Amid  shame  and  distress  of  mind  the  wife  indignantly  spumed 
the  charge,  but  to  no  effect.  The  husband  left  tlie  house  and  went  elsewhere,  but  took 
occasion  to  inform  his  wife's  relatives  of  the  state  of  affairs.  At  this  time  a  second  visit 
to  the  physician  resulted  in  a  more  positive  asseveration  of  his  opinion.     Such  Avas  the 


THE  PERIOD   OF  INCUBATION.  107 


CHAPTER    VII  I. 

THE  PEEIOD  OF  INCUBATION  AND  THE  PEEDISPOSING  CONDI- 
TIONS AND  CAUSES  OF  ACUTE  ANTERIOR  URETHRITIS  OR 
GONORRHCEA. 

Though  the  fact  was  denied  in  years  gone  by  by  Ricord  and  others, 
gonorrhoea  certainly  has  a  period  of  incubation.  In  this  it  resembles  the 
many  and  varied  infectious  processes.  Mechanical  and  chemical  irritation 
or  damage  result  promptly  in  inflammation  of  the  urethral  mucous  mem- 
brane, and  little  time  elapses  between  the  receipt  of  the  injury  and  the 
appearance  of  the  discharge.  In  urethritis,  however,  more  or  less  time 
elapses  between  the  infecting  coitus  and  the  onset  of  the  inflammatory 
symptoms.  This  lapse  of  time  is  called  the  period  of  incubation,  or,  as  I 
suggested  before,  the  period  of  microbic  colonization.  In  this  time  the 
micro-organisms  seated  on  the  mucous  membrane  are  increasing  in  num- 
ber, spreading,  and  gaining  a  firmer  foothold  before  involving  the  deeper 
parts. 

The  length  of  the  period  of  incubation  varies  in  diff"erent  cases,  being 
sometimes  quite  short  and  again  rather  prolonged.  In  intelligent,  watch- 
ful patients  it  is  commonly  easy  to  determine  with  considerable  definite- 
ness  the  exact  length  of  this  period.  Then,  again,  in  careless  and  obtuse 
patients  unsatisfactory  data  only  are  to  be  obtained.  Patients  very  fre- 
quently, for  various  motives,  make  false  statements  as  to  the  length  of 
this  period. 

In  the  following  table  are  contained  the  records  of  505  cases  very 
carefully  observed  at  my  clinic  (Vanderbilt  Venereal  and  Genito-urinary 
Clinic).  These  cases  are  instances  of  first  attacks  or  infections.  They  were 
seen  in  the  acute  stage,  when  the  symptoms  were  severe  and  typical  and 
the  discharge  profuse  and  purulent.  Time  was  wanting  in  which  to  search 
for  the  gonococcus  in  these  cases : 

desperate  state  of  affairs  that  the  husband  consulted  a  lawyer  with  a  view  of  getting  a 
divorce.  At  this  juncture  the  wife' s  brother  insisted  that  her  husband  should  accompany 
her  to  my  office,  with  the  view  of  settling  the  matter.  It  was  a  memorable  interview 
with  the  sullen  and  angry  husband  and  the  indignant  and  outraged  wife.  The  husband's 
first  question  was,  Could  "a  man  contract  gonorrhoea  from  a  wife  who  was  not  thus  aflected  ? 
To  which  I  replied,  emphatically.  Yes.  I  then  went  over  with  him  the  various  sources 
of  origin  of  gonorrhoea,  and  instanced  cases  which  I  had  met  in  which  groundless  suspi- 
cions had  been  entertained  between  husband  and  wife.  When  I  came  to  inquire  into  the 
.  circumstances  of  his  case,  I  learned  that  liis  wife  had  some  time  previously  been  the  sub- 
ject of  an  operation  upon  the  uterus,  and  that  she  suffered  from  leucorrhrea.  This  was 
sufficient  to  clear  her  of  all  suspicion  ;  but  when  I  mentioned  the  fact  that  menstrual  fluid 
sometimes  caused  severe  gonorrhoea,  the  wife  eagerly  and  triumphantly  said  to  him  that 
he  had  forced  her  on  that  night  to  have  intercourse  in  spite  of  her  waning  menstruation. 
The  liusband  was  chagrined  and  humiliated.  Later  on,  domestic  haiipiness  was  restored. 
A  still  sadder  case  was  jDublislied  in  an  old  French  M'ork  on  venereal  diseases :  A 
young  man,  after  having  lived  with  a  young  girl  for  some  years,  married  her.  Some 
montlis  after  he  was  compelled  to  take  a  journey  of  some  distance,  and  while  travelling 
was  attacked  with  gonorrhoea.  He  consulted  a  physician,  and  informed  him  that  lie  luid 
never  had  connection  with  any  woman  but  his  wife.  The  physician  laughed  and  made  a 
sarcastic  reply.  Some  days  after,  when  the  testicle  swelled,  the  latter  informed  him  that 
if  liis  wife  was  virtuous  he  must  have  liad  "une  affaire"  witli  other  women.  The  young 
man  wrote  to  his  wife  an  indignant  and  passionate  letter  and  blew  out  his  brains.  The 
unfortunate  v/oman,  who  was  found  to  ])e  free  from  disease,  miscarried  and  died. 


108 


GONOBRH(EA  AND  ITS  COMPLICATIONS. 


Days. 

1  . 

2  . 

3  . 

4  . 

5  . 

6  . 

7  . 

8  . 


Cases. 
1 

17 

67 

79 

66 

36 
105 

35 


Days. 
9  . 

10  . 

11  . 

12  . 

13  . 
14. 


Cases. 
.  47 
.  27 
.  6 
.  8 
.  2 
■   14 

505 


It  will  be  seen  that  in  this  table  the  greatest  number  of  cases  had  an 
incubation  of  seven  days,  but  that  a  goodly  number  of  cases  are  recorded 
as  occurring  on  the  second,  third,  fourth,  fifth,  and  sixth  days.  It  will 
be  further  noted  that  from  the  eighth  to  the  tenth  day,  inclusive,  the 
number  of  cases  is  107,  being  rather  more  than  are  contained  in  the 
figures  for  the  first  seven  days.^ 

These  statistics  therefore  show  that  the  early  symptoms  in  the  great 
majority  of  cases  of  gonorrhoea  occur  within  ten  days  after  the  infecting 
coitus.  From  the  tenth  day  on  to  the  fourteenth  the  cases  are  small  in 
number,  and  from  that  time  up  to  the  twentieth  day  are  still  smaller.  In 
this  connection  the  recent  statistics  of  Lanz  ^  are  interesting,  since  in  each 
instance  the  presence  of  the  gonococcus  was  said  to  have  been  demon- 


strated.    Lanz's  figures  are — 


Days. 
1  . 


Cases. 

2 
.  15 
.  4 
.  9 
.    4 


Days. 

8  . 

10  . 

14  . 

20  . 


Cases. 
.    1 
.    1 
.    1 

■Jl 
39 


Thus  it  appears  that  out  of  39  cases  the  incubation-period  was  within 
seven  days  in  34,  the  majority  occurring  on  the.  third  and  fifth  days. 
Comparing  now  my  own  statistics,  those  of  Lanz,  together  with  those 

^  Finger  has  also  collated  from  the  statistics  of  Eisenmann,  Hacker,  and  Holder  the 
following  table  of  the  duration  of  incubation  in  acute  anterior  urethritis : 


1 

day 

in 

11 

cases ; 

2 

days 

59 

3 

126 

4 

62 

5 

49 

6 

10 

7 

63 

8 
0 

12 
23 

11  days 

in    6  cases ; 

12     " 

"     8     " 

13     •' 

"     6     " 

14     " 

"  19     " 

19     " 

"     2     " 

20     " 

"     1  case ; 

30     " 

"     1     " 

Uncertain 

"     9  cases; 

479  cases. 

It  thus  appears  that  in  380  out  of  479  cases,  or  more  than  two-thirds,  tlie  period  of  incu- 
bation was  within  the  first  week.  In  my  own  statistics  the  incubation-period  was  within 
the  first  week  in  361  cases,  which  is  a  little  under  three-quarters  of  the  whole  number. 

The  statistics  of  Le  Fort  {Gazette  hebdomadaire  de  Med.  et  de  Chir.,  1869,  Nos.  23  and  24) 
are  also  of  interest  in  this  connection.  This  observer  studied  the  incubation-period  by 
exact  record  in  2070  cases  of  gonorrhcea,  many  of  whom,  however,  had  one  or  more 
previous  attacks.  In  778  of  these  cases  the  disease  appeared  within  four  days,  being  37.5 
per  cent. ;  in  869  it  began  between  the  fifth  and  eighth  days,  being  41  per  cent. ;  in  276, 
between  the  ninth  and  twelfth  days,  or  13  per  cent. ;  in  112,  from  the  thirteenth  to  the 
sixteenth  day,  or  5  per  cent. :  and  in  17  patients  only  between  the  seventeenth  and  twen- 
tieth days.  According  to  these  statistics,  gonorrhcea  most  commonly  appeared  between 
the  fourth  and  eighth  days,  there  being  1647  cases,  or  79.5  per  cent.  In  only  35  out  of 
the  total  2070  cases  did  the  incubation-period  extend  beyond  fifteen  days. 

^  "  Ein  Beitrag  zur  Frage  Incubationsdauer  beim  Tripper,"  Archivfiir  Derm,  und  Syph., 
1893,  pp.  481  et  seq. 


THE  PERIOD   OF  INCUBATION.  109 

of  Finger  and  Le  Fort,  we  find  that  the  vast  majority  of  cases  of  gon- 
orrhoea begins  within  seven  days  of  the  infecting  coitus. 

In  the  cases  of  gonococci-inoculation/  as  we  have  seen  in  the  experi- 
ments of  Welander,  Bumm,  Aufuso,  and  Wertheim,  the  period  was  two 
or  three  days. 

Much  doubt  should  be  placed  on  the  statement  that  the  incubation- 
period  was  only  one  day.  In  such  cases  preputial  irritation  is  undoubt- 
edly mistaken  for  the  true  gonorrhoeal  symptoms,  or  the  cases  are  those 
of  second,  third,  fourth,  or  fifth  infections,  in  which  inflammatory  symp- 
toms show  themselves  very  promptly.  As  a  general  rule,  it  will  be  found 
that  the  period  of  incubation  is  two  or  three  days,  but  sometimes  five, 
six,  or  seven  days.^  Considerable  incredulity  is  warranted  in  cases  in 
which  the  history  of  the  incubation  is  beyond  ten  days,  and  the  statement 
that  it  is  twelve  to  twenty  days  or  longer  needs  strong  substantiation. 
I  have  no  doubt  that  errors  have  crept  in  in  the  histories  of  many  of  the 
cases  of  prolonged  incubation  included  in  the  table  of  very  old  cases  col- 
lected by  Finger.  To  sum  the  matter  up,  Ave  may  say  that  the  symptoms 
of  gonorrhoea  may  appear  as  early  as  forty-eight  hours  after  infection  ;  that 
they  commonly  appear  about  three  to  five  days  after  it ;  and  that  periods 

^  Experimental  inoculations  with  pus  have  thrown  much  light  on  the  incubation- 
period  of  gonorrhoea.  These  experiments  have  been  made  with  gonorrhoeal  pus  and  with 
pus  from  virulent  ophthalmia. 

Thiry  [Eecherches  nouvelles  siir  la  Nature  des  Affections  blennorrhagiques,  Bruxelles,  1864, 
pp.  32  et  seq. )  took  gonorrhoeal  pus  from  the  urethra  and  placed  it  in  the  conjunctival 
fiac.  In  twenty-four  hours  an  acute  purulent  inflammation  was  produced.  Pus  from 
the  infected  eye  was  placed  in  the  urethra  of  a  man  who  had  never  had  gonorrhoea. 
In  forty-eight  hours  a  true  gonorrhoea  was  produced. 

Pauli  de  Landau  {De  la  Nature  de  rOphthahnie  d'Egypte,  Wurzburg,  1858)  placed  the 
pus  of  ophthalmia  neonatorum  in  the  urethra  of  a  healthy  man,  who  in  three  days  suf- 
fered from  acute  gonorrhoea.  He  similarly  infected  a  woman,  in  whom  also  the  incuba- 
tion-period was  three  days. 

Guyomar  ("Les  Ophthalmies  et  les  Urethrites  contagieuses,"  These  de  Paris,  1858) 
introduced  a  sound  smeared  with  pus  of  purulent  ophthalmia  into  the  male  urethra,  with 
the  result  of  producing  gonorrhoea  in  two  days. 

Welander,  as  elsewhere  stated,  produced  gonorrhoea  in  two  days  by  the  inoculation  of 
gonorrhoeal  pus. 

■■'  This  estimate  is  further  in  accord  with  the  views  of  most  of  the  recent  writers. 
Lesser  {Lehrbuch  der  Haut-  und  Gescklechtskrankheiten,  11  Theil,  1888,  p.  8)  says  that  the 
average  is  two  or  three  days — that  the  incubation  is  seldom  shorter  or  longer.  Six  to 
seven  days  would  be  the  outside  limit. 

Giiterboch  {Die  Chirurg.  Krankheiten  der  Ham- und  Mdnnlichen  Geschlechtsorgane,  1890, 
Band  i.  p.  45)  says  that  seven  days  is  the  longest  incubation-period,  while  Fiirbringer 
{Die  Krankheiten  der  Ham-  und  Geschlechtsorgane,  1884,  p.  273)  thinks  that  the  average  is 
four  days. 

Neumann  {Lehrbuch  der  Venervichen  Krankheiten  und  der  Syphilis,  1888,  p.  75)  says 
that  the  incubation -period  is  variable.     His  average  is  from  two  to  five  days. 

Podres  {Die  Chirurg.  Erkrankungen  der  Ham-  und  Geschlechtsorgane,  Theil  i.,  1887,  p. 
84)  thinks  that  the  incubation-period  of  the  first  gonorrhoea  is  twenty-four  to  forty-eight 
hours,  and  in  later  infections  it  is  longer,  lasting  from  sixty  to  eighty  hours. 

Kopp  {Lehrbuch  der  Vener.  Erkrankungen,  1889,  p.  14)  calculates  the  average  to  be 
three  to  four  days,  recognizing  rare  cases  in  which  it  is  ten  to  twelve  days,  and  others  in 
which  it  is  six  or  seven  days. 

Letzel  {Lehrbuch  der  Geschlechtskrankheiten,  1892,  p.  17)  places  the  period  at  two  to 
four  days,  sometimes  earlier  and  sometimes  later. 

.Jullien  {Traite  pratique  des  Maladies  veneriennes,  1886,  p.  29)  thinks  that  the  average 
is  from  three  to  five  days,  but  that  in  first  infections  it  may  be  four,  five,  even  six  days. 

Finger,  on  the  other  hand  {Die  Blennorrhoeder  Sexualorgane  und  ihre  Complicationen, 
1891,  p.  43),  maintains  that  the  incul):ition  of  a  first  gonorrhoea  is  shortest,  that  the  aver- 
age is  three  to  five  days,  and  that  in  later  infections  it  is  seldom  more  than  six  or  seven 
days. 


110  GONOBRH(EA  AND  ITS  COMPLICATIONS. 

of  infection  of  seven  to  ten,  and  even  fourteen,  days'  duration  may  occur, 
but  not  very  frequently.^  I  have  known  such  periods  of  incubation,  and 
even  longer  ones  up  to  twenty  days,  to  be  observed  in  patients  suffering 
from  pneumonia,  typhoid  fever,  and  erysipelas.  On  the  other  hand,  the 
period  of  incubation  is  sometimes  made  shorter  by  prolonged  sexual  inter- 
course and  alcoholic  excesses.  Then,  again,  the  intensity  of  the  infecting 
pus  containing  abnormally  large  quantities  of  the  gonococcus  may  have 
an  influence  upon  the  suddenness  of  the  attack.  It  is  also  safe  to  assume 
that  the  tissues  of  some  individuals  are  more  prone  to  the  attacks  of 
micro-organisms  than  those  of  others.  Under  these  circumstances  an 
incubation  of  twenty-four  to  thirty  hours  is  possible. 

The  fact  of  there  being  a  variable  period  of  incubation  in  gonorrhoea 
suggests  the  advisability  of  a  patient  refraining  from  coitus,  hymeneal  or 
social,  for  a  goodly  number  of  days  after  intercourse  with  a  doubtful  or 
suspicious  woman. 

In  striking  contrast  with  this  virulent  infective  process,  with  its  well- 
marked  period  of  incubation,  are  those  forms  of  purulent  urethritis  due 
to  the  passage  of  sounds  and  bougies  or  caused  by  strong  injections,  in 
all  of  which  the  discharge  comes  on  in  a  few  hours. 

Predisposing  Conditions  and  Causes. — The  size  and  conditions  of  the 
penis  are  frequently  factors  in  the  contracting  of  gonorrhoea.  Thus  a 
very  long  organ  is  frequently  infected  by  pus  from  the  uterine  neck  or 
fornix  vaginae,  while  a  shorter  one  may  escape.  A  very  large  and  thick 
oro-an  mav  scive  rise  to  friction  and  irritation,  and  in  that  wav  become 
infected.  Patients  with  naturally  large  meatuses,  and  particularly  those 
in  whom  unnecessarily  large  meatotomy  has  been  practised,  are  also  very 
susceptible.  A  meatus  which  opens  on  the  under  surface  of  the  glans, 
resembling  hypospadias,  and  the  condition  of  hypospadias  itself,  predis- 
pose the  bearer  to  gonorrhoeal  infection.  Then,  again,  cases  are  seen  in 
which  this  form  of  the  opening  exists,  and  with  it  shortness  and  tightness 
of  the  frsenum,  and  perhaps  of  the  prepuce.  In  such  cases  there  is  much 
redness  of  the  fossa  navicularis  and  a  marked  tendency  to  acquire  gonor- 
rhoea. In  these  cases,  and  in  those  of  hypospadias  where  the  meatus  is 
thus  placed  low  in  the  glans,  it  is  probable  that  the  secretions  of  the 
vagina,  which  gravitate  to  its  posterior  wall,  are  sucked  in  by  capillary 
attraction,  and  find  easy  entry  into  the  fossa  navicularis  and  there  produce 
infection. 

Phimosis,  natural  or  acquired,  tends  to  render  its  bearer  liable  to 
gonorrhoea  by  reason  of  the  hypersemia  which  it  induces  in  the  lips  of 
the  meatus  and  the  urethral  tissues  immediately  beyond.     In  the  same 

^  Several  cases  of  very  long  incubation  have  been  recently  reported.  Ehlers  {Annales 
de  Dennatologie  et  de  ki  SyphUigmphie,  1892,  p.  556)  reports  the  case  of  a  physician  who 
had  not  previously  suflered  from  gonorrhoea,  who  had  connection  Nov.  30,  1891,  and  on 
Dec.  22  felt  a  sensation  of  heat  at  the  meatus,  which  was  followed  Dec.  28  by  a  purulent 
discharge  containing  gonococci.     In  this  case  the  incubation-period  was  twenty-two  days. 

Lemonnier  {ibid.,  1892,  pp.732  et  seq.)  reports  an  unsatisfactory  case  in  which  he 
thinks  that  there  was  an  incubation  of  twenty-eight  days. 

Lanz  {op.  cit.)  i-eports  a  case  in  which  the  patient  claimed  that  ten  weeks  had  elapsed 
between  the  coitus  and  the  evidences  of  infection.  The  same  author  also  reports  a  case 
in  which  the  incubation  is  stated  as  of  five  weeks'  duration.  In  this  case  the  patient  had 
suffered  from  gonorrhoea  three  and  a  half  years  previously,  and  satisfactory  evidence  is 
not  offered  to  clear  away  the  doubt,  which  is  warranted,  that  the  case  was  one  of  the 
lighting  up  of  an  old  smouldering  inflammation. 


THE  PERIOD   OF  INCUBATION.  Ill 

manner  balanitis  and  balano-posthitis,  either  resulting  from  phimosis  or, 
as  frequently  occurs,  from  inattention  and  uncleanliness,  produce  a 
hypersemic  condition  of  the  distal  urethral  mucous  membrane  which  ren- 
ders it  favorable  to  the  growth  and  multiplication  of  the  gonococci  or  other 
pus-producing  microbes. 

Warts  at  or  near  the  meatus  are  frequent  causes  of  urethral  suppu- 
ration. Scars,  contractions,  and  hyperaemia  at  the  meatus,  left  by 
antecedent  syphilitic  infiltrations,  primary  or  late,  and  chancroids,  not 
uncommonly  tend  to  render  their  bearers  susceptible  to  gonorrhoea.  Long- 
continued  copulation,  particularly  in  persons  under  the  influence  of  alco- 
holics, is  a  potent  factor  of  infection.  In  such  cases  ejaculation  is  long 
delayed,  the  penis  and  vagina  are  much  irritated,  and  gonorrhoea  very 
frequently  follows.  Indeed,  venereal  excesses  are  common  and  prolific 
causes  of  gonorrhoea.  Persons  who  have  recently  recovered  from  an 
attack  of  gonorrhoea  are  especially  predisposed  to  subsequent  infections. 
Then,  again,  lesions  of  the  urethral  walls  from  the  meatus  to  the  bulb, 
which  generally  consist  of  submucous  thickening,  with  granular,  papillo- 
matous, or  exulcerated  hyperaemic  patches,  are  a  constant  menace  to  their 
bearers,  who  contract  gonorrhoea  at  seemingly  slight  provocation.  I  have 
many  times  seen  men  who  in  an  early  gonorrhoea  had  suffered  from  in- 
flammation of  one  or  more  of  the  glands  or  lacunae  of  the  urethra,  which, 
not  going  on  to  abscess-formation,  had  resolved  and  left  an  inflammatory 
focus,  who  thereafter  were  prone  to  gonorrhoeal  infection  even  when  guilty 
of  no  excesses. 

Masturbation  may  produce  such  a  hyperaemic  condition  of  the  meatus. 
and  fossa  navicularis  that  infection  may  readily  occur. 

There  can  be  no  question  that  in  some  cases  of  early  syphilis  the  distal 
parts  of  the  urethra  are  rendered  more  prone  to  the  invasion  of  gonococci 
and  other  microbes.  This  tendency  may  be  brought  into  action  by  ab- 
normal conditions  of  these  parts,  and  may  exist  in  cases  where  no  abnor- 
mality is  present.  An  active  syphilitic  diathesis  can  undoubtedly  be  at 
the  root  of  the  persistence  of  a  gonorrhoea,  and  may  also  be  a  factor  in 
the  induction  of  relapses.  It  must  be  borne  in  mind  that  the  disease 
then  is  not  syphilitic  in  nature.  It  is  an  infective  urethritis,  due  to 
micro-organisms,  occurring  in  a  syphilitic  in  whom  the  diathesis  is  still 
active  and  whose  tissues  are  more  vulnerable  to  irritation  and  microbic 
invasion  than  those  of  a  previously  healthy  person. 

Though  it  is  contended  that  patients  suffering  from  gout,  rheumatism, 
anaemia,  the  so-called  scrofula,  and  tuberculosis  are  more  liable  than 
others  to  gonorrhoea,  as  yet  no  truly  scientific  evidence  has  been  offered 
in  proof  thereof. 


112  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

CHAPTER    IX. 

ACUTE  ANTEEIOE  GONOEEHCEA,  OE  UEETHEITIS. 

By  the  term  "  acute  anterior  gonorrhoea  or  urethritis  "  is  meant  an 
infective  process  attended  by  abundant  suppuration,  caused  by  micro- 
organisms which  may  involve  the  urethra  from  the  meatus  to  its  bulbous 
portion,  and  which  may  stop  at  the  triangular  ligament.  In  the  majority 
of  cases  the  infective  process  spreads  from  the  meatus,  like  other  infec- 
tious diseases — for  instance,  erysipelas — to  parts  beyond,  traversing  the 
pendulous  urethra,  reaching  the  bulbous  portion,  and  there,  under  favor- 
able circumstances,  stopping,  in  the  minority  of  cases.  By  some  it  is 
claimed  that  acute  gonorrhoea  is  generally  limited  to  the  region  of  the 
fossa  navicularis,  to  the  pendulous  urethra,  and  that  it  may  reach  the 
region  of  the  bulb.  This  may  occur  in  second  and  later  infections  and 
in  cases  of  persistent  relapses,  but  long  observation  has  convinced  me 
(and  my  conclusions  are  in  accord  with  those  of  many  recent  writers)  that 
in  acute  primary  gonorrhoea  the  suppurative  process  quite  promptly 
extends  back  to  the  bulbous  urethra  and  even  beyond.  I  have  many 
times  verified  this  statement  by  the  very  careful  use  of  the  endoscope 
and  by  examination  of  the  urine.  Acute  anterior  gonorrhoea  in  primary 
or  secondary  attacks  means  suppuration  of  the  canal  from  the  meatus  to 
the  triangular  ligament. 

Exceptionally  we  see  cases — but  they  are  usually  instances  of  second 
and  even  later  infections  or  of  repeated  relapses — in  which  the  disease  is 
seemingly  limited  to  the  region  of  the  fossa  navicularis  ;  other  cases  in 
which  more  or  less  of  the  pendulous  urethra  is  involved  ;  while  in  others 
still  the  morbid  process  rapidly  runs  back  to  the  region  of  the  bulb  and 
there  becomes  most  intense.  Thus  we  come  to  speak  (a)  of  gonorrhoea 
of  the  fossa  navicularis  ;  (b)  of  the  pendulous  urethra  ;  and  (<?)  of  the 
bulb.  In  the  majority  of  cases  of  primary  infection,  however,  as  before 
stated,  the  whole  anterior  urethra  is  involved,  and  in  the  decline  of  the 
acute  stage  the  morbid  process,  as  a  general  rule,  settles  in  a  more  or  less 
subacute  condition  in  one  or  more  of  the  parts  just  named — namely,  the 
fossa  navicularis,  the  pendulous  urethra,  and  the  bulbous  urethra.  In 
between  80  and  90  per  cent,  of  these  cases  in  which  the  whole  anterior 
urethra  is  attacked  the  infection  spreads  to  the  posterior  urethra. 

Since  the  symptoms  of  anterior  gonorrhoea  or  urethritis  are  well 
marked,  it  is  best  for  clearness  of  description  to  fully  describe  them ;  then 
the  clinical  facts  concerning  the  infection  of  the  posterior  urethra  can  be 
more  lucidly  presented. 

THE    PRODROMAL    STAGE. 

At  the  end  of  the  period  of  incubation  the  symptons  of  gonorrhoea 
manifest  themselves.  These  may  be  quite  severe,  they  may  be  mild,  or, 
again,  they  may  be  entirely  absent.  Patients  usually  complain  of  a  tick- 
ling, pricking,  and  itchy  sensation  at  the  meatus  or  in  the  fossa  navicu- 


ACUTE  ANTERIOR  GONORRHCEA,   OR   URETHRITIS.  113 

laris.  Some  describe  it  as  a  sensation  of  titillation  which  is  not  at  all 
disagreeable.  Diday  compares  the  sensation  to  that  produced  by  a  fly 
alighting  on  the  skin,  while  Ricord  says  that  the  beginning  of  the  disease 
is  marked  by  an  exaltation  in  the  function  of  the  organ  and  by  an  exag- 
geration of  its  normal  sensibility,  vitality,  and  secretion.  These  sensa- 
tions may  be  accompanied  by  a  feeling  of  more  or  less  heat  in  the  parts. 
Then,  again,  in  some  cases  decided  uneasiness,  bordering  on  pain,  is  felt, 
which  may  be  spontaneous  and  continuous  or  only  felt  during  and  after 
urination.  The  intensity  of  these  early  symptoms  of  acute  gonorrhoea 
very  often  depends  largely  on  the  nature  of  the  patient.  A  nervous, 
worrying  subject  complains  more  or  less  strongly,  while  an  ignorant, 
apathetic,  or  obtuse  one  may  make  no  complaint  whatever.  We  not 
infrequently  see  patients  who  positively  state  that  the  discharge  is  the 
first  symptom  known  to  them. 

Inspection  of  the  meatus  in  the  prodromal  stage  shows  it  to  be  slightly 
reddened,  glazed,  and  perhaps  coated  with  a  film  of  colorless,  grayish,  or 
opaline  mucus,  in  which  a  few  minute  whitish  flakes  or  suet-like  lumps 
are  mixed.  This  fluid  is  usually  quite  scanty,  but  sometimes  one  or  more 
drops  may  be  expressed  from  the  canal.  It  grows  more  copious  as  time 
advances.  Frequently  this  secretion  produces  a  gluing  together  of  the 
lips  of  the  meatus  in  the  intervals  of  urination,  which  act  may  be  thereby 
impeded  for  a  few  moments.  This  symptom  of  gluing  together  of  the 
lips  of  the  meatus  is  frequently  the  first  sign  the  patient  has  of  his  on- 
coming disease. 

Microscopic  examination  of  this  secretion  shows,  as  we  have  already 
seen,  columnar — or,  at  first,  flat — epithelium,  with  more  or  less  gonococci 
seated  at  their  margins  and  over  their  surface,  and,  later  on,  the  admix- 
ture of  pus-cells.  In  this  stage  the  urine  is  clear  and  free  from  mucus, 
but  on  agitation  a  few  minute  gray  flakes  or  little  lumps  may  be  seen.  . 
In  other  words,  a  few  infected  epithelial  cells  float  in  healthy  urine. 

In  some  cases  the  infective  process  of  gonorrhoea  at  the  onset  is  quite 
slow  in  development,  and  very  little  disturbance  may  be  noted  at  the 
meatus  for  several  days.  I  have  seen  a  goodly  number  of  cases  in  which 
three,  four,  seven,  and  even  ten  days  elapsed  before  decided  symptoms  of 
inflammation  showed  themselves,  and  in  which  the  only  noticeable  abnor- 
mality was  a  little  increase  of  redness  of  the  meatus  and  a  little  exaggera- 
tion of  the  normal  quantity  of  mucus.  As  a  rule,  however,  after  the 
lapse  of  one,  two,  or  three  days  a  more  decided  state  of  inflammation  is 
seen.  The  lips  of  the  meatus  become  swollen  and  perhaps  pouting,  and 
the  redness  invades  the  glans  penis  in  a  disk-like  form  around  the  meatus. 
The  mucous  secretion  becomes  increased  in  quantity,  then  assumes  a 
decidedly  opalescent  hue,  from  which  it  is  rapidly  transformed  into  a 
milky-looking  fluid,  and  then  into  true  greenish  pus.  A  decided  smart- 
ing or  burning  pain,  called  ardor  urinse,  is  then  felt  in  the  fossa  navicu- ' 
laris,  particularly  during  urination  and  sometimes  continuously. 

The  irritation  incident  to  the  prodromal  stage  being  limited  to  the  dis- 
tal part  of  the  penis — namely,  the  region  of  the  fossa  navicularis,  Avhich 
Zeissl  very  truly  calls  "  the  sensorium  commune  of  the  entire  territory 
of  the  genital  organs" — frequently  gives  rise  to  a  condition  of  erethism 
in  that  organ,  which  remains  in  a  state  of  incomplete  erection.  Desire 
for  coitus  is  sometimes  so  urgent  and  uncontrollable  that  sexual  excesses 


114  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

are  committed  and  masturbation  is  practised,  much  to  the  aggravation  of 
the  disease. 

I  have  many  times  seen  women,  wives  and  mistresses,  infected  by  men 
in  the  prodromal  stage  of  gonorrhoea,  whose  urethrse  were  as  yet  free  from 
pus.  Zeissl  speaks  of  a  similar  experience.  In  these  cases  the  infection 
is  carried  by  the  epithelial  cells,  which  are  covered  or  infiltrated  with 
gonococci. 

As  a  rule,  the  symptoms  of  acute  anterior  gonorrhoea  in  its  prodromal 
stage  are  strictly  local  in  character.  Finger  states  that  in  sensitive  indi- 
viduals slight  general  symptoms,  such  as  depression,  malaise,  and  ano- 
rexia, may  occur  at  this  time.  Though  I  have  looked  into  the  subject 
very  carefully,  I  have  been  unable  to  convince  myself  that  these  symp- 
toms are  due  to  the  infective  process  per  se.  I  am  led  to  think  that 
trouble  and  worry  of  mind,  induced  by  an  impending  gonorrhoea,  are  the 
factors  of  the  patient's  indisposition,  rather  than  a  general  reaction  of  the 
infection. 

As  a  rule,  a  patient's  worry  and  fret  begin  in  the  next  stage.  With 
the  onset  of  the  classical  symptoms  of  true  inflammation — namely,  red- 
ness, swelling,  pain,  and  pus — the  prodromal  stage  is  said  to  end  and  the 
acute  or  florid  stage  to  begin. 

The  Acute  Stage. — The  redness,  previously  limited  to  the  halo-like 
disk  around  the  meatus,  may  spread  and  involve  the  whole  glans,  which 
then  becomes  swollen.  Then,  particularly  in  cases  in  which  the  prepuce 
is  long  and  tight,  this  muco-tegumentary  covering  becomes  red  and 
swollen  in  part  or  in  its  entirety.  As  a  result  oedema  may  be  produced, 
which  may  be  limited  to  the  region  of  the  fossae  of  the  frgenum  or  it  may 
involve  the  distal  part  of  the  prepuce.  In  very  severe  cases  it  attacks 
the  whole  integument  of  the  penis,  and  thereby  causes  much  pain,  tension, 
and  discomfort.  Frequently  very  little  oedema  is  present,  but  we  may 
find  the  lymphatics  on  either  side  of  the  fraenum  swollen,  and  can  trace 
them  as  small,  red,  tender  cords  along  the  dorsum  of  the  penis  to  the 
lymphatic  ganglia  in  the  groin,  which  may  be  more  or  less  swollen  and 
painful.  Not  infrequently  phimosis  is  induced,  which  much  distorts  the 
shape  of  the  penis.  Then,  again,  paraphimosis  is  a  not  infrequent,  pain- 
ful, and  disquieting  complication.  The  discharge  is  then  profuse,  thick, 
creamy,  and  decidedly  purulent,  and  sometimes  mixed  Avith  blood.  It 
dries  upon  and  soils  the  patient's  linen,  and  may  often  be  seen  in  the 
form  of  crusts  near  the  meatus  and  on  the  glans  when  not  covered  by  the 
prepuce.  This  condition  of  affairs,  which  is  usually  reached  toward  the 
end  of  the  first  or  early  in  the  second  week,  and  perhaps  earlier,  is  at- 
tended by  the  extension  of  the  disease  down  the  urethra,  perhaps  as  far 
as  the  bulb.  Then  in  severe  cases  the  corpus  spongiosum  can  be  felt  as  a 
swollen,  hard,  cord-like  tube  which  is  painful  to  the  touch.  Occasionally 
we  can  detect  along  the  course  of  the  corpus  spongiosum  one  or  more 
little  swellings  or  periurethral  nodules  of  the  size  of  small  shot  or  of  a 
pea,  which  are  simply  inflamed  follicles.  They  show,  however,  that  the 
gonorrhoeal  process  has  involved  the  whole  thickness  of  the  mucous  mem- 
brane, and  has  attacked  the  meshes  of  the  corpus  spongiosum.  In  cases 
presenting  this  intensity  of  symptoms  the  whole  thickness  of  the  mucous 
membrane,  the  subcutaneous  connective  tissues,  and  the  erectile  tissue  of 
the  corpus  spongiosum  are  involved.     In  these  cases  the  gonorrhoeal  pro- 


ACUTE  ANTERIOR   GONORRH(EA,   OR    URETHRITIS.  115 

cess  has  extended  deeply,  but  there  are  cases  in  which  the  symptoms  are 
very  severe,  but  in  which  this  depth  of  invasion  of  the  inflammatory  pro- 
cess cannot  be  made  out,  since  the  spongy  urethra  does  not  feel  very 
much  swollen.  There  are  instances  in  which  the  gonorrhoeal  process  is 
superficial  and  only  invades  the  mucous  membrane  and  the  submucous 
coat  slightly  ;  such  cases  are  not  at  all  uncommon.  As  a  result  of  this 
inflammatory  swelling  of  the  mucous  and  submucous  tissues  the  calibre  of 
the  urethral  canal  is  very  much  narrowed.  Urination  then  becomes  an 
act  of  pain,  and  even  of  agony,  by  reason  of  the  induced  scalding  and 
burning  sensations,  described  by  some  as  if  a  hot  iron  had  been  intro- 
duced into  the  canal,  which  may  be  felt  along  the  whole  of  the  pendulous 
urethra,  or  it  may  be  most  severe  at  the  fossa  navicularis.  Sometimes 
the  pain  is  said  to  be  at  the  peno-scrotal  angle,  and  at  others  as  far  as  the 
bulb.  The  patient  dreads  to  void  his  urine,  and  ventures  to  do  so  as 
seldom  as  possible.  In  the  graphic  language  of  my  late  colleague.  Dr. 
Bumstead,  the  dysuria  of  gonorrhoea  is  thus  described :  "  During  the  act 
the  patient  involuntarily  relaxes  the  abdominal  walls,  holds  his  breath, 
and  keeps  the  diaphragm  elevated  in  order  to  diminish  the  pressure  on 
the  bladder  and  lessen  the  size  and  force  of  the  stream."  As  pointed  out 
long  ago  by  Ricord,  this  burning  pain  on  urination  is  due  to  the  forcible 
distention  of  the  inflamed  and  suppurating  urethra,  and  also  to  the  acid 
condition  of  the  urine.  A  further  result  of  this  mechanical  narrowing  of 
the  canal  is  seen  in  the  character  of  the  stream  of  urine.  This  becomes 
hesitating,  weak,  sputtering,  forked,  twisted,  narrow,  and  wiry,  and  the 
urine  may  even  escape  by  drops.  All  the  shapes  of  the  stream  of  urine 
produced  by  stricture  may  be  simulated  in  the  acute  stage  of  gonorrhoea. 
At  this  time  a  patient's  suffering  during  urination  may  be  still  more 
intensified  by  spasmodic  contractions  of  the  compressor  urethrae  muscle, 
which  not  unfrequently  causes  strangury  and  retention  of  urine. 

Very  often,  both  in  the  acute,  declining,  and  chronic  stages  of  gonor- 
rhoea, patients  complain  of  dribbling  of  urine  on  their  linen  for  a  few 
minutes  after  each  urination.  This  condition  is  due  to  the  loss  of  the 
resiliency  of  the  urethral  canal,  which  by  its  contraction  aids  in  the  final 
expulsion  of  the  last  drops.  The  urethral  walls  are  so  swollen  and  oede- 
matous  that  their  muscular  fibres  have  lost  their  tonus. 

It  must  not  be  forgotten  that  in  uncomplicated  acute  anterior  gonor- 
rhoea there  is  usually  not  much,  if  any,  increased  desire  to  urinate.  Such 
patients  can,  as  a  rule,  hold  their  water  nearly  as  well  as  they  did  in 
health.  Sometimes  the  patient  urinates  a  little  more  often  than  he  does 
normally ;  consequently,  he  seldom  has  to  get  up  at  night  more  than  once 
for  the  purpose  of  urination.  In  acute  anterior  gonorrhoea  we  never 
observe  tenesmus  and  uncontrollable  desire  to  urinate,  as  we  do  in  acute 
posterior  gonorrhoea. 

The  acme  of  this  acute  stage,  which  is  reached  usually  in  the  second 
week,  is  attended  with  a  still  more  unpleasant  train  of  s^miptoms.  The 
urethra  is  then  involved  from  the  meatus  to  the  bulb.  The  pendulous 
urethra  is  sensitive,  and  even  painful,  and  when  the  disease  is  located  at 
the  bulb  there  is  a  sensation  of  tightness,  and  even  anguish,  between  the 
testes ;  walking  is  rendered  uncomfortable  and  sudden  jarring  causes 
much  pain.  When  such  patients  attempt  to  sit  down,  they  go  about  it 
slowly  and  carefully  and  avoid  pressure  upon  the  perineum.     They  are 


116  GONOBBHCEA  AXD  ITS  COMPLICATIONS. 

also  careful  in  crossing  their  legs  lest  the}^  should  suffer  thereby.  Besides 
these  pains  in  the  penis  and  perineum,  there  may  be  a  more  or  less  uneasy 
aching  and  dragging  pain  in  the  testes,  which,  however,  may  not  be 
aflFected,  and  also  in  the  groins  and  lumbar  region.  As  a  consequence 
of  all  this  suffering  many  patients  become  really  ill,  and  they  look  pale, 
-worried,  and  hollow-eyed,  lose  their  appetites,  feel  weak,  and,  in  short, 
suffer  from  malaise  and  mental  depression.  Some  patients  have  a  mild 
or  pronounced  fever,^  accompanied  by  chilliness,  especially  toward  night. 
While  such  patients  suffer  much  during  the  day,  they  frequently  endure 
much  discomfort,  and  even  torture,  during  the  night.  Insomnia  is  not 
infrequently  experienced  as  the  result  of  painful  erections,  accompanied 
by  debilitating  pollutions,  and  also  by  chordee  or  chorda  venerea,  by 
which  the  penis  is  bent  in  the  shape  of  a  bow  and  much  pain,  and  even 
agony,  is  produced.  Chordee  is  due  to  oedematous  infiltration  of  the 
corpus  spongiosum,  Avhich  becomes  less  extensible  than  the  corpus 
cavernosum.  As  a  result,  Avhen  in  erection  the  cavernous  bodies  undergo 
extension  and  lengthening  they  are  drawn  down  or  to  one  side  by  the 
thickened  and  unyielding  spongy  body,  which  acts  like  the  string  of  a 
bow.^  Though  chordee  is  so  much  spoken  of  as  an  accompaniment  of 
acute  gonorrhoea,  it  is  really  not  a  very  frequent  symptom.  My  observa- 
tion teaches  me  that  in  most  cases  it  is  the  result  of  the  too  early  use  of 
strong  injections  and  balsamics  or  of  alcoholics,  which  greatly  intensify 
the  severity  of  the  disease. 

Erections  and  chordee,  induced  by  the  warmth  of  the  bed,  torment 
and  debilitate  a  patient  by  reason  of  their  persistence.  Having  relieved 
himself  of  one  attack,  he  goes  back  to  bed  and  falls  asleep,  only  to  be 
seized  sooner  or  later  by  another  spasm.  As  a  result,  the  patient  feels 
weak  and  dejected  in  the  morning,  and  is  often  unfitted  for  the  proper 
performance  of  his  daily  duties. 

^  Trikaki.  in  Mauriac's  service  at  the  Ricord  Hospital  ("De  la  Fievre  dans  la  Blen- 
norrhagic  aigue,"  Annales  des  Mai.  des  Organes  Gea.-urin.,  1895,  pp.  154  et  seq. ),  examined 
by  means  of  the  thermometer  in  the  rectum,  methodically  and  with  great  care,  50  cases 
of  acute  gonorrhsea  without  complications,  and  in  which  was  no  intercurrent  disease. 
Of  these  50  cases,  fever  was  found  in  31,  and  not  in  19.  In  these  19  cases,  however,  there 
were  6  in  which  the  acute  stage  had  passed  away.  Trikaki  concludes  that  in  cases  of 
acute  gonorrhoea  the  rectal  temperature  is  above  the  normal,  reaching  to  103°  and  even 
105°  Fahr.  It  is  a  true  fever,  and  is  observed  in  about  two-thirds  of  all  cases.  It  is 
found  in  the  acute  stage,  and  is  intense  in  proportion  to  the  severity  of  the  gonorrhoea, 
and  declines  with  the  amelioration  of  the  urethral  suppuration. 

These  statements  of  Trikaki,  being  in  contradiction  to  the  views  of  Guyon,  who  main- 
tains that  there  is  usually  no  fever  during  the  course  of  gonorrhoea,  Nogues  ("  De  la  Tem- 
perature dans  la  Blennorrhagie  aigue,"  ibid.,  1895,  pp.  433  et  seq.j,  a  pupil  of  that  emi- 
nent French  surgeon,  carefully  examined  thirteen  cases  of  acute  gonorrhoea,  and  found 
an  ephemeral  fever  in  only  one  case,  in  which  there  was  acute  prostatitis  of  short  dura- 
tion. 

'^  Hilton  thinks  that  in  erection  there  is  a  sudden  spasm  of  the  vaso-motor  muscles  of 
the  penis,  caused  by  irritation  of  the  branches  of  the  pudic  nerve  which  go  to  the  urethra, 
and  that  erections  are  caused  by  excito-motor  action  upon  the  spinal  cord,  M'hich  during 
sleep  is  not  under  control  of  the  brain.  The  mechanism  of  chordee  can  be  well  illus- 
trated by  fixing  a  narrow  piece  of  adliesive  plaster  along  the  surface  of  an  India-rubber 
condom,  and  then  distending  it  with  the  breath.  Patients  .should  always  be  warned  that 
in  case  of  chordee  no  violence  should  be  done  tlie  organ  by  forcibly  straightening  it  or 
"  breaking  the  cord,"  .since  severe  hemorrhage,  and  even  septic  infection,  may  occur,  and 
a  lesion  of  continuity  may  be  made  wliich  will  almost  inevitably  terminate  in  stricture. 
Cases  are  on  record  in  which  phlebitis  and  gangrene  followed  injury  to  the  penis  during 
chordee,  and  resulted  in  death. 


ACUTE  ANTERIOR  GOXORRHCEA,   OR    URETHRITIS.  117 

During  all  this  time  the  discharge  is  purulent  and  greenish,  and  often 
mixed  or  streaked  with  blood,  when  it  may  present  a  dusky  hue. 

In  this  acute  stage  we  often  see  a  peculiar  form  of  hasmaturia.  Toward 
the  end  of  urination  or  a  short  time  thereafter  a  few  drops  of  blood  may 
escape  from  the  urethra.  Sometimes  this  does  not  occur  until  after  the 
patient  has  replaced  his  penis  under  his  clothes,  which  he  subsequently 
finds  stained.  This  post-mictional  hematuria  is  due  to  compression  of 
the  inflamed  mucous  membrane  by  the  accelerator  urinse  muscle  and  to 
its  forced  distention  by  the  stream  of  urine. 

In  most  patients  the  purulent  discharge  is  more  profuse  in  the  morn- 
ing, from  which  time  it  diminishes  in  quantity  till  night,  when  it  reaches 
its  minimum.  This  condition  is  largely  due  to  the  less  frequency  in 
urination  during  the  night,  when,  of  course,  the  secretion  accumulates 
in  the  canal.  It  is  also  due  in  many  cases  to  nocturnal  exacerbation  of 
the  disease,  resulting  undoubtedly  largely  from  exercise  taken  and  exer- 
tion made  on  the  day  previous.  There  can  be  no  doubt  that  in  a  large 
proportion  of  cases  of  acute  anterior  gonorrhoea  there  are  nocturnal 
exacerbations  and  diurnal  remissions.  In  other  cases  we  see  a  continual 
profuse  flow  of  pus  from  the  meatus,  and  we  hear  patients  express  wonder 
as  to  where  so  much  discharge  comes  from.  Coming,  as  it  does,  from  the 
pendulous  and  bulbous  portions  of  the  urethra,  it  is  easy  to  see,  consider- 
ing the  extent  of  the  surface,  why  it  is  so  profuse.  When  patients  remain 
in  bed,  then  the  exacerbation  and  remission  of  symptoms  are  usually  very 
much  less  marked. 

This  ensemble  of  morbid  phenomena,  inflammatory  and  subjective,  is 
generally  complete  toward  the  end  of  the  second  or  early  in  the  third 
week,  and  its  further  duration  depends  largely  upon  the  hygiene,  reg- 
imen, diet,  and  treatment  of  the  patient.  If  rest  and  quiet  can  be 
obtained  and  proper  medication  is  followed,  the  patient's  condition  will 
begin  to  mend  at  this  time.  The  first  noticeable  feature  of  improvement 
is  a  diminution  in  the  patient's  suff"erings,  particularly  during  urination. 
Then  he  will  be  progressively  less  troubled  with  his  painful  nocturnal 
symptoms,  and,  as  a  result,  he  will  sleep  better  and  will  feel  stronger  and 
more  cheerful.  His  appetite  will  become  better  and  his  general  morale 
improved. 

In  some  cases,  however,  pain,  soreness,  or  a  burning  sensation  on  urina- 
tion persists  after  all  other  symptoms  have  become  ameliorated  or  have 
even  disappeared. 

The  symptomatic  pains  and  uneasiness  in  the  testes,  loins,  and  groins 
will  become  markedly  less,  when  inspection  and  examination  of  the 
morbid  parts  will  show  that  the  inflammatory  process  is  on  the  decline. 
The  redness  (and  swelling,  if  present)  about  the  glans  and  prepuce  will 
subside,  the  meatus  will  appear  more  normal  in  color  and  in  shape,  and. 
the  corpus  spongiosum  will  be  much  less  tense,  swollen,  and  painful. 
Then,  owing  to  the  as  yet  partial  subsidence  of  the  swelling  of  the 
urethral  mucous  membrane,  the  stream  of  urine  will  become  stronger 
and  larger.  The  discharge  is  at  this  time  usually  copious,  but  it  insen- 
sibly grows  less  green  and  becomes  more  milky  and  mucoid.  Its  quan- 
tity then  decreases,  and  it  gradually  grows  thinner  in  consistence.  Thus 
it  slowly  disappears  under  favorable  circumstances  until  only  a  little 
grayish  muco-pus  may  be  seen  during  the  day,  or  it  may  be  only  visible 


118  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

in  the  morning,  when  it  glues  the  lips  of  the  meatus  together.  This 
condition  may  remain  for  a  few  or  several  days,  and  then,  if  treatment 
is  followed,  no  discharge  can  be  seen  and  the  urethra  seems  again  in  a 
normal  condition. 

The  foregoing  description  applies  only  to  cases  of  anterior  gonorrhoea, 
in  which  the  morbid  process,  as  already  stated,  stops  at  the  triangular 
ligament.  In  many  such  cases,  unfortunately,  toward  the  end  of  the 
first  and  in  the  second  Aveek  the  suppurative  process  extends  to  the  pos- 
terior urethra,  and  a  new  order  of  phenomena,  to  be  described  later  on,  is 
ushered  in.  In  this  event  the  suppurative  process  in  the  anterior  urethra 
may  cease  entirely  or  it  may  smoulder  in  a  subacute  form. 

It  must  be  clearly  borne  in  mind  that  the  foregoing  symptom-complex 
is  that  presented  by  a  severe  form  of  acute  anterior  gonorrhoea,  and  that 
there  are  milder  forms  in  Avhich  the  gonorrhoeal  process  is  less  intense  and 
the  symptoms  less  severe.  Thus  the  pain  or  burning  on  urination  may 
only  amount  to  a  mild  sensation  of  heat  or  a  slight  pricking  or  smarting. 
Erections  may  be  attended  with  little  if  any  discomfort,  and  interfere  but 
little  with  the  patient's  sleep.  There  is,  therefore,  less  heat  in  the  canal 
and  the  erethism  is  mild  or  absent. 

We  constantly  see  cases  of  primary  anterior  gonorrhoea  in  which, 
though  the  purulent  discharge  is  profuse,  even  sanguinolent,  the  inflam- 
matory symptoms  are  not  strongly  marked  and  the  patient's  suiferings  are 
correspondingly  mild.  Indeed,  we  see  cases  of  profuse  discharge  in  which 
patients  make  little  if  any  complaint,  though  the  inflammatory  phenomena 
seem  well  marked.  This  may  also  be  observed  in  cases  in  which  the 
symptoms  have  been  acute  and  intense. 

In  favorable  cases  of  acute  anterior  urethritis  a  cure  may  be  brought 
about  in  from  six  to  eight  Aveeks,  in  which  event  the  patient  may  con- 
sider himself  a  very  lucky  man.  We  occasionally  see,  however,  some 
patients  get  well  in  three  or  four  weeks.  These  favorable  cases  generally 
are  instances  of  the  result  of  careful  hygiene  and  discreet  regimen,  com- 
bined Avith  judicious  and  efficient  treatment.  In  private  practice  it  is 
very  often  impossible  to  place  patients  at  rest,  and  they  thereby  are  un- 
able at  first  to  avail  themselves  of  one  of  the  most  important  means  of 
cure.  Even  in  hospitals  it  is  a  most  difficult  task  to  keep  such  patients 
in  bed.  Therefore,  in  a  large  number  of  cases  gonorrhoea  runs  on  in 
patients  who  cannot  follow  the  requirements  of  strict  regimen,  hygiene, 
and  treatment.  As  a  result  the  acute  stage  passes  into  the  subacute  or 
declining  stage,  which  may  last  many  months.  In  such  cases  the  more 
or  less  scanty  or  copious  discharge  is  the  most  prominent  symptom. 
Sometimes  mild  or  severe  burning  is  experienced  in  urination  even  in  a 
declining  gonorrhoea. 

In  this  declining  stage  annoying  relapses  are  quite  frequent.  Some- 
times these  relapses  are  mild,  and  again  they  are  severe  in  character. 
They  usually  grow  less  and  less  severe,  and  then  a  cure  folloAvs.  Most 
instances  of  relapse  are  due  to  the  carelessness  and  heedlessness  of  the 
patient,  who  indulges  in  alcoholics  and  highly-seasoned  food,  in  venery, 
and  in  active  exercise.  Very  often  the  abstinence  from  sexual  intercourse 
necessitated  b}'"  the  gonorrhoea  induces  a  condition  of  erethism  in  the 
patient,  Avhich  gives  rise  to  nocturnal  emissions  and  brings  on  a  relapse. 
Then,  again,  the  tissues  of  some  patients  seem  prone  to  become  inflamed 


ACUTE  ANTERIOR   GONORRHCEA,   OR    URETHRITIS.  119 

and  slow  to  return  to  a  normal  condition,  and  in  such  subjects  relapses 
are  common.  It  is  said  that  scrofula,  rheumatism,  cachexia,  poor  nutri- 
tion, and  the  syphilitic  diathesis  may  be  at  the  bottom  of  this  morbid 
tendency ;    and  perhaps  they  are. 

It  is  usually  in  the  course  of  or  as  a  result  of  these  relapses,  after  first 
and  later  infections,  that  the  gonorrhoea!  process  seems  to  localize  itself 
in  certain  portions  of  the  urethra — namely,  the  bulbous  portion,  the 
spongy  portion,  at  the  peno-scrotal  angle,  the  portion  of  the  urethra  im- 
mediately anterior  to  this,  and  in  the  fossa  navicularis.  In  many  cases  a 
latent  inflammation  remains  in  one  or  more  of  the  urethral  crypts  and 
follicles.  Then  external  irritation  develops  this  chronic  condition  into 
an  active  stage,  when  a  greater  or  less  segment  of  the  urethra  becomes 
involved.  It  is  to  the  persistency  of  these  relapses  that  the  development 
of  stricture  of  the  urethra  is  due. 

Many  patients  regard  these  relapses  at  periods  more  or  less  remote 
from  the  original  infection  as  new  infections.  They  are  really,  in  many 
instances,  ephemeral  suppurations  induced  in  a  chronically-inflamed  patch 
or  segment  of  the  urethra,  Avhich  commonly  cease  on  the  removal  of  the 
exciting  cause  or  as  a  result  of  proper  treatment.  It  is  these  relapsing 
suppurations  Avhich  laymen  often  speak  of  so  slightingly  when  they  say 
they  would  rather  have  an  attack  of  gonorrhoea  than  a  bad  cold.  They 
are  usually  promptly  responsive  to  treatment,  and  in  consequence  of  the 
rapidity  of  cure  in  such  cases  certain  methods  of  treatment,  as  injections 
of  no  particular  energy  or  value,  come  to  have  a  great  reputation. 

Besides  the  foregoing  objective  and  subjective  symptoms  of  gonorrhoea, 
there  are  certain  intrinsic  conditions  of  the  disease  which  must  be  studied 
by  means  of  the  microscope  and  by  a  study  of  the  condition  of  the  urine. 
These  studies  are  absolutely  essential  to  the  systematic  treatment  of  the 
disease. 

Much  information  as  to  the  course  of  acute  anterior  urethritis  may  be 
gained  from  a  systematic  microscopical  study  of  the  secretion.  We  have 
already  given  the  facts  concerning  the  onset  of  the  infection.  (See  page 
63.)  When  the  suppuration  is  at  its  height  it  will  be  seen  that  the  whole 
microscopical  field  is  covered  with  pus-corpuscles,  and  when  it  is  very 
severe  it  will  be  found  that  a  proportionately  large  number  of  these  cells 
contain  gonococci.  As  the  process  improves,  though  the  pus-cells  are  still 
numerous,  the  number  of  them  which  contain  the  microbe  Avill  be  smaller. 
Then  we  observe  a  diminution  in  the  amount  of  suppuration  and  the 
gradual  decline  in  the  number  of  the  gonococci.  As  the  declining  stage 
advances  epithelium  becomes  mixed  with  the  pus-corpuscles,  and  then, 
under  favorable  circumstances,  the  latter  grow  less  numerous,  while  the 
epithelial  element  becomes  more  copious.  Then  the  pus-cells  finally  dis- 
appear, and  soon  after  the  epithelial  cells  cease  to  be  proliferated,  and  a 
cure  results. 

Much  light  is  also  thrown  on  the  progress  of  a  case  of  acute  anterior 
urethritis  by  the  examination  of  the  urine.  As  we  have  already  seen,  in 
the  prodromal  stage  the  urine  is  at  first  clear,  but  contains  little  rice-like 
or  suet-like  masses,  Avhich  may  look  like  little  balls  or  flakes  or  even 
threads.  Then,  perhaps  for  a  few  hours  or  for  a  day,  there  may  be  a 
further  admixture  of  mucus  in  small  quantity.  Usually  a  marked  change 
then  ensues.     The  urine  becomes  quite  opaque,  and  looks  very  much  as 


120  GONORRHCEA   AND  ITS  COMPLICATIONS. 

if  Indian  meal  had  been  mixed  with  it.  This  opacity  increases,  and 
becomes  quite  intense  in  the  acme  of  the  infection,  in  the  second  and  third 
weeks  and  even  later.  The  purulent  secretion  may,  as  it  escapes  from 
the  urethra,  seem  very  copious,  but  its  quantity  can  be  better  judged 
after  the  patient  has  held  his  water  from  four  to  eight  hours.  If  it  is 
then  passed  and  allowed  to  stand  for  several  hours,  the  pus  will  settle  to 
the  bottom  in  a  broad,  quite  firm,  seemingly  homogeneous  yellowish-white, 
even  greenish,  layer,  perhaps  an  inch  or  more  thick.  In  cases  of  hemor- 
rhage a  thin  red  layer  of  blood  rests  on  the  pus-layer.  Over  this  pus- 
layer  will  be  seen  a  grayish  nebulous  spider-web-looking,  very  easily 
movable  layer  of  mucus,  which  at  first  will  not  be  as  thick  as  the 
underlying  pus-layer.  The  further  progress  of  the  case  could  be  made 
out,  if  necessary,  by  the  daily  study  of  the  urine,  without  any  informa- 
tion from  the  patient.  As  the  suppuration  grows  less,  the  urine  becomes 
less  cloudy  and  opaque  and  rather  more  milky-looking.  Then,  day  by 
day,  the  pus-layer  grows  less  thick,  is  less  compact,  and  is  exceeded  in 
thickness  by  the  supernatant  mucous  layer.  In  many  cases,  just  as  the 
pus  declines  and  the  urine  is  less  opaque  than  before,  the  quantity  of 
mucus  is  so  pronounced  that  an  opacity  comparable  to  that  of  mucilage 
is  noticed.  This  opacity  usually  clears  up  slowly,  but  it  may  exist,  some- 
times, for  long  periods.  As  the  pus-layer  decreases  in  thickness  it  is 
seen  to  consist  of  small  and  large  clumps  and  masses,  while  the  mucous 
layer  is  further  increased  in  volume.  As  the  morbid  process  goes  on  to 
decline  these  clumps  become  less  plentiful,  while  the  mucous  layer  remains 
in  an  unchanged  condition.  Then  these  clumps  become  smaller  and 
smallei",  until  at  last,  just  before  the  cessation  of  the  suppuration,  they 
are  so  minute  (pinhead  or  pinpoint  size)  that  they  do  not  sink,  but  are 
held  in  suspension  by  the  mucous  layer,  which  is  more  transparent  than 
previously,  and  usually  floats  just  below  the  surface  of  the  fluid.  The 
next  favorable  change  is  the  disappearance  of  these  very  minute  masses 
of  pus  (with  sometimes  epithelial  admixture),  leaving  the  mucous  secre- 
tion, which  may  be  for  a  time  above  normal  in  quantity. 

The  foregoing  description  applies  to  cases  which  do  not  hitch  or  halt 
in  the  declining  stage.  Unfortunately,  as  we  have  seen,  in  many  cases 
various  causes  tend  to  retard  the  cure  in  the  declining  stage.  Then  we 
find  scarcely,  if  any,  discharge  at  the  meatus  in  the  morning,  but  exami- 
nation of  the  urine  shows,  after  the  clumpy  pus  has  disappeared,  first 
mucus  and  the  mucous  threads  already  described,  and  then  mucus  and  the 
firmer  form  of  threads.  In  this  condition  the  process  may  remain  indef- 
initely for  weeks  and  months,  and  even  years.  At  first  the  threads  are 
formed  of  pus-cells  in  excess  of  epithelium,  and  thus  the  ratio  may  remain 
for  a  long  time.  Then,  as  the  cure  takes  place,  the  pus-cells  decrease  in 
number  and  the  epithelial  cells  predominate  in  the  microscopic  field. 
In  auspicious  cases  the  pus  then  disappears,  while  epithelium  may  still 
be  discovered.  Then,  when  the  integrity  of  the  mucous  membrane  has 
been  restored,  nothing  but  a  normal  amount  of  mucus  can  be  seen.  The 
foregoing  facts  are  amplified  on  page  73. 

In  these  frequent  cases  of  chronic  urethritis  or  gleet  the  pus 
and  epithelial  cells  continue  present  in  tliread  form,  often  with  discour- 
aging persistence. 

It  is  always  very  important  to  accurately  know  how  deeply  in  the 


ACUTE  ANTERIOR   GONORRHCEA,   OR    URETHRITIS.  121 

urethra  the  infection  has  spread.  In  acute  gonorrhoea  the  urine  may  be 
examined  by  what  is  called  Thompson's  or  the  two-glass  test.  If  the 
morbid  process  is  still  confined  to  the  anterior  urethra,  and  the  purulent 
secretion  is  quite  copious  and  the  urine  is  voided  into  two  glass  cylinders 
or  beakers,  it  will  be  seen  that  the  jet  passed  into  the  first  vessel  is  turbid, 
while  that  in  the  second  is  transparent  and  clear.  It  is  then  evident  that 
the  morbid  process  is  still  localized  in  the  anterior  urethra.  If  the  infec- 
tion has  reached  the  posterior  urethra  and  the  secretion  is  still  quite 
copious  and  the  patient  passes  his  urine  into  two  vessels,  the  urine  in  the 
first  will  be  opaque,  and  so  will  that  in  the  second  vessel  be.  Up  to  this 
stage,  therefore,  the  two-glass  test  is  valuable  in  cases  of  gonorrhoea  of 
the  totality  of  the  urethra.  In  other  words,  just  as  long  as  the  secretion 
is  quite  copious  this  two-glass  test  will  yield  accurate  information  ;  but 
when  the  morbid  products  become  much  less  in  quantity,  less  fluid  in 
consistency,  and  more  inspissated,  then  they  are  usually  washed  out  with 
the  first  flow  of  urine,  which  flushes  and  cleans  out  both  the  anterior  and 
posterior  urethrae.  It  follows,  therefore,  that  in  all  cases  of  declining 
gonorrhoea  with  scanty  secretion,  and  in  cases  of  chronic  gonorrhoea,  the 
two-glass  test  Avill  be  found  wanting,  and  will  give  no  information  as  to 
whether  the  morbid  process  is  confined  to  the  anterior  or  posterior  urethra, 
or  at  best  misleading  information.  It  is  evident  that  under  these  circum- 
stances a  knowledge  of  the  condition  of  the  posterior  urethra  can  only  be 
obtained  by  thoroughly  cleansing  the  anterior  urethra,  and  then  allowing 
the  patient  to  pass  his  urine  into  one  or  into  two  glasses  if  a  knowledge 
of  the  condition  of  the  bladder  is  essential.  It  is  very  important  that 
this  cleansing  process  should  be  thoroughly  done,  and  that  the  urethra 
should  not  be  irritated  or  damaged  in  any  degree  in  the  operation. 
Consequently,  we  must  first  consider  what  procedures  should  be  avoided,, 
since  they  are  advocated  by  some  authors. 

In  the  declining  stage  of  gonorrhoea  and  in  many  cases  of  chronic 
posterior  gonorrhoea  the  use  of  the  endoscope  must  be  interdicted.  The 
field  of  usefulness  of  the  endoscope  in  troubles  of  the  posterior  urethra 
is  quite  narrow,  and  when  the  inflammation  of  these  parts  is  hovering 
between  an  acute  and  a  chronic  condition,  its  use  may  be  attended  by 
bad  results.  It  is  well,  therefore,  to  dismiss  this  agent  of  diagnosis  from 
our  minds  under  these  circumstances. 

The  next  method  is  one  largely  used  in  France.  It  consists  in  the 
introduction  of  a  good-sized  bougie  a  boule  down  as  far  as  the  bulbous 
portion  of  the  urethra,  and  then  in  gently  scraping  backward  and  forward 
with  the  hope  of  bringing  away  any  secretion  on  the  proximal  end  or 
neck  of  the  bulb.  This  procedure  is  a  bungling  and  unsatisfactory  one, 
rarely  productive  of  any  result,  and  very  liable  to  set  up  acute  inflamma- 
tion. It  is  a  good  general  rule  not  to  introduce  a  bougie  a  boule,  a  sound, 
or  metallic  instrument  of  any  kind  into  the  urethra,  even  as  far  as  the 
bulb,  until  several  months  have  elapsed  since  the  onset  of  the  infection. 

The  next  method  is  equally  as  objectionable  and  as  faulty.  It  con- 
sists in  the  introduction  of  a  long,  flexible  applicator  in  the  end  of  which 
a  small  ball  of  absorbent  cotton  is  attached.  The  object  is  to  wipe  or 
swab  out  the  canal.  This  procedure  is  followed  by  uncertain  results,  and 
may  lead  to  inflammatory  reaction. 

Still  another  method  is  to  introduce  a  short  endoscopic  tube  as  far  as 


122  GONORBHCEA  AND  ITS  COMPLICATIONS. 

the  bulbo-membranous  junction,  and  then  employ  the  last  procedure. 
This  method  is  fallacious,  and  may  cause  an  exacerbation  of  the  gonor- 
rhoeal  trouble.  In  all  these  methods  of  cleansing  the  anterior  urethra 
lurks  the  danger  of  infecting  the  posterior  urethra  in  case  that  region  is 
yet  intact.  All  these  methods  have  their  objections  and  drawbacks; 
therefore  we  resort  to  washing  out  the  anterior  urethra. 

Several  methods  are  employed  in  the  washing  out  or  lavage  of  the 
anterior  urethra.  The  simplest  one  is  to  pass  down  to  the  bulb  (5  to  6J 
inches  usually),  the  patient  being  in  a  standing  position,  a  soft-rubber 
velvet-eye  catheter  lightly  smeared  with  glycerin,  of  No.  10  or  12  French 
scale,  or  a  Mitchell  reflux  catheter,  and  then,  by  means  of  the  hand- 
syringe,  to  inject  five  to  ten  ounces  of  quite  warm  borax,  boracic-acid,  or 
salt  water.  The  fluid  should  be  thrown  in  slowly,  and  collected  as  it 
runs  out  of  the  meatus.  It  may  be  w^ell  for  a  few  seconds  to  compress 
the  meatus,  and  thus  to  cause  the  stream  to  exert  greater  force  upon  the 
urethral  walls.  When  the  water  flows  from  the  meatus  clear  and  with- 
out admixture,  it  is  fair  to  assume,  if  proper  care  and  technique  have 
been  used,  that  the  anterior  urethra  is  cleansed.  The  patient  may  then 
pass  his  urine  into  one  or  two  glass  cylinders  or  beakers.  If  the  quan- 
tity of  urine  in  the  bladder  is  yet  quite  small,  it  is  very  probable  that 
the  prostatic  urethra  has  not  yet  become  part  of  the  bladder,  and  that  its 
secretion  has  not  been  regurgitated  into  or  mixed  with  the  vesical  con- 
tents. Consequently,  the  first  jet  of  urine  will  carry  away  all  secretion 
from  the  prostatic  urethra.  The  second  stream,  coming  directly  from  the 
bladder,  will  give  information  as  to  its  condition,  and  will  determine 
whether  the  infection  has  invaded  that  viscus. 

Now,  in  the  event  of  the  patient  having  much  urine  in  his  bladder, 
it  is  safe  to  assume  that  the  prostatic  urethra  has  been  drawn  into  that 
viscus,  and  that  its  secretion  is  mixed  with  its  contents.  As  a  result  of 
this  condition  it  will  be  necessary  to  study  the  secretion  with  the  micro- 
scope after  it  has  settled,  and  to  determine  whether  the  tissue-elements 
have  come  from  the  posterior  urethra  alone  or  also  from  the  bladder.  It 
is  always  a  good  rule,  therefore,  to  use  lavage  of  the  anterior  urethra 
with  a  view  of  determining  the  condition  of  the  posterior  urethra.  When 
the  patient  has  only  three  or  four  ounces  of  urine  in  the  bladder,  the 
internal  sphincter  usually  remains  competent,  and  the  prostatic  urethra 
and  bladder  do  not  then  form  one  cavity.  It  is  very  probable,  when 
the  morbid  process  in  the  posterior  urethra  is  active  and  the  secretion  is 
thin  and  copious,  that  it  tends  to  flow  toward  the  bladder,  since  the 
internal  sphincter  is  weaker  than  its  external  fellow.  In  this  case  the 
intermingling  of  the  fluids  occurs  quite  early.  If,  however,  the  secretion 
is  thick  and  viscid  and  small  in  quantity,  it  will  remain  in  the  prostatic 
urethra  until  it  is  carried  away  with  the  first  jet  of  urine,  or  it  may 
become  mixed  with  the  urine  in  the  fusion  of  the  prostatic  urethra  with 
the  bladder. 

The  secretion  washed  from  the  anterior  urethra  should  be  allowed  to 
settle,  and  then  should  be  examined  microscopically  for  gonococci  and 
tissue-elements.  The  urine  in  the  first  glass  should  be  similarly  treated. 
If  two  glasses  have  been  used,  the  second  urine  may  also  be  examinedo 
The  microscopical  appearances  of  the  secretion  of  the  anterior  and  posterior 
urethra  have  already  been  described.     (See  page  74.)     If  the  bladder 


ACUTE  ANTERIOR   GONORRHCEA,    OR    URETHRITIS.  123 

has  been  involved  (and  in  most  of  the  recent  and  even  quite  advanced 
cases  the  inflammation  will  have  extended  only  to  the  portion  near  the 
neck  and  base),  there  will  be  found  more  or  less  pus  and  flat  epithelium, 
due  to  catarrhal  desquamation — a  microscopic  picture  in  striking  con- 
trast with  that  presented  by  the  secretion  of  the  posterior  urethra.  By 
these  means,  therefore,  we  determine  whether  the  gonorrhoeal  process  has 
stopped  at  the  bulb  of  the  urethra  or  whether  it  has  invaded  the  posterior 
urethra,  and  still  further  involved  a  small  or  a  large  portion  of  the  bladder. 

We  are  now  in  a  position  to  study  the  course  of  gonorrhoeal  infection 
in  the  posterior  urethra.  Before  doing  so,  however,  it  is  necessary  to 
make  a  slight  digression  of  an  historical  character. 

In  the  year  1883,  Guyon^  put  forth  the  claim  that  gonorrhoea  in  the 
vast  majority  of  cases  stopped  at  the  cul  de  sac  of  the  bulb,  and  that  when 
not  cured  it  usually  localized  itself  there  in  a  chronic  condition.  The 
cause  of  this  localization  was  said  to  be  the  sphincteric  action  of  the  com- 
pressor urethrse  muscle,  which  was  dignified  with  the  names  intra-urethral 
barrier,  membranous  sphincter,  and  urethral  diaphragm.  In  support  of 
his  views  Guyon  cited  103  cases  of  chronic  gonorrhoea  in  Avhich  he  claimed 
that  it  was  proven  that  the  anterior  urethra  only  was  involved  in  74,  and 
that  the  disease  had  extended  to  the  posterior  urethra  in  29  cases.  Guyon's 
views  were  quite  generally  received  (with  eagerness  by  Ultzmann  and 
Finger),  and  they  were  spread  broadcast  by  the  ambitious  thesis  of  his 
pupil,  Jamin,^  which  was  widely  read.  Thus  Ave  find  that  authors  went 
so  far  as  to  claim  that  gonorrhoea  proper  involved  only  the  urethra 
from  the  glans  to  the  triangular  ligament,  and  that  when  it  extended  to 
parts  beyond  this  structure  the  process  should  be  considered  as  only  a 
complication  of  gonorrhoea,  and  not  an  essential  condition.  This  is  illus- 
trated by  the  statement  made  by  Ultzmann,^  who  says :  "  Gonorrhoeal 
urethritis  has  a  typical  course.  Beginning  at  the  external  orifice,  the 
inflammation  progresses  farther  backward,  so  that  the  bulb  of  the  urethra 
is  attacked  in  the  fourth  week,  and  the  process  ceases  here  in  most  cases." 
It  was  further  claimed  that  this  extension  only  occurred  as  a  result  of 
traumatisms  (forcible  and  irritating  injections,  overwork,  excessive  motion, 
and  operative  manipulations)  or  under  the  influence  of  certain  diatheses, 
rheumatic,  tuberculous,  scrofulous,  and  lymphatic.  Through  the  influence 
of  a  justly  great  name  these  views  of  Guyon  were  quite  generally  accepted, 
except  by  Flirbringer,^  who  strongly  opposed  them.  As  time  went  on  they 
were  attacked  by  other  scientific  men.  The  first  facts  in  refutation  of 
Guyon's  thesis  were  offered  by  Aubert,^  who  showed  very  clearly  that 
by  proper  methods  of  investigation — namely,  washing  out  the  anterior 
urethra  and  lavage — posterior  urethritis  could  be  diagnosticated  in  very 
many  cases  in  the  acute  stage,  and  that  it  was  of  frequent  rather  than  of 
rare  occurrence.     He  further  rendered  clear  the  fact  that  in  many  cases 

^  "  Lefons  cliniques  sur  I'Ur^tlirites  blennorrhagiques,  etc.,"  Annales  des  Mai.  des 
Organ^  Gen.-urin.,  vol.  i.,  1883,  pp.  333  et  seq. 

^  Etude  sur  I'  Urethrite  chronique  blennorrhagique,  Paris,  1883. 

^  Vorlesungen  iiber  Krankheiten  der  Harnurgane,  Vienna,  1892,  p.  60. 

*  Die  Inneren  Krankheiten  der  Ham-  und  Geschlechtsorgane,  2d  ed.,  1890,  pp.  402  et  seq. 
(Also  in  1st  ed.,  1884,  p.  274.) 

^  "Sur  I'Etat  latent  du  D^bnt  de  la  Cystite  blennorrhagique,"  Lyon  Medical,  June  15, 
1884,  pp.  197  et  seq.  (Dr.  Goldenberg  (Medical  Record,  Dec,  1888)  advisedlavage  of  the 
anterior  urethra,  with  the  view  of  ascertaining  the  condition  of  the  posterior  portion  of 
the  canal.) 


124  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

of  posterior  urethritis  there  were  no  symptoms  (or  at  most  they  were  insig- 
nificant ones)  present  which  would  lead  to  a  suspicion  of  the  involvement 
of  the  posterior  urethra.  The  demonstration  of  this  fact  was  of  the 
utmost  importance,  for  the  reason  that  Guy  on' s  statement  was  quite 
generally  accepted,  that,  when  in  the  course  of  gonorrhoea  the  posterior 
urethra  was  attacked,  there  were  inevitable/  symptoms  present  of  such  an 
extension.  These  statements  were  confirmed  by  Eraud,^  who  claimed, 
with  the  authority  of  investigation,  that  the  posterior  urethra  is  invaded 
in  nine-tenths  of  all  cases  of  acute  gonorrhoea,  and  stated  that  in  155 
cases  scarcely  one-third  complained  of  symptoms  referable  to  an  inflamed 
posterior  urethra.  These  observations  were  confirmed  by  Jadassohn,^  who 
also  used  lavage  of  the  anterior  urethra  in  his  experiments.  In  163 
cases  of  acute  and  chronic  gonorrhoea  (even  in  cases  lasting  several  years) 
this  observer  shows  that  in  87^^  per  cent,  the  posterior  urethra  was  in- 
volved, while  in  only  12^  per  cent,  the  morbid  process  was  localized  in 
the  anterior  urethra. 

Further  evidence  was  given  by  Rona,  who  at  first ^  claimed  that  in 
gonorrhoea  lasting  eight  or  ten  Aveeks  the  posterior  urethra  was  involved 
in  62  per  cent.,  and  in  66  per  cent,  of  more  advanced  cases.  In  a  later 
communication*  this  observer  claims  that  the  whole  urethra  is  attacked 
in  80  per  cent,  of  acute  gonorrhoeas,  and  that  it  is  an  error  to  state  that 
posterior  urethritis  is  a  complication  of  acute  urethritis,  since  it  is  only  a 
further  extension  of  the  process. 

Testimony  to  the  same  effect  is  given  by  Letzel,  Heisler,  and  Lanz, 
whose  observations  are  more  satisfactory  than  some  of  the  preceding, 
since  among  the  statistics  thus  far  given  cases  were  included  in  which 
several  infections  had  already  occurred,  whereas  in  the  statistics  now  to 
be  given  the  cases  were  those  of  first  infection  with  gonorrhoea. 

Letzel's^  material  consisted  of  53  cases  of  seven  and  ten  weeks'  dura- 
tion, in  only  4  of  which  (7^^  per  cent.)  the  disease  remained  localized 
in  the  anterior  urethra. 

Heisler's^  results  are  based  on  the  study  of  50  cases,  watched,  for  the 
most  part,  from  the  first  days  of  the  infection,  and  his  figures  are  as  follows: 


In  the  first 

week, 

10  cases 

=  20 

"       second 

17     " 

=  34 

"       third 

7     " 

=  14 

''       fourth 

10     " 

=  20 

"       sixth 

2     " 

=    4 

"       seventh 

2     " 

=    4 

"       third  month, 

1     " 

—    2 

"       fourth 

a 

1     " 

—     9 

^  "  De  I'Urethrite  posterieure  Simple  ou  Compliquee,"  Lyon  Medical,  vol.  xxviii.,  1885, 
pp.  113  et  seq. 

^  '•  Beitrivge  zur  Lehre  von  Urethritis  posterior,"  VerhamUungen  der  Deut.  Dermat. 
Gesellssch.  zu  Prag,  Vienna,  1889,  pp.  172  et  seq. 

^  "  Vermag  der  Compressor  Urethra;  das  Weiterschreiten  der  akuten  Gonorrhoe  zu 
Verhindern,"  Orvon  Ilctilap,  No.  43,  1890,  and  Monatshefte  j'ilr  Prakt.  Dermatologie,  vol. 
xii.,  1891,  pp.  162  et  seq. 

^"Neuere  Beitrage  zur  Pathologie  der  Akuten  Urethritis  blennorrhagica,"  Ungar. 
Arch,  fur  Medizin,  Band  i.  5  and  6  Hefte,  pp.  350  et  seq. 

^"Ueber  die  Hiiufigkeit  der  Beteilignng  der  Urethra  post,  am  Gonorrhoischen 
Entziindungsprozesse,  etc.,"  Internaf.  Centralhlatt  fiir  die  Physiologie  und  Pathologie  der 
Ham-  und  Sexual- Or gane,  vol.  ii.,  1890-91,  pp.  284  et.  seq. 

•*  "  Ueber  die  Zeit  und  Ursache  des  Ueberganges  der  Gonorrhoe  auf  die  Pars  Posterior 
Urethrse,"  Archivfilr  Derm,  und  Syphilis,  vol.  xxiii.,  1891,  pp.  761  et  seq. 


TREATMENT  OF  ACUTE   URETHRITIS,   OR  GONORRHCEA.      125 

It  is  probable  that  in  some  of  these  cases,  Avhich  were  not  seen  quite  early 
enough,  the  invasion  of  the  posterior  urethra  occurred  earlier  than  has 
been  stated. 

Lanz's^  statistics  of  61  cases  are  in  striking  confirmation  of  Heisler's. 
They  are  as  follows  : 


In  the  first          week,  12 

cases, 

=  19tV 

second         "      18 

=  29^ 

third           "        7 

=  11^ 

fourth         "        6 

=     ^^7> 

fifth             "        5 

=    8j\ 

sixth           "        7 

=  11-5- 

-^  -^  1  n 

seventh       "        2 

=    3fV 

eighth         "         1 

=    1t% 

ninth           "         2 

=    3i% 

eleventh     "        1 

=    lA 

These  observations  show  very  clearly  that  in  more  than  50  per  cent. 
<of  the  cases  the  invasion  of  the  posterior  urethra  took  place  within  the 
first  ten  weeks  of  infection,  and  that  this  extension  occurs  in  from  60  to 
^8  per  cent,  of  cases  in  the  first  three  weeks.  The  percentages  of  occur- 
rence are  less  for  the  few  succeeding  weeks,  but  they  are,  as  Avill  be  seen, 
;sufi]ciently  large  to  warrant  the  assertion  that  in  most  cases  of  gonorrhoea 
involvement  of  the  posterior  urethra  occurs  within  the  first  eight  weeks, 
-and  may  occur  earlier.  My  own  observations  in  private  and  public  prac- 
tice, made  with  much  care  upon  85  cases,  are  in  accord  with  those  of  Let- 
zel,  Heisler,  and  Lanz. 

It  follows,  therefore,  that  the  opinion  heretofore  entertained,  that  gon- 
orrhoea, as  a  rule,  limits  itself  to  the  anterior  urethra,  localizing  itself 
chiefly  at  the  bulbous  portion,  is  wholly  incorrect,  since  the  reverse  is 
true — namely,  that,  as  a  rule,  the  infection  spreads  in  between  80  and 
90  per  cent,  of  cases  through  the  entire  length  of  the  urethra,  and  only 
exceptionally  in  a  minimum  of  cases  is  limited  to  the  anterior  urethra. 
The  contention,  therefore,  that  posterior  urethritis  is  a  complication  of 
^interior  urethritis  is  false. 


CHAPTEK    X. 

TREATMENT  OF  ACUTE  URETHRITIS,  OR  GONORRHCEA. 

The  treatment  of  gonorrhoea  varies  according  to  the  stage  of  the  dis- 
ease and  the  condition  of  the  patient.  In  the  majority  of  cases  gonorrhoea 
is  seen  in  the  acute  stage,  with  its  well-developed  discharge  and  inflamma- 
tory symptoms.  Exceptionally  patients  present  themselves  a  few  hours 
or  a  day  or  two  after  the  onset  of  the  prodromal  stage,  in  which  the  dis- 
charge is  a  mucous  secretion  containing  epithelial  cells  and  gonococci,  and 
perhaps  no  pus.     In  every  instance,  if  possible,  when  a  patient  presents 

^  "  Ueber  die  Hiinfigkeit  und  Zeit  des  Anflreten  des  Urethritis  posterior  bei  der  acuten 
•Gonorrhoe,"  Archivfur  Derm,  und  Syphilis,  vol.  xxvii.,  1894,  pp.  213  et  seq. 


126  GOyOBEHCEA  AXD  ITS  COMPLICATIONS. 

himself  in  this  stage,  the  secretion  should  be  examined  by  means  of  the 
microscope,  which  at  this  time  gives  much  really  important  information. 

The  Abortive  Treatment. — With  the  discovery  of  the  microbic  origin 
of  o-onorrhoea  the  old  idea  of  aborting  the  disease  took  new  life,  and 
to-day  a  vast  literature  (the  greater  part  of  which  is  utterly  worthless) 
exists  upon  this  question.  Many  patients,  for  reasons  more  or  less  urgent 
and  even  imperative,  desire  to  rid  themselves  with  the  utmost  speed  of 
this  virulent  infection.  Then,  again,  when  the  severe  suffering  and  the 
dangerous  sequelae  incident  to  gonorrhoea  are  considered,  the  surgeon 
naturally  feels  that  if  he  can  abort  the  disease  it  is  his  duty  to  do  so. 
There  can  be  no  doubt  that  gonorrhoea  can  be  aborted  very  early  in  its 
course,  but  cases  in  which  this  is  possible  are  not  common.  Before 
attempting  this  procedure  the  case  must  be  studied  carefully  in  the  light 
of  our  knowledge  of  the  gonorrhoeal  process.  We  have  already  seen  that 
in  the  prodromal  stage  the  gonococcus  multiplies  and  spreads  like  a  sod 
over  the  mucous  membrane,  and  gains  a  hold  on  a  limited  portion  before 
it  begins  its  inward  invasion.  If  the  disease  can  be  caught  in  this  condi- 
tion, there  is  a  reasonable  probability  of  aborting  it.  Now,  by  means  of 
the  microscope  this  condition  can  be  made  out  with  the  utmost  clearness. 
When  on  the  first  and  perhaps  the  second  day  the  patient  complains  of  a 
little  tickling  or  burning  sensation,  and  the  mucoid  secretion,  containing 
little  whitish-gray  particles  resembling  suet  or  rice,  shows  nothing  but 
epithelial  cells  and  gonococci,  but  no  pus-cells,  then,  the  patient  being 
desirous  and  urgent,  the  surgeon  should  make  an  effort  to  abort  the  dis- 
ease. Under  these  circumstances  he  can  offer  a  reasonable  hope.  He, 
however,  should  make  it  very  clear  to  the  patient's  mind  that  the  treat- 
ment may  be  quite  painful,  and  that  it  may  fail.  However,  even  when 
the  reaction  following  the  treatment  is  severe,  it  is  readily  calmed  in  a 
few  days.  The  method  of  procedure  is  as  follows :  The  patient  stands 
and  urinates,  and  the  urethra  is  injected,  by  means  of  a  penis-syringe  or 
of  a  12  French  soft  catheter  introduced  three  and  a  half  inches  into  the 
urethra,  with  one  or  more  ounces  of  very  warm  saturated  solution  of  boric 
acid.  Then  a  Weir's  meatoscope  is  introduced,  the  obturator  withdrawn, 
and  an  applicator  charged  on  its  end  with  a  tuft  of  absorbent  cotton,  large 
enough  to  gently  spread  the  urethral  lumen  and  soaked  in  a  watery  solu- 
tion of  nitrate  of  silver,  15  grains  to  the  ounce,  is  pushed  down  the  tube, 
and  the  cotton  is  allowed  to  protrude  just  beyond  it.  Then  the  tube  and 
the  applicator  are  very  slowly  withdrawn,  the  surgeon  gently  rotating  them 
from  side  to  side.  After  this  operation  the  patient  should  lie  down  and 
apply  graduated  cold  either  by  means  of  an  ice-bag  or  of  ice-water  on  lint 
to  the  penis.  A  cathartic  should  be  given  and  low  diet  allowed.  The 
reaction  may  be  slight,  and  it  may  be  very  severe.  Usually  in  a  few 
hours  the  discharge  becomes  decidedly  purulent  and  copious,  and  urina- 
tion is  attended  with  scalding.  If  success  has  been  attained,  the  suppura- 
tion (for  a  substitutive  inflammation  has  been  produced)  gradually  grows 
less,  the  secretion  becomes  thin,  watery,  and  perhaps  a  little  bloody,  and 
disappears  in  four  or  five  days.  In  some  cases  an  astringent  injection 
may  be  required  to  cause  the  mucous  membrane  to  become  healthy.  In 
the  event  of  failure  the  acute  stage  develops  with  perhaps  much  severity. 

By  this  procedure  the  gonococci  are  destroyed,  and  the  epithelial  layer 
upon  which  they  are  seated  is  so  necrosed  by  the  caustic  that  it  is  thrown 


TREATMENT  OF  ACUTE   URETHRITIS,   OR  GONORRHCEA.      127 

oflf.  In  a  few  days  it  is  replaced,  the  engorgement  of  the  vessels  and  the 
oedema  of  the  tissues  subside,  and  a  healthy  condition  is  left. 

The  abortive  treatment  of  incipient  gonorrhoea  was  strenuously  advo- 
cated by  the  late  Dr.  Diday,  who  carried  it  to  an  extreme.  This  surgeon 
advised  the  injection  into  the  urethra  of  solutions  of  nitrate  of  silver, 
1  to  20,  and  even  1  to  7,  of  water.  According  to  Diday,  the  criterion  to 
be  guided  by  is  the  pain^  produced,  which  should  be  so  severe  and  even 
atrocious  as  to  cause  shock  to  the  patients.  In  order  that  the  abortive 
fluid  should  have  full  opportunity  to  penetrate  the  mucous  membrane  it 
should  be  held  in  the  urethra  from  fifteen  to  twenty  seconds,  and  even 
two  minutes.  Diday  advises  that  the  patient  should  be  informed  before- 
hand of  the  severity  of  his  suffering,  and  that  if  he  refuses  the  treatment 
the  surgeon  should  not  insist,  but  should  consign  him  to  the  use  of  his 
"carafe  d'orgeat."  Thiery,^  on  the  other  hand,  thinks  we  should  be 
more  persuasive,  should  mildly  deceive  him  as  to  his  sufferings,  and 
frighten  with  the  lugubrious  account  of  a  prolonged  gonorrhoea  and  its 
painful  and  dangerous  sequelae.  It  may  be  remarked  that  such  a  course 
might  work  well  if  a  successful  result  is  obtained,  but  in  the  event  of 
failure  the  relations  between  the  patient  and  his  physician  might  be  more 
or  less  strained.^ 

A  less  radical  and  less  painful  procedure  consists  in  the  introduction 
to  the  extent  of  three  or  four  inches  into  the  already  cleansed  urethra  of 
a  No.  12  F.  soft-rubber  catheter  and  the  injection  of  several  antiseptic 
solutions  at  the  temperature  of  100°  F.  For  this  purpose  permanganate 
of  potassa,  1 :  1000  or  1 :  2000,  may  be  thrown  into  the  urethral  canal 
twice  a  day ;  or  bichloride  of  mercury  and  water,  1 :  2000  or  1 :  5000, 
or  of  nitrate  of  silver,  1 :  3000  or  1 :  5000,  may  be  used.  In  the  quite 
early  stage  these  retrojection  fluids  may  be  used  of  much  greater  strength 
than  can  be  borne  when  the  acute  stage  is  well  developed.  By  these 
means  I  have  been  able  to  abort  gonorrhoea  when  it  was  in  the  exact 
condition  already  described. 

When  the  gonococci  have  penetrated  into  the  epithelial ,  layer,  particu- 
larly when  they  have  reached  the  region  of  the  vessels  and  have  produced 
an  exudation  of  leucocytes,  when  we  have  under  the  microscope  pus- 

^"Traitement  ultra-abortif  de  la  Blennorrhagie,"  Lyon  Med.,  May  25,  1890,  pp.  109 
et  seq. 

■^  Essai  de  Traitement  m^thodique  de  la  Blennorrhagie,  etc.,"  Annales  des  Mai.  des 
Orr/.  Gdn.-urin.,  1891,  pp.  395  et  seq. 

^  The  extent  to  which  the  hunt  for  the  gonococcus  is  carried  in  the  antiseptic  abortive 
treatment  of  gonorrhoea  is  strikingly  shown  in  the  abortive  method  gravely  proposed 
by  Huguet  (Ann.  des  Mai.  des  Org.  Gen.-urin.,  May,  1889).  This  author  advises  that  the 
urethra  shall  be  well  sponged  out  by  means  of  a  long  hair-brush  having  a  calibre  of  12 
French  scale.  The  urethra  is  thoroughly  cocainized,  and  then  the  brush,  which  is  simi- 
lar to  that  used  by  smokers  to  clean  out  the  stems  of  their  pipes,  is  pushed  forward  and 
backward  until  a  debris  of  epithelium  and  blood  is  produced.  Then  when  the  mucous 
membrane  is  denuded  of  its  epithelium,  sublimate  injections  (1 :  10,000)  are  used.  Uri- 
nation is  said  to  be  a  little  painful,  but  a  cure  is  claimed  in  seven  or  eight  days. 

The  climax  in  the  abortive  treatment  has  been  reached  by  Boureau  (Bull,  de  la  Societe 
fran(^.  de  Derm,  et  de  Syph.,  1893,  pp.  517  et  seq.),  who  has  invented  a  2)orte  topique  or 
urithro-meche,  which  is  a  miniature  lampwick  made  of  cotton  with  loose  strands,  having  a 
calibre  of  No.  12  French  scale.  This  cylinder  of  cotton  is  smeared  with  vaseline  mixed 
with  sublimate  (1  :  1000),  and  then  introduced  into  the  urethra  by  means  of  a  soft  olivary 
bougie.  Boureau  placed  gonorrheal  pus  in  the  urethrre  of  three  men,  and  within  twelve 
hours  applied  his  sublimate  meche.  AH  three  esca[jed  gonorrho?a.  He  claims  to  have 
cured  many  cases  by  this  treatment.     What  next  may  we  expect? 


128  GONORBHCEA  AND  ITS  COMPLICATIONS. 

cells  and  epithelial  cells,  the  abortion  of  gonorrhoea  is  a  very  difficult  and 
very  often  indeed  an  unsuccessful  task.  In  these  conditions  either  of  the 
first-mentioned  retrojections  may  be  given.  They  should  be  quite  copious, 
twelve  ounces  or  a  pint  being  thrown  up  at  each  session  by  the  surgeon 
himself  or  his  assistant.  If  a  perfect  cure  is  produced,  we  may  say,  w^ith 
Ricord,  that  some  good  deity  has  saved  the  patient. 

General  Considerations  on  Treatment. — With  the  onset  of  the  acute 
stage  an  entirely  different  line  of  treatment  is  to  be  followed.  While  we 
know  that  the  gonococcus  is  the  materies  morhi  of  the  virulent  process, 
we  must  not  lose  sight  of  the  fact  that  besides  it  we  have  an  intense 
inflammation  involving  the  mucous  membrane  and  the  submucous  con- 
nective tissue  to  treat,  to  ameliorate,  to  curtail,  and  to  cure.  The  object- 
ive point  in  the  treatment  of  acute  gonorrhoea,  according  to  the  doctrine 
of  Neisser's  followers,  is  the  gonococcus,  so  that  Friedheim^  says  that 
"the  most  appropriate  remedy  for  the  acute  purulent  stages  is  one  that — 
1,  kills  the  gonococcus;  2,  that  does  not  injure  mucous  membranes;  3, 
that  at  least  does  not  increase  the  inflammatory  symptoms  if  it  does  not 
lessen  them."  In  this  scheme  too  much  prominence  is  given  to  the  neces- 
sity of  training  our  guns  on  the  very  active  and  virulent  microbe,  and 
too  little  is  said  about  general  practical  therapeutical  measures  which  will 
allay  inflammation  of  tissues.  To  my  mind,  our  duty  is — 1,  to  try  to 
abort  the  disease  in  proper  cases ;  failing  in  that  eflbrt,  2,  to  use 
means  to  lessen  the  severity  of  the  inflammation  and  to  reduce  the 
patient's  sufferings  ;  3,  to  cut  short  the  acute  stage  as  much  as  possible ; 
and,  4,  to  thoroughly  remove  the  morbid  process  in  the  declining  stage. 
In  this  treatment,  of  course,  it  is  assumed  that  the  remedies  used  will 
allay  the  inflammation  in  which  the  gonococcus  luxuriates.  Then,  in 
proportion  as  we  cure  the  inflammation  of  the  tissues,  the  condition  which 
favors  the  virulent  action  of  the  gonococcus  is  so  altered  that  the  microbe 
perishes  in  uncongenial  soil.  It  is  true  that  we  must  destroy  the  gono- 
coccus, but  this  end  is  brought  about  mainly  by  indirect  means. 

Much  has  been  written  about  the  prompt  cure  of  the  acute  stage  of 
gonorrhoea  by  means  of  copious  injections,  irrigations,  and  retrojections 
of  antiseptic  solutions,  but  when  the  results  are  judicially  studied  it  will 
be  seen  that  in  the  main  they  are  little  if  any  better,  and  sometimes  they 
are  worse,  than  those  obtained  by  the  older  methods.  The  trouble  with 
these  antiseptic  methods  of  treatment  is  that  they  are  narrow  in  view 
and  scope,  and  only  aim  to  kill  the  gonococcus  and  thus  relieve  the  patient 
of  his  ill.  But  it  must  be  conceded  that  good  will  result  from  the  claims, 
the  methods  of  procedure,  and  from  the  results  obtained  by  these  anti- 
septic enthusiasts.  They  have  been  the  sappers  and  the  miners  of  the 
urethra,  and  they  have  demonstrated,  contrary  to  our  early  belief,  that 
catheters  can  be  introduced,  when  great  care  is  used,  into  the  urethra  the 
seat  of  acute  gonorrhoea,  and  that  copious  injections  can  be  given  without 
ill,  and  perhaps  with  good,  effect.  The  error  committed  is  in  making 
the  procedures  a  routine  treatment  rather  than  an  accessory  and  elective 
measure  to  be  adopted  when  the  indications  point  to  their  rational  use. 

There  are  very  many  methods  prescribed  for  the  treatment  of  gonor- 
rhoea, some  of  which  are  good,  or  at  least  produce  no  harm.     Then,  again, 

^  "  Zur  Injectionsbehandlung   der   Acuten  Gonorrhoe,"  Archiv  Jur  Derm,  unci  Syph., 
vol.  xxi.  pp.  525  et  seq.  , 


TREATMENT  OF  ACUTE   URETHRITIS,   OR   GONORRHCEA.      129 

there  are  methods  which  are  impracticable,  unwieldy,  unsafe,  and  many  are 
utterly  chimerical  and  even  dangerous. 

A  methodical,  safe,  and  efficient  treatment  will  be  described,  Avhich 
the  experience  of  many  years  has  convinced  me  will  prove  of  benefit  to 
any  one  who  carefully  employs  it. 

In  order  that  this  chapter  shall  be  complete,  and  shall  serve  as  a  store- 
house of  reference,  all  the  new  methods  of  treatment,  new  drugs,  and  the 
more  prominent  of  the  new  instruments  for  urethral  treatment,  will  be 
mentioned  or  described.  While  little  of  very  useful  character  or  of 
practical  application  can  be  obtained  from  these  descriptions,  they  will  at 
least  present  to  the  reader  an  up-to-date  view  of  progress  in  the  treatment 
of  gonorrhoea. 

Treatment  of  the  Acute  Stage. — The  surgeon  should  carefully  ex- 
amine the  penis  of  every  man  presenting  himself  for  the  treatment  of 
gonorrhoea.  He  thus  familiarizes  himself  with  the  anatomical  peculiar- 
ities of  the  organ,  and  can  thus  foresee  and  take  measures  to  prevent  com- 
plications. Thus  a  long  tight  prepuce  may  lead  to  balanitis,  to  phimosis, 
and  to  paraphimosis,  or  even  to  lymphitis  and  adenitis.  These  com- 
plications are  readily  prevented,  but  if  they  supervene  the  sufferings  of  the 
patient  are  much  increased  and  his  cure  is  greatly  delayed.  Then,  again, 
the  conformation  of  the  meatus  should  be  taken  into  consideration,  with 
the  view  of  ordering  for  the  patient  a  syringe  best  adapted  to  the  parts. 
Should  there  exist  a  tendency  to  balanitis  or  if  any  warts  are  present 
upon  or  around  the  glans,  attention  must  be  paid  to  them.  In  a  case  of 
very  small  meatus  an  incision  will  be  required  as  early  as  it  is  practicable 
in  the  course  of  the  virulent  inflammation. 

Assuming,  now,  that  we  have  to  treat  an  acute  case,  either  as  a  first  or 
a  later  infection,  the  most  important  measure  is  absolute  rest,  preferably 
in  the  recumbent  position,  but  the  majority  of  patients  are  unwilling  to 
thus  submit.  The  great  advantages  to  be  attained,  however,  should  be 
thoroughly  explained  to  them.  Taking  cases,  therefore,  as  Ave  find  them, 
they  should  be  enjoined  to  walk  and  exercise  as  little  as  possible,  to  spare 
themselves  in  every  way,  to  avoid  muscular  exertion,  to  ride  rather  than 
walk,  to  sit  rather  than  stand,  and  to  lie  down  as  often  and  as  long  as 
possible.  Horseback  riding,  bicycling,  out-door  sports,  dancing,  jump- 
ing— in  fact,  any  form  of  severe  bodily  exercise — are  to  be  absolutely 
avoided.  In  very  bad  cases,  in  which  the  inflammation  is  so  active  that 
a  patient  is  forced  to  seek  the  recumbent  position,  it  is  well  to  apply  cool- 
ing lotions  on  lint  to  the  organ  or  to  employ  an  India-rubber  ice-bag.  For 
all  itinerant  cases  in  the  acute  stage  a  nicely-fitting  and  comfortable  suspen- 
sory bandage  should  be  ordered  at  once.  Care  should  be  taken  that  the 
opening  for  the  penis  is  sufficiently  large,  and  that  the  urethra  is  not  in 
any  degree  pressed  upon  by  the  bandage. 

The  patient  must  be  informed  of  the  great  virulency  of  the  urethral 
pus,  and  that  contamination  of  the  eyes  with  it  may  result  in  the  loss  of 
one  or  both  of  these  organs.  Therefore  the  hands  should  be  thoroughly 
washed  immediately  after  handling  the  penis.  Too  much  stress  cannot  be 
laid  upon  this  injunction. 

Cai'eful  attention  to  diet  is  an  important  consideration.  It  should  be 
light  and  plain  and  in  moderate  quantity.  All  highly-seasoned  foods, 
salads,  gravies,  soups,  and  condiments  should  be  absolutely  interdicted. 


130 


GONORBHCEA  AND  ITS  COMPLICATIONS. 


CoiFee,  cocoa,  beer,  alcoholic  liquors,  ginger  ale,  and  asparagus  should  be 
avoided.  The  utmost  cleanliness  of  the  genital  parts  should  be  recom- 
mended, using  by  preference  carbolic-acid  soap.  All  sexual  excitement 
must  be  sedulously  avoided,  and  the  patient  should  be  Avarned  against 
lascivious  thoughts  and  suggestive  pictures. 

Much  care  is  necessary  in  adapting  dressings  to  the  penis  for  the  pur- 
pose of  catching  the  discharge.  Patients  should  be  warned  not  to  place 
pieces  of  lint  or  cotton  over  the  urethral  orifice,  nor  to  use  stockings  or 
bags  at  the  bottom  of  which  a  bird's-nest-shaped  wad  of  cotton  is  placed, 
since  by  all  of  these  procedures  the  pus  is  injuriously  kept  against  the 
meatus  and  glans.  India-rubber  condoms  are  also  objectionable.  The 
most  cleanly  and  efficient  method  of  dressing  the  penis  is  that  portrayed 
in  Fiffs.  5l'and  52,  which  I  have  used  many  years.     A  piece  of  old  linen 


Fig.  51. 


Fig.  52. 


Dressings  for  the  penis  in  acute  gonorrhcea. 

or  muslin  or  two  thicknesses  of  absorbent  gauze  about  four  inches  square, 
in  the  centre  of  Avhich  is  a  small  oval  aperture,  is  slipped  over  the  exposed 
glans  behind  the  corona,  and  the  prepuce  is  then  pushed  forward.  From 
its  orifice  the  linen  protrudes  and  catches  all  of  the  secretion.  If  the 
patient  has  no  foreskin  to  thus  hold  the  bandage,  a  piece  of  linen  or  gauze 
four  inches  by  six  may  be  Avound  around  the  whole  penis,  and  there  re- 
tained by  means  of  a  small  piece  of  adhesive  plaster  or  a  loosely-fitting 
India-rubber  band.  All  these  dressings  for  the  penis  should  be  destroyed 
by  fire,  or  at  least  thrown  down  the  water-closet.  The  surgeon  should  em- 
phasize this  important  prophylactic  measure.  If  practicable,  the  penis  may 
be  suspended  by  means  of  the  under-clothes  along  the  fold  of  the  groin. 
The  utmost  care  and  delicacy  must  be  observed  in  handling  the  organ : 
squeezing  to  cause  pus  to  exude  is  very  harmful,  and  pressure  of  any  kind 


TREATMENT  OF  ACUTE   URETHRITIS,   OR   GONORRHCEA.      131 

must  be  avoided.  Patients  sometimes  take  the  penis  from  their  trousers 
by  unbuttoning  one  or  two  buttons,  and  then  they  violently  pull  the  organ 
out,  very  often  with  unnecessary  force.  This  procedure  should  be  inter- 
dicted. Tightly-fitting  pantaloons  sometimes  cause  an  increase  of  the 
inflammatory  process. 

During  the  acuteness  of  the  attack,  purgation  at  intervals  of  three  or 
four  days  is  very  essential.  For  this  purpose  two  to  four  compound 
cathartic  pills  or  ten  grains  each  of  calomel  and  supercarbonate  of  soda 
taken  at  night  are  excellent.  Saline  cathartics  and  the  natural  cathartic 
waters  are  to  be  avoided,  since  much  of  the  sulphate  of  magnesia  passes 
oiF  in  the  urine  and  irritates  the  urethra. 

Early  in  the  acute  or  inflammatory  stage  of  gonorrhoea  strong  stimulat- 
ing and  astringent  injections  and  oleo-resins  are  contraindicated.  The 
chief  object  of  our  therapeusis  at  this  time  is  to  render  the  urine  mode- 
rately alkaline,  bland,  and  as  little  irritating  as  possible.  For  this  pur- 
pose there  is  no  better  remedy  than  the  bicarbonate  of  potassa.  In 
general,  the  following  prescription  may  be  used : 

^.  Potassse  bicarbonatis,  fj  ; 

Syr.  aurantii  corticis,  §ij  ; 

Aquae,  |vj. — M. 

Dose  for  an  adult,  one  tablespoonful  in  a  wineglass  of  water  three  times 
a  day  an  hour  after  eating. 

In  very  acute  cases  I  have  used  for  many  years  the  following  prescrip- 
tion, containing  hyoscyamus,  which  acts  beneficially  as  a  sedative  to  the 
genito-urinary  tract  : 

^.  Potassae  bicarbonatis,  ij  ; 

Tr.  hyoscyami,  ^ss ; 

Aquae,  Sviij. — M. 

To  be  taken  in  the  same  manner  as  the  foregoing  prescription.  The 
citrate  and  acetate  of  potassa  may  also  be  remembered  and  used  in  the 
same  proportions. 

Flaxseed,  sassafras-pith  and  slippery-elm  teas,  and  gum-arabic  and 
barley-waters,  pleasantly  flavored,  may  be  taken  as  beverages.  They 
are  regarded  as  beneficial  by  many  physicians,  and  patients  sometimes 
think  that  they  render  urination  less  painful.  Under  any  circumstances 
they  are  harmless.  Vichy,  Apollinaris,  Poland,  Bethesda,  Stafibrd,  and 
soda  waters  are  pleasant  and  suitable  drinks,  and  to  them  may  be  added 
a  few  grains  of  supercarbonate  of  soda. 

Locally,  the  most  important  measure  is  the  immersion  of  the  penis  in 
very  hot  water  for  fully  fifteen  minutes  three  times  a  day,  by  which  means 
the  pain  and  soreness  are  relieved  and  the  redness  and  swelling  reduced. 
A  small  quantity  of  laudanum  or  of  fluid  extract  of  belladonna  may 
often  be  with  benefit  added  to  the  hot  water.  In  the  early  days  of  the 
inflammatory  stage  baths  at  a  temperature  of  96°  or  98°  Fahr.  are  of 
much  benefit  in  tending  to  produce  a  comfortable  night's  sleep.  If  pos- 
sible, the  whole  body  should  be  immersed  ;  if  not,  the  hip-bath  may  be 
used.  Immersion  of  the  penis  in  very  hot  water  during  urination  is  often 
productive  of  amelioration  of  the  pain. 


132  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

For  the  prevention  of  erections  and  chordee,  besides  the  observance  of 
a  rigid  hygiene,  the  patient  must  retire  early  and  sleep  on  his  side,  and 
never  on  his  back,  on  a  hair  mattress,  with  light  bed-clothes.  It  is  always 
well,  if  possible,  to  avoid  the  use  of  anodynes,  and  much  benefit  has  been 
derived,  in  my  experience,  from  the  use  of  the  following  injection  in  cases 
of  persistent  nocturnal  erections  and  chordee : 

'Ey,.  Liq.  morphiae  Magendie,  Sij  ; 

Cocaine  muriat.,  gr.  vj-viij  ; 

Aquae,  lij.— M. 

Of  this  one  or  two  drachms  may  be  carefully  and  slowly  throAvn  into  the 
urethra,  and  there  retained  for  fully  five  minutes,  just  before  retiring. 
Or  the  following  may  be  used  in  the  same  way : 

^i.  Extracti  opii  aquos,  3ij  ; 

Aquae,  liv. — M.  and  filter. 

Signa :  injection. 

For  immediate  use  any  cold  body,  such  as  a  flat-iron,  may  be  applied 
to  the  perineum  and  the  under  surface  of  the  urethra,  or  cold-water  affu- 
sions may  be  tried.  Owing  to  idiosyncrasy,  cold  is  not  beneficial  in  some 
cases,  while  hot-water  immersions  are  very  efficacious.  I  have  seen  much 
relief  in  some  very  severe  cases  of  chordee  by  the  use  of  the  following 
prescription : 

I^.  Chloroformi,  .Ij  ; 

Tr.  belladonnae,  5ss ; 

Liniment,  saponis,  5iiss. — M. 

A  small  quantity  of  this  may  be  applied  over  the  affected  part  on  lint  or 
cotton,  and  there  kept  for  some  time.  I  have  also  seen  benefit  in  severe 
cases  by  allowing  sulphuric  ether  to  evaporate  from  a  strip  of  old  linen 
wound  around  the  penis.  Care  must  be  exercised  that  the  chloroform  and 
ether  vapors  do  not  reach  the  head  of  the  penis. 

In  those  cases  in  which  there  is  much  malaise,  nervousness,  and  worri- 
ment,  when  hyoscyamus  fails,  laudanum  in  doses  of  two  or  three  drops  in 
a  small  quantity  of  water,  taken  three,  four,  or  five  times  a  day,  is  pro- 
ductive of  a  sense  of  comparative  comfort  during  the  day  and  of  sleep  at 
night.  Besides  being  nauseous  and  irritating  to  the  stomach,  camphor 
has  proved  a  very  unreliable  remedy  in  my  hands.  The  monobromide 
of  camphor  seems  to  have  a  good  effect  in  some  cases  when  given  in  full 
and  repeated  doses.  Lupuline  in  any  form  is  at  best  a  nauseous  remedy, 
possessing  very  little  therapeutic  effect. 

In  many  cases,  besides  the  erections  and  chordee,  there  is  considerable 
vesical  irritation,  with  frequent  and  imperious  desire  to  urinate,  together, 
perhaps,  with  nain  in  the  perineum,  loins,  scrotum,  and  groins,  due  to  the 
onward  extension  of  the  infection.  In  such  cases  laudanum,  as  just 
advised,  may  be  used,  or  suppositories  may  be  ordered,  as  follows : 

^i.  Morphiae  sulphatis,  gr.  ij  ; 

Ext.  belladonnae,  gr.  iij  ; 

01.  theobromae,  q.  s. 
To  make  suppositories  No.  iv. 


TREATMENT  OF  ACUTE   URETHRITIS,    OR   GONORRHOEA.      133 

One  of  these  may  be  introduced  into  the  rectum  just  on  retiring,  and  a 
second  during  the  night  if  necessary.  Digitalis  is  not  uniformly  reliable, 
and  gelsemium  in  potent  doses  is  sometimes  dangerous  from  its  depressing 
action  upon  the  heart.  In  many  cases  calm  sleep  may  be  induced  by 
using  the  following  combination,  which  is  not  folloAved  by  unpleasant 
eifects : 

I^.  Potassii  bromidi,  Bxvj  ; 

Chloral,  hydrat.,  gr.  Ixxx  ; 

Liq.  morphise  Magendie,  gtt.  Ixxx  ; 

Syr.  simplicis, 

Aquae,  da.  sj. — M. 

Dose,  one  teaspoonful  in  a  little  water  on  retiring,  and  it  may  be  repeated 
during  the  night  if  necessary.  In  some  cases,  owing  to  tolerance,  the 
quantity  of  all  of  the  active  agents  may  be  suitably  increased.  Bromide 
of  potassium  alone  proves  of  much  benefit  in  the  milder  order  of  cases. 

Physicians  must  use  the  utmost  caution  in  giving  anodynes  in  gonor- 
rhoea :  they  must  be  given  in  the  smallest  doses  and  repeated  as  seldom 
as  possible,  and  discontinued  at  the  earliest  moment  upon  the  relief  of  the 
urgent  symptoms.  Antipyrine  very  often  is  very  soothing  and  beneficial 
in  acute  gonorrhoea  and  in  various  forms  of  cystitis.  This  remedy  may 
also  be  given  in  combination  with  phenacetin. 

The  tendency  of  gonorrhoea  being  toward  disturbance  of  the  nervous 
system  and  debility,  much  circumspection  is  required  in  preventing  them. 
Purgation  must  not  be  pushed  to  the  extent  of  weakening  the  patient, 
and  if  signs  of  falling  away  show  themselves,  a  rather  more  liberal  diet 
should  be  allowed  so  soon  as  admissible.  Milk  may  be  used  generously, 
replacing  water  as  a  beverage.  If  patients  remain  indoors,  they  should 
be  allowed  a  daily  ride  in  the  open  air  in  the  cars,  in  preference  to 
carriages  and  coupes. 

Free  drinkers  suff"ering  from  acute  gonorrhoea  often  complain  bitterly 
of  the  loss  of  their  accustomed  stimulant,  and  even  show  physical  evidences 
of  it.  Such  cases  may  be  benefited  and  placated  by  giving  them  from  a 
half  to  one  drachm  of  the  fluid  extract  of  coca  at  the  periods  of  depression. 
Such  is  the  restraint  enforced  upon  patients  that  it  is  well  to  allow  them 
to  smoke  with  moderation  during  an  attack  of  gonorrhoea. 

Assuming  now  that  the  extreme  severity  of  the  acute  stage  is  mode- 
rating, Ave  .should  take  active  but  conservative  measures  to  still  lessen  its 
activity  and  to,  if  possible,  abbreviate  it.  The  immersions  in  hot  alka- 
line water  already  mentioned  should  be  steadily  and  methodically  kept 
up.  Then,  at  the  same  time  with  the  immersions,  injections  should  be 
cautiously  begun.  Care  should  be  exercised  in  selecting  a  syringe  Avhich 
should  hold  two  or  three  drachms,  should  Avork  easily,  and  its  nozzle, 
which  should  be  perfectly  smooth,  should  fit  readily  into  the  meatus. 
The  syringes  made  by  the  Butler  Rubber  Co.  answer  every  purpose, 
and  the  three  here  portrayed  Avill  be  useful  in  any  case.  Fig.  58  shoAvs 
a  particularly  useful  instrument  holding  three  drachms ;  its  nozzle  is  coni- 
cal in  shape  and  soft  and  compressible,  being  made  of  soft  black  rubber. 
The  syringe  depicted  in  Fig.  54  is  made  Avholly  of  hard  rubber,  Avith  a 
conical  nozzle  especially  adapted  to  meati  Avith  open,  trumpet-like  lips. 


134 


GONORBHCEA  AND  ITS  COMPLICATIONS. 


into  which  it  will  fit  perfectly,  and  can  be  used  without  discomforting 
pressure  or  pain.  Fig.  55  shows  a  syringe  adopted  to  meati  whose  lips  are 
closely  in  coaptation  like  the  leaves  of  a  book. 


Its  small  bulbous-ended 


Fig.  53. 


No.  96. 

Urethral  syringes. 


nozzle  fits  well  into  the  meatus,  the  lips  of  which  can  be  so  readily  pressed 
around  it  that  no  backward  flow  of  the  injection  can  occur.     Another 
very  useful  injector  or  irrigator  is  a  soft-rubber  round  bag  with  a  conical 
nozzle,   holding   rather   more    than    an    ounce,  and 
Fig.  56.  called  the  "  universal  syringe."    The  injection  should 

be  poured  into  a  wide-mouthed  vial  or  a  cup,  from 
which  it  is  drawn  into  the  syringe.  Care  should  be 
taken  that  air  is  expelled  from  the  syringe.  The 
patient  stands  Avith  his  feet  about  three  feet  apart, 
or  he  may  sit  on  the  edge  of  a  stool,  his  weight  rest- 
ing on  the  coccyx.  With  the  forefinger  and  thumb 
of  the  left  hand  the  patient  separates  the  vertical 
lips  of  the  meatus,  Avhile  he  steadies  the  penis  with 
the  middle  finger.  The  point  of  the  syringe,  held 
in  the  right  hand,  being  in  the  meatus,  the  thumb 
and  forefinger  compress  the  lips  together  under- 
Universai  syringe.  neath  the  nozzle,  by  Avhich  manoeuvre  the  reflux 
of  the  injection  is  prevented.  In  order  that  benefit 
shall  result,  it  is  necessary  that  the  fluid  sliall  reach  every  portion  of 
the  mucous  membrane  of  the  anterior  urethra,  including  the  bulb,  and 


TREATMENT  OF  ACUTE   URETHRITIS,  OR   GONORRHCEA.      135 


that  the  canal  should  be  somewhat,  but  mildly,  distended  in  the  opera- 
tion. It  is  always  well  for  the  surgeon  to  give  minute  directions  as 
to  the  technique  of  urethral  injections,  and  to  warn  patients  to  proceed 
slowly  and  cautiously,  being  careful  to  avoid  rapid  and  forcible  dis- 
tention of  the  canal.  It  is  a  good  rule  to  begin  with  the  slow  injec- 
tion of  about  one  drachm  of  fluid,  and  then  to  increase  as  the  toler- 
ance of  the  urethra  will  admit,  until  a  syringeful  can  be  thrown  in  the 
canal  without  any  resistance  whatever.  In  this  way  the  urethra  be- 
comes accustomed  to  the  operation,  and  its  walls  can  be  well  acted  upon 
by  the  medicated  fluid.  The  fluid  should  be  kept  in  the  canal  for  several 
minutes.     It  may  be  necessary  to  press  the  injection  backward  by  the 

Fig.  57. 


Mitchell's  reflux  catheter. 


Fig.  58. 


Ultzmann's  hand-syringe. 
Fig.  59. 


Soft-rubber-bag  injector,  with  stopcock. 


finger-tip,  passing  it  toward  the  perineum,  and  thus  making  sure  of  a 
thorough  application.^ 

'  The  syringes  here  recommended  can  do  no  harm  to  the  patient.  Of  course  these  in- 
jections only  medicate  the  anterior  urethra.  Guiard  ("De  la  Technique  des  Inject, 
urethrales,"  Annal.  des  Mai.  f/e.s  Org.  G^n.-urin.,  1894,  p.  432  et  seq.)  proposes  to  use  a 
syringe  holding  five  drachms,  with  the  view  of  overcoming  the  resistance  of  the  com- 
pressor urethrre  muscle  and  of  throwing  the  injection  into  the  posterior  urethra,  which  is 
so  commonly  aflected  in  anterior  urethritis.  There  is  no  good  to  be  gained  by  forcing 
the  compressor,  and  harm  may  be  done,  particularly  if  the  injection  is  administered  by 
the  patient  himself.     There  is  so  mucli  said  now  about  overcoming  the  compressor  and 


136 


GONORBHCEA   AND  ITS  COMPLICATIONS. 


When  insoluble  substances  held  in  suspension  in  the  injections  are 
used,  it  is  well  for  the  patient  to  lie  down  m  the  lithotomy  position,  and 
thus  give  himself  bis  injection. 

In  the  acute  stage,  just  as  soon  as  we  can  do  so  without  discomfort  to 
the  patient,  we  should  order  the  injection  of  a  few  syringefuls  of  the  hot 
solution  of  boric  acid,  borax,  or  of  supercarbonate  of  soda,  taking  care 
that  the  injections  go  as  far  down  the  urethra  as  they  can  be  sent,  which 
will  not  be  farther  than  the  bulb.  If  the  patient  has  three  immersions 
of  the  penis  daily,  he  can  also  have  three  injections,  consisting  of  two  or 
more  syringefuls  of  the  fluid,  according  to  his  sensations.  This  procedure 
has  a  markedly  soothing  effect  upon  the  inflammatory  state,  and  does 
much  to  prevent  chordee  and  painful  erections  at  night.  When  the  con- 
ditions of  the  patient  will  permit,  this  treatment  may  be  given  once  a  day 
by  the  surgeon  in  a  more  radical  manner.  This  may  be  attained  by  the 
administration  of  hot  injections,  consisting  of  from  four  ounces,  or  even  a 
pint  and  over,  of  the  medicated  solution,  according  to  the  effect  produced. 
Tor  this  purpose  a  soft-rubber  catheter  No.  12  F.  or  a  Mitchell  reflux 
soft-rubber  catheter  is  employed.  (See  Fig.  57.)  The  instrument  should 
be  sparingly  lubricated  with  glycerin,  and  gently  and  slowly  pushed  doAvn 
as  far  as  the  bulb.  The  injectors  suitable  for  large  quantities  of  fluids 
are  Ultzmann's  hand-syringe  (see  Fig.  58),  and  the  soft-rubber  bag  and 
stopcock,  which  holds  eight  ounces.     (See  Fig.  59.) 

Ultzmann's  hand-syringe'  is  a  particularly  useful  instrument  for  urethral 
and  bladder  work.     It  holds  five  ounces,  and  can  be  made  to  fit  into  even 

the   smallest   catheter  by  means 
I^icj.  60.  of  a  hard-rubber  conical  coupling 

with  and  without  a  stopcock. 
(See  Figs.  60  and  61.)  By  means 
of  the  Ultzmann  instrument  sev- 
eral ounces  of  the  hot  injection 
(temp.  100°  Fahr.)  may  be  thrown  slowly  into  the  bulbous  urethra  and 
allowed  to   run  out  of  the  meatus.     The  feelings  of  the  patient  and  the 

progress  made  will  be  the  guides  as  to 
Fi«.  61.  the  amount  of  fluid  used  and  as  to  the 

frequency  of  the  injections  or  lavages. 
When    benefit    is    assuredly    produced 
this  treatment  should  be  persevered  in, 
But  if  the  patient  is  in  any  way  dis- 
tressed or  discomforted,  or  the  inflam- 
mation is  seemingly  increased,  it  should 
be  stopped  immediately.     In  very  many  cases,  all  circumstances  and  con- 
ditions being   favorable,  these  irrigations  will   perceptibh^  mitigate  and 
shorten  the  acute  stage. 

The  evidence  of  the  subsidence  of  the  acute  process  is  that  the  painful 
symptoms,  particularly  at  urination,  are  less  severe  and  the  redness  and 
swelling  of  the  penis  have  markedly  diminished.     Then  it  will  be  observed 

medicating  the  posterior  urethra  without  a  conducting  tube  (see  method  of  Janet,  p.  143) 
that  it  is  probable  that  Guiard's  procedure  may  come  into  fashion.  It  is  not  wise  to  put 
in  the  hands  of  patients  instruments  which  may  do  them  harm.  It  is  well  to  let  the 
patient  inject  his  anterior  urethra,  but  all  applications  to  tlie  posterior  segment  should  be 
made  only  by  the  surgeon. 

^  This  syringe  is  made  in  New  York  by  the  Butler  Hard-rubber  Co. 


TREATMENT  OF  ACUTE   URETHRITIS,   OR   GONORRHCEA.      137 

that  the  discharge  is  less  copious,  that  it  has  lost  its  decidedly  greenish 
hue,  and  has  become  grayish--\Yhite,  or  that  the  greenish  hue  of  the  pus  is 
streaked  with  a  white  mucus.  It  is  more  gluey  than  it  w^as  formerly,  and 
a  drop  of  it  being  placed  between  the  forefinger  and  the  thumb,  and  these 
members  being  separated  slowly,  it  is  drawn  out  in  minute  threads,  some- 
times nearly  an  inch  long,  as  we  see  molasses  candy  drawn  out  in  the 
shop-Avindows.  Microscopical  examination  then  shows  that  the  pus-cells, 
instead  of  being  scattered  over  the  field,  show  a  tendency  to  become 
grouped  together  in  mosaic  form,  being  thus  held  by  the  mucin  of  the 
secretion.  Then  it  will  further  be  seen  that  comparatively  few  gono- 
cocci  are  present  in  the  pus-cells,  and  none,  or  very  few  indeed,  between 
the  cells.  At  this  time  we  may  see  those  harbingers  of  cure — namely, 
round,  pale,  thin  epithelial  cells,  perhaps  with  transition  epithelium. 

These  indications  point  unerringly  to  a  radical  change  of  treatment 
and  to  the  speedy  onset  of  the  terminal  stage  (all  things  going  on  auspi- 
ciously). At  this  time  astringent  and  mildly-stimulating  injections  may 
be  given.  The  patient  is  then  prepared  to  help  himself  as  far  as  self- 
administered  injections  will  help  him.  The  drugs  generally  used  for 
urethral  injections  are  the  sulphate,  acetate,  sulphocarbolate,  and  chlo- 
ride of  zinc,  acetate  of  lead,  sulphate  of  copper,  sulphate  of  alum  and  of 
thalline,  muriate  of  hydrastis,  and  the  white  fluid  extract  of  hydrastis. 
As  a  broad  general  rule,  all  of  the  above  drugs,  except  the  chloride  of 
zinc  and  sulphate  of  copper,  may  be  used  in  the  beginning  of  treatment 
in  |-  or  1  per  cent,  solutions  in  water.  The  chloride-of-zinc  solution 
should  be  1  :  2000  or  1  :  1000  to  begin  with,  and  if  its  use  warrants  its 
continuance  it  may  be  used  of  the  strength  of  1  :  300  or  1  :  250.  It  is 
always  w^ell  to  proceed  cautiously  with  this  drug.  The  sulphate-of-copper 
injection  should  be  1 :  500,  and  it  may  be  increased  to  1  :  100,  but  if  it 
fails  to  produce  good  results  in  this  strength,  it  is  well  to  discard  its  use. 
No  reliance  can  be  placed  on  tannin.  The  foregoing  is  a  quite  generous 
armamentarium  for  injections,  and  all  of  them  may  be  employed  carefully 
in  the  beginning  of  the  declining  stage. 

The  following  injections  may  be  used,  care  being  taken  to  dilute  them 
if  they  produce  any  uneasy  symptoms  beyond  a  feeling  of  pleasant  warmth. 
For  the  very  first  series  of  injections  a  solution  containing  one  grain  each 
of  acetate  of  lead  or  of  acetate  of  alum  to  the  ounce  of  water  will  gen- 
erally prove  very  acceptable.     Other  injections  are — 

^.  Zinci  sulphatis,  gr.  vj  ad  viij  ; 

Liq.  Magendie,  oij  ; 

Aquae,  q.  s.  ad  ^iv. — M. 

A  combination  of  sulphate  of  zinc  and  acetate  of  lead  forms  a  very 
excellent  injection,  as  follows: 

I^.  Zinci  sulphat., 

Plumbi  acetat.,  da.  gr.  vj  ad  xij  ; 
Ext.  opii  aq.,  3ij  ; 

Aquae,  5vj. — M. 

This  with  tincture  of  catechu  and  Sydenham's  laudanum  is  said  to  be  the 


138  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

composition  of  the  injection  Bru,  which  has  such  favor  with  the  laity. 
The  efficacy  of  both  of  the  foregoing  injections  may  be  increased  in  some 
cases  by  the  addition  of  calamine  or  of  subnitrate  of  bismuth.  The  latter 
sometimes  causes  burning. 

'B^.  Bismuth,  subnit.  or  zinci  carbon.,  3iij  ; 
Tr.  catechu, 

Vin.  opii.,  da.  sij  ; 

Glycerinse,  Iss ; 

Aquae,  ad  ^vj. — M.  To  be  well  shaken. 

The  following  imitation  of  the  Bru  injection  was  proposed  by  Dr.  Bum- 
stead  : 

I|i.  Zinci  sulph.,  da.  gr.  xv  ; 

Plumbi  acetat.,  gr.  xxx  ; 

Ext.  kramerise  fl., 

Tr.  opii,  dd.  3iij  ; 

Aquae,  ad  |vj. — M. 

It  is  my  custom  to  prescribe  this  injection,  using  eight  ounces  of  water 
instead  of  six.     It  is  then  often  of  much  benefit. 
The  following  injections  were  employed  by  Ricord: 

I^.   Zinci  sulphatis, 

Plumbi  acetatis,  dd.  gr.  xxx  ; 

Aquae  rosae,  Ivj. — M. 

I^.  Zinci  sulphatis,  gr.  xv  ; 

Plumbi  acetatis,  gr.  xxx  ; 

Tr.  catechu, 

Vin.  opii,  dd.  3j  ; 
Aquae  rosae,  ^vj. — M. 

Another  radical  change  of  treatment  in  the  declining  part  of  the  acute 
stage  is  the  administration  of  copaiba,  oil  of  santal-wood,  and  cubebs,  the 
so-called  antiblennorrhagics.  At  this  late  day  it  is  not  necessary  to  dis- 
course at  length  upon  the  therapeutic  value  of  these  remedies.  They 
have  stood  the  test  of  many  decades,  and  to-day,  in  certain  conditions, 
they  are  of  much  benefit  in  subacute  and  chronic  gonorrhoea.  When  the 
change  in  the  character  of  the  discharge  from  pus  to  muco-pus  occurs, 
then  it  is  time  to  stop  the  alkaline  mixture  and  to  give  the  antiblennor- 
rhagics. In  private  practice  these  remedies  should,  as  a  general  rule,  be 
administered  in  capsule  form.  In  default  of  American  productions  (which 
is  very  singular,  Avhen  we  consider  how  far  Ave  are  advanced  in  the  art  of 
pharmacy)  we  resort  to  French  capsules.  Raquin's  capsules  of  copaiba 
are  of  especial  worth,  and  three  of  them  may  be  given  as  a  dose,  repeated 
three  times  a  day.  The  cubebs  and  copaiba  capsules  of  Mathey-Caylus 
are  also  efficient,  and  should  be  given  in  the  same  quantity  as  the  Raquin 
capsules.  We  have  so  many  excellent  capsules  of  pure  oil  of  yellow  santal 
made  in  this  country  that  we  need  not  go  abroad  for  foreign  productions. 
In  general  terms,  thirty  to  sixty  drops  of  oil  of  santal,  divided  into  three 


TREATMENT  OF  ACUTE   URETHRITIS,    OR   GONORRHCEA.      139 

doses,  should  be  given  daily,  so  that,  when  the  capsules  contain  five  drops, 
six  to  twelve  may  be  given,  or  w^hen  they  contain  ten  drops  six  will 
usually  be  sufficient.  The  dose  can  be  pushed  slightly  higher,  but  the 
surgeon  should  always  look  out  for  the  gastric  effects  of  the  oil,  and 
should  discontinue  its  use  if  severe  lumbar  pain,  supposed  to  be  due  to 
renal  congestion,  is  complained  of.  Cubebs,  either  in  powder  or  in  the 
form  of  fluid  extract,  in  spite  of  its  detractors  has  considerable  anti- 
blennorrhagic  effect  when  the  pure,  fresh  drug  is  used.  Salol  some  years 
ago  was  looked  upon  as  the  coming  antiblennorrhagic,  but  the  general 
opinion  of  those  who  use  it  is  that  it  is  only  feebly  active  or  really  inert. 
It  is  significant  that  those  who  recommend  it  always  make  a  point  of  pre- 
scribing it  combined  with  one  or  more  of  the  old-time  antiblennorrhagics. 
Combinations  of  these  remedies  may  be  used  in  the  shape  of  mixtures, 
emulsions,  and  pastes,  which  may  be  made  into  pill  or  bolus  form.  The 
capsules  already  mentioned,  being  somewhat  expensive,  cannot  be  used  in 
dispensaries  and  clinics.  The  combination  known  as  Lafayette  mixture  ^ 
is  a  very  good  one,  and  is  very  largely  used  in  nearly  all  medical  charities. 
Its  formula  is  as  follows : 

I^.  Bals.  copaibse,  ^j  ; 

Liq.  potassse,  3ij  ; 

Ext.  glycyrrhizge,  ^ss ; 

Spts.  aether,  nitrosi,  §j  ; 

Syrup,  acacise,  §vj  > 

01.  gaultheriae,  gtt.  xvj. 

Mix  the  copaiba  and  liquor  potasses  and  the  extract  of  liquorice  and  sweet 
spirits  of  nitre  separately,  and  then  add  the  other  ingredients.  The  dose 
is  from  one  to  four  teaspoonfuls  three  times  a  day. 

The  following  is  a  particularly  effective  combination,  but  it  is  some- 
times distressing  to  the  stomach : 

^.  Bals.  copaibse, 

01.  santal.  fl.,  ad.  ^ss ; 

Liq.  potassse,  3vj  ; 

Syr.  aurantii  cort.,  5ij  ; 

Aq.,  q.  s.  ad  §iv. 

Dose,  one  teaspoonful  three  or  four  times  a  day  in  a  wineglass  of  water. 

All  antiblennorrhagics  should  be  taken  at  the  end  of  stomach  diges- 
tion,  usually  an  hour  and  a  half  after  eating. 

The  following  prescription  is  of  benefit  in  cases  of  delicate  stomach ; 

!^.  Copaibse  bals.,  sij  ; 

Magnesise,  3J  ; 

01.  menth.  piperitse,  gtt.  xx  ; 

Pulv.  cubebge, 

Bismuthi  subnitrat.,  da.  Sij. 

^  I  have  often  been  asked  whether  the  formula  of  the  Lafayette  mixture  was  a  favorite 
prescription  brought  over  from  France  by  its  ilhistrious  and  grateful  namesake.  Its  real 
origin  is  as  follows  :  It  was  a  remedy  which  a  druggist  in  Greenwich  street,  named  Lud- 
wig,  dispensed  to  sailors,  and  was  in  great  demand.  This  was  about  the  time  of  Lafayette's 
third  visit  to  America,  and  his  advent  was  honored  by  this  mi.xture  being  named  after 
him.  Thirty  or  forty  years  ago  a  similar  mixture  was  called  the  Washington  mixture, 
but  the  patriotism  of  Americans  frowned  this  name  down. 


140  GONORBH(EA  AND  ITS  COMPLICATIONS. 

M.  and  divide  into  pills  of  five  grains  each,  and  coat  with  sugar.  Dose, 
three  to  six  pills  three  times  a  days. 

This  prescription  gives  a  good  idea  of  the  bases  of  cubeb  and  copaiba 
paste.  There  is  much  latitude  in  this  direction  for  the  exercise  of  phar- 
maceutical skill.  Pastes  containing  cubebs,  copaiba,  and  oil  of  santal- 
wood  may  be  of  decided  benefit,  and  they  may  be  paraded  as  novelties  if 
a  few  antiseptics  are  judiciously  interspersed  in  the  combination.^ 

Kava-kava  has  little  antiblennorrhagic  effect  in  the  declining  acute 
stage,  but  it  is   beneficial  a  little  later  on. 

The  sphere  of  usefulness  of  these  antiblennorrhagics  is  in  the  declining 
stage  of  acute  gonorrhoea  and  in  those  subacute  suppurations  of  the  urethra 
which  are  really  relapses  or  exacerbations  of  a  smouldering  process. 

It  is  important  to  know  when  to  stop  this  form  of  internal  treatment, 
since  it  may  be  pushed  to  the  patient's  disadvantage.  As  a  rule,  Avhen 
the  urethral  discharge  found  in  the  urine  consists  of  mucus  with  very  little 
pus  and  more  or  less  epithelium — in  other  words,  when  cure  is  in  sight — 
it  is  well  to  cease  using  these  stimulant  remedies.  There  can  be  no  ques- 
tion that  their  prolonged  use  really  tends  to  keep  the  inflammatory  state 
in  a  slumbering  condition,  with  the  discharge  scant  in  quantity.  Many 
men  are  thus  over-treated,  and  they  promptly  get  well  when  the  medicine 
is  discontinued. 

The  foregoing  measures  constitute  what  the  patient  should  do  for  him- 
self in  the  declining  acute  stage. 

It  is  in  this  declining  stage  really  that  the  most  effective  treatment  of 
gonorrhoea  may  be  used.  At  this  time,  in  first  infections,  the  subepithe- 
lial exudative  inflammation  is  in  a  favorable  condition  to  yield  to  proper 
measures.  The  new  tissue-cells  are  yet  young  and  not  firmly  developed, 
and  their  absorption  may  then  be  brought  about.  The  hypergemic  and 
catarrhal  condition  of  the  mucous  membrane  is  on  the  wane,  and  can  be 
acted  upon  noAV  with  better  effect  than  later  on.  What  is  now  needed  is 
an  application  which  shall  be  astringent  and  sufficiently  stimulating  to 
cause  absorption,  and  yet  not  to  set  up  irritation.  There  is  no  known 
remedy  which  answers  these  requirements  and  indications  so  well  as 
nitrate  of  silver.^  The  delicate  point  in  its  use  is  the  determination  of 
the  strength  of  solutions  which  will  do  good  and  produce  no  harm.  My 
studies  on  the  action  of  nitrate  of  silver  in  gonorrhoea,  acute  and  chronic, 
convince  me  that  in  very  weak  solutions  it  is  an  astringent  of  decided 
power.     In  rather  stronger  solutions  it  acts  as  a  stimulant  and  an  astrin- 

^  As  a  matter  of  history  it  may  be  well  to  state  that  gurjun  balsam,  Peruvian  balsam, 
balsam  of  tolu,  the  fluid  extracts  of  matico,  stigmata  maidis,  of  senecio  Jacobsea,  of  Indian 
hemp,  of  piscidia  erythrina,  and  of  schinus  moUe,  the  oils  of  matico,  eucalyptus,  and 
erigeron  canadensis,  and  turpentine,  are  remedies  which  have  had  in  the  past  ephemeral 
popularity  as  antiblennorrhagics,  used  either  alone  or  in  combination  with  copaiba  and 
cubebs.     It  is  possible  that  some  of  these  old  friends  may- be  rejuvenated  later  on. 

^  A  silver  preparation,  named  argentamine,  has  been  used  clinically  and  bacteriolng- 
ically  by  Schiiffer  (  Wlen.  med.  Wochenschrift,  1894,  No.  12),  who  considers  it  superior 
to  nitrate  of  silver  for  the  reason  that  it  is  not  decomposed  in  fluids  containing  chloride 
of  sodium  and  albumin,  and  that  in  its  action  it  penetrates  more  deeply  into  the  tissues. 
This  preparation  is  colorless,  of  alkaline  reaction,  and  consists  of  a  solution  of  10  parts  of 
phosphate  of  silver  in  a  solution  of  10  parts  of  ethylendiamine  (CjH^NHjj)  in  100  parts 
of  water.     In  due  time  the  worth  of  this  drug  may  be  determined. 

Argentum  natro-subsulphurosum,  the  sulphate  of  sodium  and  silver,  was  used  by 
Friedheim  (op.  cit.),  and,  although  it  does  not  precipitate  albumin,  its  action  is  more 
feeble  than  that  of  the  silver  nitrate. 


TREATMENT  OF  ACUTE   URETHRITIS,   OR   GONORRHCEA.      141 

gent,  and  causes  the  absorption  of  the  exudation  into  the  mucous  mem- 
brane. The  critical  point  in  its  use  is  to  get  the  astringent  and  absorp- 
tive effects,  and  this  can  be  done  by  beginning  with  very  mild  solutions 
and  increasing  the  strength  very  sloAvly  and  intelligently.  When  used 
successfully  in  the  declining  stage  of  gonorrhoea  the  evidence  of  benefit 
will  be  seen  on  examining  the  urine,  in  which  pus-cells  will  be  seen  to 
gradually  grow  less  in  number  and  the  epithelial  cells  to  be  more  numer- 
ous and  more  fully  developed.  Used  in  a  concentration  stronger  than  that 
productive  of  absorption,  this  invaluable  agent  becomes  a  decided  stim- 
ulant and  a  producer  of  suppuration.  The  tendency  of  to-day  is  to  use 
this  agent  in  too  strong  solutions,  and  it  often  fails  in  its  salutary  effects 
for  this  reason.  In  the  declining  stage,  when  the  urine  shows  under  the 
microscope  some  pus-cells  and  few  or  perhaps  no  gonococci  and  a  predom- 
inance of  epithelial  cells,  together  with  an  excess  of  mucus,  much  can  be 
done  toward  bringing  the  waning  process  to  an  auspicious  end.  This,  in 
my  judgment,  is  the  critical  period  in  gonorrhoea.  If  the  patient  can  and 
will  follow  proper  treatment  at  this  time,  he  has  a  very  good  chance  of 
being  thoroughly  cured.  There  are  some  cases  of  gonorrhoea,  as  of  other 
diseases,  which  resist  all  treatment,  however  well  directed. 

At  this  stage  the  surgeon  should  throw  into  the  posterior  urethra 
(assuming  that  a  diagnosis  of  the  infection  of  that  segment  has  been 
made)  a  very  weak  and  warm  solution  of  nitrate  of  silver,  beginning  with 
1 :  20,000  or  1 :  16,000,  using  the  Ultzmann's  hand-syringe.  The  soft- 
rubber  catheter,  sparingly  lubricated  with  glycerin,  is  passed  down  the 
urethra  until  the  urine  flows,  which  will  usually  occur  when  the  instru- 
ment has  got  as  far  as  seven  or  seven  and  a  half  inches  down.  The 
bladder  being  empty,  pressure  on  the  piston  then  throws  the  injection 
into  the  prostatic  urethra.  It  is  well  now  to  withdraw  the  catheter  a  little 
until  its  end  is  in  the  membranous  urethra ;  then  on  pressing  the  piston 
gently,  resistance  will  be  felt  and  no  fluid  will  flow.  This  tells  the  sur- 
geon that  he  is  in  the  membranous  urethra,  and  that  the  irritation  of  his 
procedure  has  caused  the  conti-action  of  the  compressor  urethrse  muscle. 
Then  push  the  catheter  inward  about  half  an  inch  and  inject  again, 
when  the  fluid  will  pass  readily.  By  this  manoeuvre  the  eye  of  the 
catheter  is  placed  just  at  the  apex  of  the  prostate  and  at  the  very  begin- 
ning of  the  prostatic  urethra.  The  injection  is  then  slowly  thrown  in, 
and  it  passes  through  the  whole  of  the  prostatic  urethra  into  the  bladder. 
If  only  a  rather  small  injection  is  to  be  given,  about  one-half  of  the  con- 
tents of  the  syringe  may  be  used  posteriorly.  Then,  while  still  pressing 
the  piston,  the  surgeon  gently  draws  out  the  catheter,  and  finds  that  as 
its  eye  passes  thi'ough  the  membranous  urethra  the  flow  stops  again,  but 
is  at  once  resumed  Avhen  the  eye  reaches  the  bulbous  urethra,  which  is 
then  irrigated  with  the  balance  of  the  fluid.  It  may  be  necessarj^  to  use 
one  syringeful  for  the  posterior  urethra  and  another  for  the  anterior.  The 
sensations  of  the  patient  and  the  condition  of  the  urine  are  the  indices 
for  the  continuance  of  the  treatment.  Usually  a  feeling  of  benefit  is 
produced,  and  the  patient  desires  another  irrigation  in  a  day  or  two.  It 
is  always  well  to  proceed  very  cautiously.  If  the  treatment  is  well  borne 
and  the  urine  shows  a  decline  in  the  quantity  of  pus  and  mucus,  and  the 
epithelial  cells  show  rather  more  development,  then  one  is  safe  in  going 
on.     It  is  most  important  not  to  give  the  injections  too  frequently,  and 


142  GONOEBHCEA  AND  ITS  COMPLICATIONS. 

this  point  will  be  determined  by  the  sensations  of  the  patient  and  the 
examination  of  the  urine.  Just  before  the  final  cure  there  will  be  found 
an  excess  of  mucus,  which  floats  as  a  cobweb-like  cloud,  in  the  meshes  of 
which  are  minute  little  pinpoint-  or  pinhead-sized  granules  of  pus  and 
epithelium.  As  the  morbid  process  ceases  these  little  granules  disappear, 
and  then  for  a  short  time  there  is  only  a  slight  excess  of  mucus,  which 
Avill,  under  treatment,  soon  be  reduced  to  its  normal  quantity,  and  then 
the  patient  may  be  pronounced  cured. 

In  very  dilute  solutions  bichloride  of  mercury,  1  :  40,000-1  :  20,000, 
and  permanganate  of  potassa,  1  :  10,000—4000,  may,  according  to  the 
fancy  of  the  surgeon,  be  used  in  the  manner  just  detailed  in  the  declining 
stage  of  gonorrhoea.  In  like  manner,  very  dilute  solutions  of  alum  and 
sulphate  of  zinc  may  be  used.  A  large  experience  has  taught  me  that 
the  action  both  of  the  bichloride  and  permanganate  of  potassa  is,  as 
a  rule  subject  to  few  exceptions,  far  inferior  to  that  of  nitrate  of  silver. 
The  action  of  these  two  much- vaunted  agents  is  superficial  and  expended 
on  the  catarrhal  condition  of  the  mucous  membrane.  They  have  very 
little,  if  any,  effect  in  causing  the  absorption  of  the  products  of  inflam- 
mation, so  that,  in  my  judgment,  alum  and  zinc  sulphate  are  far  superior 
to  them. 

It  is  appropriate  here  to  call  particular  attention  to  the  tendency  very 
prevalent  to-day  to  treat  gonorrhoea  in  the  acute  stage  in  a  heedlessly 
heroic  manner.  We  read  of  cures  being  produced  in  five,  eight,  twelve, 
and  twenty  days,  and  persons  not  thoroughly  versed  in  the  knowledge 
and  treatment  of  gonorrhoea  may  be  influenced  by  these  dazzling  and 
misleading  claims.  The  scheme  of  these  treatments  consists  in  the  use 
of  some  antiseptic  drug  (preparations  of  mercury,  silver,  permanganate 
of  potassa,  and  others),  either  in  very  strong  solutions  or  in  irrigations 
given  sevei'al  times  a  day,  very  hot.  These  treatments,  and  others  men- 
tioned later,  certainly  cut  short  the  severe  symptoms  and  quite  promptly 
cause  the  purulent  discharge  to  become  muco-purulent.  These  results 
are  then  paraded  as  astonishing,  and  cases  presenting  them  are  looked 
upon  as  having  been  cured.  When  these  enthusiasts  are  asked  in  what 
a  cure  consists,  they  reply,  "  There  may  be  some  little  redness  of  the 
mucous  membrane  left  and  a  little  sticky  discharge,  but  the  patient  is  all 
right."  It  is  hard  to  understand  how  intelligent  men  can  thus  deceive 
themselves.  Many  patients  thus  treated,  knowing  little  of  gonorrhoea, 
consider  themselves  cured ;  others  see  that  they  are  really  not  cured,  and 
they  disappear  and  their  cases  are  registered  on  the  books  as  cures. 
Then,  again,  in  this  sticky  condition  antiblennorrhagics  and  the  usual 
astringents  are  used  to  complete  the  cure,  but  if  they  are  successful  the 
credit  is  given  to  the  heroic  remedy  which  calmed  inflammation  and  more 
or  less  rapidly  changed  the  character  of  the  discharge. 

In  the  majority  of  these  cases,  there  can  be  no  doubt,  the  patients  are 
not  in  any  sense  cured.  They  have  been  rapidly  pushed  into  the  terminal 
stage,  which  in  many  cases  has  no  end.  Now,  if  we  study  these  cases 
carefully  (as,  so  unhappily,  it  is  our  frequent  duty  to  do)  in  the  light  of 
the  pathology  of  the  gonorrheal  process  and  of  their  pathological  course, 
we  see  that  the  treatment  has  caused  a  much  greater  exudative  inflam- 
mation into  the  submucous  connective  tissue  than  is  seen  in  cases  tem- 
perately treated,  and  that  the  catarrhal  inflammation  has  been  brought 


TREATMENT  OF  ACUTE   URETHRITIS,    OR   GONORRHCEA.      143 

down  from  suppuration  to  the  production  of  a  thick  muco-purulent  secre- 
tion. This  is  shown  in  the  earlier  times  by  the  decidedly  full,  tense,  and 
thickened  condition  of  the  pendulous  and  subpubic  urethra,  and  by  the 
examination  of  the  urine,  which,  strange  to  say,  is  not  insisted  upon  by 
the  authors  of  these  rapid-transit  treatments,  as  they  are  called.  Then 
the  patients,  if  they  have  escaped  epididymitis,  have  symptoms  of  posterior 
urethritis,  urethro-cystitis,  and  often  bladder  incompetence,  and  more  or 
less  incontinence.  They  often  further  suifer  from  urine-dribbling,  which 
is  due  to  the  infiltration  into  the  urethral  walls,  which  prevents  the  canal 
from  performing  the  final  expulsive  acts  of  urination.  As  time  goes  on 
this  exudative  process,  which  involves  nearly  if  not  all  of  the  anterior 
urethra,  and  perhaps  the  posterior  part  also,  produces  connective  tissue, 
and  as  a  result  the  canal  is  more  and  more  constricted,  until  in  some  very 
bad  cases  a  condition  bordering  on  stenosis  is  left,  accompanied  by  all  the 
distressing  conditions  incident  to  the  blockade  of  the  bladder.  This 
picture  is  not  in  one  particular  overdrawn,  but  is  based  on  the  unbiassed 
study  of  cases  of  acute  gonorrhoea  which  have  been  railroaded  into  the 
terminal  stage.  It  may  be  claimed  by  those  who  advocate  this  form  of 
treatment  that  they  never  see  tjiese  results.  Perhaps  they  fail  to  appre- 
ciate the  deplorable  condition  the  patients  are  in,  but,  as  a  rule,  these 
same  patients  think  that  they  have  had  enough  of  that  sort  of  treatment, 
and  they  have  sense  enough  to  go  elsewhere.  It  follows,  therefore,  that 
a  treatment  which  is  at  once  sufficiently  active,  but  conservative  and 
based  on  a  knowledge  of  the  pathology  and  course  of  gonorrhoea,  is  the 
one  which  in  the  end  will  give  the  best  results  and  spare  the  patients 
much  trouble  and  suffering,  and  perhaps  permanent  infirmities. 

Irrigations,  Eetrojections,  and  Endoscopic  Applications  as  Abortive 
Measures. — A  treatment  of  gonorrhoea  known  as  the  method  of  Janet  ^  is 
noAV  attracting  considerable  attention  both  in  this  country  and  abroad. 
This  treatment  is  essentially  based  on  the  fact,  well  brought  out  by  Feleki^ 
(but  known  quite  generally  for  many  years),  that  as  a  result  of  a  certain 
technique  the  posterior  urethra  and  the  bladder  can  be  injected  from  the 
meatus  without  the  aid  of  a  catheter.  It  is  assumed  that  the  catheter 
may  not  only  act  as  an  irritant,  but  that  it  is  a  fruitful  source  of  infection. 
Janet  uses  an  irrigator  or  a  fountain  syringe,  to  which  is  attached  about  six 
feet  of  India-rubber  tubing  of  30  F.  calibre.  Into  the  distal  end  of  this 
tube  a  goodly-sized  conical  glass  nozzle  is  inserted,  while  an  India-rubber 
stopcock  completes  the  apparatus.  The  reservoir  for  the  injection,  what- 
ever it  may  be,  is  elevated  above  the  patient  about  two  feet  when  the 
anterior  urethra  only  is  irrigated,  and  about  four  and  half  feet  when  the 
posterior  urethra  and  bladder  are  medicated.  The  patient,  after  urination, 
is  placed  on  his  back  and  the  conical  nozzle  is  well,  but  not  forcibly, 
introduced  into  the  meatus ;  then  the  current  is  allowed  to  flow. 

If  irrigation  of  the  anterior  urethra  is  practised,  the  stopcock  is  so 
held  that  the  return  current  may  run  out  of  the  meatus.  When  the 
deeper  urethra  and  the  bladder  are  to  be  irrigated,  the  nozzle  is  firmly 
held  in  the  meatus. 

*  "Traitement  abortif  de  la  Blennorrhagie  par  le  Permanganate  de  Potasse,  etc,"  3d 
series,  Annales  de  Derm,  et  de  Syphil.,  vol.  iv.  pp.  1013  et  seq. 

^  "Experimentelle  Beitriige  zur  Funktion  der  Harnrohrenschliessmuskeln  und  zur 
Ausspiilung  der  Blase  ohne  Katheterismus,"  Internat.  Centrblt.  fur  de  Physiol,  und  Pathol, 
der  Ham-  und  Sex.-Org.,  1890-91,  vol.  iii.  pp.  80  et  seq. 


144  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

In  some  cases,  after  a  little  resistance,  the  compressor  urethrae  muscle 
and  the  feeble  external  sphincter  yield,  and  the  injection  flows  through  the 
posterior  urethra  into  the  bladder.  If  any  resistance  is  offered,  the  patient- 
must  practise  the  little  procedure  recommended  by  Bennett^ — namely,  "to 
strain  as  if  to  pass  a  very  slow  stream,  or  to  strain  a  little."  If  the  opera- 
tion causes  a  desire  to  urinate,  the  patient  should  be  allowed  to  evacuate 
the  bladder,  and  then  the  irrigation  should  be  repeated.  For  the  abortive 
treatment  of  acute  anterior  urethritis  one  or  two  irrigations  daily  are 
necessary.  For  gonorrhoea  of  the  totality  of  the  urethra,  for  the  first  few 
days  two  irrigations  daily  are  given,  and  after  that  only  one  each  day. 

The  therapeutic  agent  employed  by  Janet  is  permanganate  of  potassa 
dissolved  in  warm  water.  The  solutions  vary  in  strength  from  1 :  1000 
of  water  to  1 :  4000.  Toward  the  end  of  treatment,  with  the  decline  of 
the  acute  symptoms,  the  strength  may  be  1  :  500.  For  the  irrigation  of 
the  anterior  urethra  about  one  pint  of  injection  may  be  used,  while  for 
the  bladder  two  lavages  or  irrigations  of  about  a  pint  each  may  be  intro- 
duced. 

By  this  treatment  Janet  claims  that  he  not  only  aborts  incipient 
gonorrhoea,  but  promptly  cures  cases  in  the  acute  purulent  stage.  The 
noticeable  effects  of  these  irrigations,  as  stated  by  Janet,  are — first,  the 
appearance  of  a  whitish  secretion,  which  soon  becomes  serous,  and  then  an 
almost  absolute  dryness  of  the  whole  urethral  canal.  In  unsuccessful 
cases  after  this  dry  stage  the  discharge  again  becomes  purulent,  in  which 
case  these  lavages  should  be  discontinued  for  eight  days  and  then  resumed. 
Janet  says  that  on  an  average  ten  or  eleven  irrigations  are  sufficient  to 
abort  incipient  cases,  and  nine  for  other  acute  cases,  but  in  general  the 
patient  is  cured  by  five  lavages.  As  to  the  stability  and  validity  of  the 
cure,  we  find  these  significant  words :  "  Sometimes  there  remains  a  slight 
mucous  secretion;"  "at  other  times  the  patient  has  a  slight  mucous  dis- 
charge, in  which  case  I  gave  a  little  irrigation  of  nitrate  of  silver,  1 :  2000, 
in  the  anterior  urethra."  It  is  astonishing  how  complacently  exploiters 
of  abortive  treatments  wdth  uniformly  favorable  results  look  upon  these 
mucous  secretions  and  fail  to  appreciate  their  gravity. 

This  treatment  of  Janet  must,  of  necessity,  be  administered  by  the 
surgeon,  to  whom  the  patient  must  come  once  or  perhaps  twice  a  day, 
morning  and  evening.  I  have  it  from  the  word  of  mouth  of  gentlemen 
who  have  been  thus  treated  that  in  the  manipulations  necessary  for  flushing 
out  the  anterior  urethra  and  filling  the  bladder  some  of  the  injection,  as 
a  rule,  escapes,  and  not  only  dampens  but  stains  their  linen.  And  what 
is  the  benefit  ?  It  is  claimed  that  the  urethra  is  spared  the  irritation  of  a 
catheter  and  the  danger  of  infection  by  this  instrument  (which  with  ordi- 
nary cleanliness  is  nit).  A  12  F.  velvet-eyed,  soft-rubber  catheter  can 
be  passed  into  the  bladder  after  urination,  the  patient  standing  or  lying 
down,  and  that  viscus  can  be  filled  by  means  of  a  hand-syringe  in  a  short 
time  and  without  any  discomfort  whatever.  Why,  therefore,  should  a 
patient  be  subjected  to  this  ordeal  Avith  all  its  technique,  its  drawbacks, 
and  its  compromising  stigmata?  There  is  no  benefit  derived  in  over- 
coming the  resistance  to  hydraulic  pressure  of  the  compressor  urethrae. 
If  the  small-calibred  soft  catheter  is  gently  pushed  into  the  bladder,  in 
the  vast  majority  of  cases  the  compressor  will  off"er  no  hindrance,  and 

^  Journal  Ciitan.  and  Gen.-urin.  Diseases,  vol.  x.,  1892,  p.  284. 


TREATMENT  OF  ACUTE   URETHRITIS,   OR   GONORRHCEA.      145 

then,  if  the  surgeon  elects  to  use  Janet's  solution  in  the  conditions  before 
indicated,  the  man  can  at  least  go  home  with  an  unsoiled  shirt-flap. 

This  method  is  one  of  the  oft-recurring  fads  of  which  there  seem  to 
be  no  end.  We  have  already  seen  that  in  a  simple  manner  of  application 
permanganate  of  potassa  may  be  of  benefit  early  in  the  course  of  gonor- 
rhoea. 

A  treatment  of  gonorrhoea  known  as  the  hot-bichloride-retrojection 
method  was  held  in  high  esteem  by  a  few  surgeons  in  New  York  some 
years  ago.  The  method  was  invented  by  Dr.  W.  S.  Halstead,  but  its 
most  ardent  advocate  has  been  Dr.  G.  E.  Brewer.^  A  tin  pail  is  sus- 
pended from  the  ceiling  by  means  of  a  pulley,  and  under  it  is  a  Bunsen 
burner  or  an  alcohol  lamp.  To  a  short  tin  tube  at  the  lower  part  of  the 
pail  a  long  soft-rubber  tube  is  attached.  Into  this  tube  a  short  glass-tube 
coupling  is  inserted,  to  the  distal  end  of  which  an  18  F.  soft-rubber 
catheter  is  attached.  The  patient  having  urinated,  the  catheter  is  oiled 
and  passed  into  the  urethra  about  five  inches  or  even  deeper,  as  far  as 
the  bulb.  He  then  is  seated  at  the  edge  of  a  stool  over  a  large-sized  slop- 
jar  or  pail.  Then  about  two  quarts  of  a  solution  of  bichloride  of  mercury 
(1 :  40,000  of  water,  increased  in  some  cases  to  1 :  30,000  or  1 :  20,000)  are 
passed  through  the  urethra.  The  temperature  of  the  injection  at  the 
beginning  of  the  stance  is  about  that  of  the  body,  but  it  must  be  increased 
until  the  solution  is  as  hot  as  the  patient  can  bear.  Two  or  three  such 
treatments  are  to  be  given  each  day.  The  result  is  said  to  be  a  diminu- 
tion of  the  inflammatory  symptoms  and  a  rapid  transformation  of  the  pus 
into  a  mucoid  and  watery  secretion.  If  much  pain  is  produced,  the  retro- 
jection  should  be  suspended  for  a  few  days  and  oil  of  santal-wood  given 
internally.  When  the  discharge  has  been  watery  for  three  or  four  days, 
the  bichloride  is  suspended  and  sulphocarbolate-of-zinc  or  subnitrate-of- 
bismuth  injections  are  used.  In  uncomplicated  cases  the  discharge  ceases 
in  from  six  to  twelve  days. 

The  main  objection  to  this  treatment  is  that  other  surgeons  cannot  get 
the  same  results  that  its  advocate  says  he  gets.  Personal  observations, 
carried  on  in  a  perfectly  unbiassed  frame  of  mind,  convince  me  that  this 
treatment  off"ers  no  advantages  whatever  over  the  older  and  more  con- 
servative methods,  and  that  it  is  attended  with  marked  discomfort  and 
inconvenience  to  the  patients,  who  as  a  result  of  it  frequently  have  severe 
posterior  urethritis,  urethro-cystitis,  and  even  epididymitis.  It  is  now 
more  than  ten  years  since  this  treatment  was  introduced  in  New  York, 
and  it  has  failed  utterly  to  obtain  even  a  limited  acceptance. 

Cotes  ^  recommends  the  following  method  of  treatment  of  acute  gonor- 
rhoea :  After  urination  a  well-oiled  warmed  endoscopic  tube  is  passed  down 
the  urethra  four  or  five  inches,  the  patient  lying  on  a  couch.  If  necessary 
there  may  be  a  preliminary  injection  of  cocaine.  The  canal  is  carefully 
mopped  and  rendered  free  from  secretion,  and  examined  by  means  of 
electric  light.  Then  a  tuft  of  absorbent  cotton  tAvisted  around  the  end 
of  an  applicator  is  saturated  in  a  solution  of  nitrate  of  silver  (gr.  x  to  sj 
of  water),  and  pushed  down  the  tube  through  its  distal  aperture.  The  tube 
and  the  applicator  are  then  withdrawn,  and  as  a  result  the  urethra  is 
thoroughly  moistened  by  the  solution.     A  second  insertion  and  a  similar 

'  A  System  of  Oenito-urin.  Disease,  etc.,  vol.  i.,  1893,  pp.  161  et  seq. 
.  "  Lancet,  Feb.  27,  1892,  pp.  461  et  seq. 
10 


146  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

application  are  made  to  the  two  inches  of  the  urethra  near  the  meatus. 
A  saline  purgative  with  an  alkaline  or  copaiba  mixture  is  given  internally, 
and  the  patient  injects,  using  a  syringe  which  holds  only  two  drachms,  a 
solution  made  of  one  drachm  of  Condy's  fluid  to  a  pint  of  water.  These 
injections  should  be  given  six  times  a  day,  the  urethra  having  previously 
been  cleansed  by  the  injection  of  some  warm  water.  Cotes  claims  for 
this  treatment  remarkable  success  in  amelioration  of  the  symptoms  and 
quick  cure  in  from  five  to  twelve  days. 

Seeing  that  in  the  great  majority  of  cases  the  gonorrhoeal  process 
promptly  travels  back  to  the  bulb,  it  seems  queer  that  Cotes,  who  began 
treatment,  as  he  says,  in  most  cases  many  days  after  the  disease  began, 
was  able  to  "  head  it  off"  at  from  four  or  five  inches. 

A  startling  novelty  in  the  abortive  treatment  of  incipient  gonorrhoea 
has  recently  been  offered  by  Dr.  J.  C.  DaCosta.^  The  urethra  having 
been  thoroughly  cleansed  by  urination  and  by  the  injection  or  spray  of 
equal  parts  of  water  and  peroxide  of  hydrogen  (15-volume  solution),  the 
part  is  then  sprayed  by  means  of  a  metal-nozzled  atomizer  with  a  mixture 
of  oil  of  cinnamon  and  benzoinol.  This  mixture  should  consist  of  one 
drop  of  the  oil  to  the  ounce  of  excipient  for  the  first  day's  injection,  two 
for  the  second,  and  three  for  the  third.  In  40  cases  of  beginning  acute 
urethritis  of  from  three  to  five  days'  duration,  in  6  the  discharge  ceased  in 
two  days  and  did  not  return ;  in  12,  in  five  days ;  in  6,  from  eight  to  ten 
days ;  in  10,  from  ten  to  fifteen  days ;  in  10  the  treatment  failed ;  and  4 
patients  disappeared  after  their  first  visit.  The  injections  or  spray  appli- 
cations should  be  made  three  or  four  times  a  day,  always  into  a  thoroughly 
cleansed  urethra.  When  pain  is  caused  by  the  stronger  solution,  a  weaker 
one  should  be  used.  It  will  be  interesting  to  learn  whether  other  observ- 
ers can  obtain  like  results  from  this  method. 

Various  New  Agents  and  Methods  of  Treatment. — Iodoform. — This 
agent,  on  account  of  its  decided  antiseptic  action,  has  been  used  in 
the  treatment  of  acute  and  declining  gonorrhoea.  Campana^  claims 
good  results  from  the  following  prescription :  lodoformyl  alcohol,  20 ; 
carbolic  acid,  0.1  to  .02  ;  glycerini,  80  ;  and  water,  20 — used  as  an 
injection  three  times  a  day.  He  claims  that  this  drug  calms  pains  and 
cures  gonorrhoea  promptly  when  used  as  an  injection  consisting  of  4  parts 
of  iodoform  to  80  of  water.  This  should  be  well  shaken  and  drawn  up 
in  a  glass  syringe.  The  patient  should  lie  on  his  back,  with  the  penis 
held  vertically  when  the  injection  is  entering  ;  then  the  iodoform  will  be 
carried  down  the  urethra. 

Cheyne^  claimed  success  from  the  use  of  bougies  made  of  iodoform,  oil 
of  eucalyptus,  and  wax. 

Thiery*  used  10  grammes  of  iodoform  suspended  in  60  grammes  of  oil 
of  sweet  almonds.  One  or  two  injections  of  two  drachms  of  this  com- 
pound are  thrown  into  the  urethra  once  or  twice  a  day  after  urination, 
and  there  retained  for  twenty  minutes  by  compressing  the  lips  of  the 
meatus  together.  A  complete  cure  was  produced  in  from  five  to  twenty- 
three  days.      He  advises  this  method  as  an  early  abortive  treatment. 

1  3Ied.  Neivs,  Oct.  21,  1893,  pp.  458  et  seq. 

2  La  Salute,  Ital.  Med.,  Genoa,  1883,  2d  Ser.,  vol.  xvii.  p.  33. 
^  British  Med.  Journal,  1880,  vol.  ii.  p.  124. 

*  Annates  des  Mai.  de  Org.  Gin.-urin.,  1891,  pp.  395  et  seq. 


TREATMENT  OF  ACUTE   URETHRITIS,    OR   GONORRHCEA.       147 

This  agent  has  also  been  used  in  the  form  of  wax  and  butter-of-cocoa 
bougies,  and  of  antrophores,  sometimes  in  combination  with  other  anti- 
septics.     On  the  whole,  it  is  an  unsatisfactory  remedy  for  gonorrhoea. 

Resorcin. — LetzeP  first  used  resorcin  in  acute  and  chronic  gonorrhoea 
in  3  to  4  per  cent,  watery  solutions  as  injections.  He  claims  marked 
benefit  and  quick  cures  for  this  drug,  which  to  be  pure  must  be  snow- 
white  in  color,  and  when  dissolved  in  pure  water  should  make  a  clear 
solution. 

Lychowski^  thinks  that  resorcin  has  an  antiseptic  and  astringent  efi"ect, 
quickly  killing  the  gonococci.  He  used  2  to  3  per  cent,  solutions,  and 
claims  a  cure  on  an  average  in  six  days. 

In  the  decline  of  the  acute  stage  I  have  seen  cases  progress  favorably 
while  using  a  resorcin  solution,  1  drachm  to  4  ounces  of  pure  water.  I 
have  yet  to  see  any  noteworthy  effects  of  this  drug  as  compared  with  the 
results  obtained  by  nitrate  of  silver  and  the  zinc  salts. 

Thallin. — Kreis^  put  forth  the  claim  that  a  4  per  cent,  solution  of 
sulphate  of  thallin  in  water  killed  gonococci  in  the  process  of  cultivation 
by  making  the  culture  medium  sterile.  He  also  claimed  that  it  was  para- 
siticidal  against  the  anthrax  bacillus  and  the  staphylococcus  aureus. 

Influenced  by  these  results,  Goll  "*  used  a  2  to  2|^  per  cent,  solution  of 
the  sulphate  of  thallin  in  acute  gonorrhoea,  giving  a  double  injection 
daily,  the  first  being  allowed  to  flow  out,  while  the  second  one  is  retained 
for  a  few  minutes.  In  chronic  gonorrhoea  he  used  1  to  IJ  per  cent,  retro- 
jections,  together  with  instillations  of  a  few  drops  of  5  to  7  per  cent, 
solution,  and  butter-of-cocoa-and-thallin  pencils.  He  also  prescribed  the 
drug  internally.  Goll  thinks  that  besides  its  specific  effect  on  the  gono- 
coccus,  sulphate  of  thallin  passes  into  the  submucous  connective  tissue  and 
into  the  crypt-spaces  and  there  exercises  a  curative  eff"ect. 

Irminger^  used  with  good  results  bougies  containing  3J  grains  of  sul- 
phate of  thallin.  He  also  gave  the  drug  internally  in  4-grain  doses  three 
times  a  day. 

Istamanoff"^  claims  that  he  found  a  2  per  cent,  solution  the  best  of  all 
injections  for  acute  and  chronic  gonorrhoea.  He,  following  the  lead  of 
Nachtigael,  Fenwick,  and  Lohnstein,  used  antrophores  of  sulphate  of 
thallin  with  prompt  and  good  results. 

After  repeated  trials  my  own  conclusion  is  that  sulphate  of  thallin  is 
no  better  than,  and  perhaps  not  as  eff"ective  as,  the  old-time  chemicals. 

IcJithyol. — This  drug  was  used  by  Jadassohn  in  a  large  number  of 
well-observed  cases  in  solutions  of  1  to  5  per  cent,  in  the  anterior  urethra 
and  1  to  10  per  cent,  in  the  posterior  urethra.  Jadassohn  thinks  its  field 
of  action  is  early  in  the  acute  stage  of  gonorrhoea,  in  which  it  is  more 
eff'ective  than  resorcin,  Aveak  sublimate  solutions,  and  permanganate  of 

'  "Ziir  Resorcin  behandlung  de  Gonorrhoe,"  Allg.  Med.  Cent.  Ztg.,  No.  66,  1885. 

^  "Eehandlung  des  acuten  Harnsrohren-Trippers  mit  Eesorcin,"  Guzeta  Lekarska,  Iso. 
4,  1887. 

^  "Ueber  das  Verhalten  der  Gonococcen  zur  Thallinsalzen,"  Corresp.  Bltt.fur  Schweiz. 
Aerzte,  1887,  No.  1,  pp.  9  et  seq. 

■*  "Dn  Traitement  de  la  Gonorrhode  par  les  Sels  de  Thalline,"  Gaz.  med.  d' Algerie, 
1887,  vol.  xxxii.  pp.  91  et  seq. 

5  Deui.  med.  Zeil.,  1887,  No.  77. 

^  "Ueber  die  Behandlung  des  infektiosen  Urethritis  mittels  der  Thallin-Antrophore," 
Mmatshefte  fur  Prakt.  Dermat,  Dec.  15,  1888,  p.  1215. 


148  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

potassa.^  It  causes  the  rapid  disappearance  of  the  gonococci,  and  as  a 
result  the  pus  rapidly  changes  into  a  serous  fluid.  In  later  stages  it  is 
beneficial,  and  in  posterior  urethritis,  but  does  not  rank  with  nitrate  of 
silver.     Many  cases  are  refractory  to  the  action  of  this  drug. 

Colombini  ^  observed  that  a  strength  of  2  and  3  per  cent,  ichthyol 
retarded  the  growth  of  the  gonococcus  in  cultures  :  1  to  2  per  cent, 
watery  solutions  were  well  borne  in  acute  gonorrhoea,  while  8  and  9  per 
cent,  solutions  only  caused  a  slight  burning  sensation.  In  very  acute 
gonorrhoea  a  1  per  cent,  solution  calmed  pain,  diminished  the  number  of 
erections,  and  caused  the  discharge  to  become  sero-purulent,  then  serous. 
By  increasing  the  strength  to  2,  3,  or  4  per  cent,  the  discharge  ceased  in 
from  ten  to  thirty  days.  In  the  acute  stage  2  per  cent,  injections,  whilst 
they  change  the  character  of  the  secretion,  also  cause  an  epithelial  des- 
quamation which  the  author  thinks  aids  in  the  elimination  of  the  gono- 
coccus. In  subacute  gonorrhoea  3  to  4,  and  even  7  or  8,  per  cent,  injec- 
tions usually  cause  the  discharge  to  disappear  in  fifteen  days.  In  chronic 
localized  gonorrhoea  Colombini  used  solutions  of  strengths  as  high  as  8, 
10,  and  15  per  cent.,  with  the  addition  of  10  per  cent,  of  glycerin,  with 
good  results. 

Ichthyol,  according  to  this  observer,  possesses  an  undoubted  anti- 
blennorrhagic  action,  and  is  well  borne  by  the  urethral  mucous  membrane, 
and,  while  he  does  not  regard  it,  as  Jadassohn  does,  as  an  ideal  remedy,  it 
is  one  of  great  value. 

Villetti  ^  confirms  the  claims  of  Columbini  as  to  the  soothing  nature 
of  ichthyol  injections.  He  found  that  the  results  were  favorable  and 
prompt,  and  that  complications  were  avoided.  Villetti  used  lavages  of 
ichthyol  (1  per  cent.),  one  each  day,  in  cystitis,  by  which  he  means  pos- 
terior urethritis  and  urethro-cystitis.  He  found  they  had  an  antiseptic, 
curative,  and  analgesic  efi"ect. 

The  truth  is,  that  ichthyol  is  perhaps  about  as  effective  as  lead-water 
in  acute  gonorrhoea,  and  injections  made  of  it  are  objectionable  to  patients 
by  reason  of  their  staining  quality  and  of  their  unpleasant  odor. 

Crallohromol. — Cazeneuve  and  Rollet^  claim  that  this  drug  is  valuable 
in  the  treatment  of  gonorrhoea.  They  used  it  diluted  in  water  (1  part  to 
100  or  1  part  to  50)  as  both  injection  and  lavage.  They  claim  that  in 
the  acute  stage  it  calms  pain,  acts  antiseptically,  reduces  inflammation, 
and  changes  the  purulent  secretion  into  muco-purulent,  and  may  cause  a 
cure  in  from  six  to  eight  days.  They  significantly  remark  that  it  may 
happen  that  they  have  to  prescribe  the  zinc  salts. 

Letzel  ^  used  this  remedy  in  1  to  2  per  cent,  solution  in  the  anterior 
urethra,  and  in  2  and  sometimes  3  and  4  per  cent,  solutions  in  the  pos- 
terior urethra.  In  some  acute  cases  Letzel  found  the  discharge  to  cease 
in  from  seven  to  ten  days,  and  gonorrhoeal  threads  no  longer  to  appear  in 

^  "  Ueber  die  Behandlung  der  Gonorrhoe  mit  Ichthyol,"  Deut.  med.  Wochenschrifl, 
If  OS.  38  and  39,  1S92. 

^  "  Ictiolo  nella  cura  della  Blennorrhagia,"  Commentario  Clinico  della  Malaitie  Cutanee 
e  Genito-urinarie,  2d  Series,  1893,  fascic.  5,  6,  and  7. 

^  L' Ichthyol  dans  le  Traitement  des  Urelhriiis  et  des  Cystites,  Rome,  1894. 

*  "  Traitement  de  la  Blennorrhagie  par  le  Gallobromol,"  Lyon  Medical,  No.  29,  July 
16,  1893. 

^  "  Gallobromol  als  Secretionsbeschriinkendes  Mittel  bei  Gonorrhoe  und  Eczema," 
Aerztliche  Rundschau,  Ko.  13,  1894. 


TREATMENT  OF  ACUTE   URETHRITIS,    OR   GONORRHCEA.      149 

the  urine.  In  chronic  gonorrhoea  it  was  also  very  curative.  Antrophores 
introduced  into  the  urethra  at  night,  together  with  the  use  of  the  sound, 
were  beneficial. 

Miiller  ^  tested  the  therapeutic  value  of  gallobromol  very  carefully  and 
reached  the  conclusion  that  it  is  inferior  to  ichthyol  in  calming  the  severe 
symptoms  and  in  shortening  the  course  of  the  disease.  Neither  ichthyol 
nor  gallobromol,  according  to  the  opinion  of  this  author,  possess  potent 
action  against  the  gonococcus.  Gallobromol  is  obj  ectionable  for  the  reason 
that  it  stains  the  patient's  linen. 

Alumnol. — Chotzen  exploited  this  drug  as  non-toxic,  antiseptic,  and 
astringent,  acting  not  only  superficially,  but  deeply  in  the  tissues.  In 
his  first  essay  Chotzen^  claimed  that  this  agent  was  preferable  to  nitrate 
of  silver,  for  the  reason  that  it  does  not  cause  pain  or  stain  the  linen. 
As  a  destroj^er  of  the  gonococcus  he  gives  it  a  prominence  above  all  other 
therapeutic  agents.  In  a  second  essay  this  author^  claims  that  in  cultures 
alumnol  promptly  kills  the  gonococcus,  and  in  1  and  2  per  cent,  solutions 
it  penetrates  the  tissues  of  the  male  urethra  and  of  the  cervix  uteri,  and 
exerts  a  specific  action,  killing  the  gonococci  and  causing  the  inflammatory 
process  to  wane.  He  makes  the  astonishing  assertion  that  he  cured  a  goodly 
number  of  cases  of  acute  gonorrhoea  in  one  week. 

The  experience  of  Casper'*  is  not  in  accord  with  that  of  Chotzen. 
The  former  found  alumnol  in  acute  gonorrhoea  no  better  than  the  old 
remedies,  and  in  chronic  gonorrhoea  it  was  inferior  to  nitrate  of  silver. 
Samter,^  together  w^ith  Lewin,  treated  twelve  cases  of  gonorrhoea  with 
this  remedy.  They  found  that  it  does  not  exert  a  specific  curative  action, 
and  their  results  were  so  unfavorable  that  they  have  renounced  its  use  in 
chronic  gonorrhoea. 

The  foregoing  experiences  are  interesting,  since  they  conspicuously 
show  how  the  exploiter  or  promoter  of  a  new  drug  or  treatment  invariably 
sees  specific  results  which  no  one  else  can  obtain. 

Retinol. — Dubois^  experimented  with  the  injection  of  balsamics,  and 
used  retinol  alone  or  in  combination  with  salol  10  to  15  per  cent.,  copaiba 
5  per  cent.,  and  creoline  1  per  cent.  These  injections  are  said  to  favor- 
ably modify  the  discharge. 

PyoManin. — From  its  well-known  afiinities  for  micro-organisms  it 
would  seem  that  this  agent  might  be  especially  useful  in  the  treatment  of 
gonorrhoea.  Burghard''  used  pyoktanin  in  thirty  cases  with  what  does 
not  seem  a  striking  success.  When  injections  (1 :  1000)  were  used,  the 
discharge  was  in  some  cases  decreased  and  in  others  increased.  In  all, 
smarting  and  scalding  on  urination  were  produced,  together  with  much 
inflammatory    reaction.     When    the    solution    was    reduced    in    strength 

^  "  Ueber  die  Einwirkung  von  Gallobromol  auf  die  Acute  Gonorrhoe,"  Dermatologische 
Zeiischrifi,  vol.  i.,  1894,  pp.  516  et  seq.  '_ 

^"Alumnol,  ein  neues  Mittel  gegen  Hautkrankheiten  und  Gonorrhoe,"  Berl.  Hin. 
Wochenschrift,  1892,  pp.  1219  et  seq. 

*"  Alumnol,  ein  Antigonorrhoicura,"  Verhandl.  der  Deut.  Derm,  G eselhchaft,  4ih.  Con- 
gress, Wien,  1894,  pp.  673  et  seq. 

■*  "Ueber  die  Wirkung  des  Alumnol  auf  die  Gonorrhoe,  etc.,"  JBerl.  klin.  Wochenschrift^ 
1893,  p.  306. 

*  "1st  das  Alumnol  ein  specificum  gegen  Gonorrhoe?"  ibid.,  1893,  p.  308. 

6  Thise  de  Faria,  1891. 

'  "  On  the  Action  of  Methyl  Violet,  with  especial  reference  to  its  use  in  Gonorrhoea, 
etc.,"  Lancet,  May  23,  1891,  p.  1147. 


150  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

(1 :  3000)  it  worked  better.  Burghard  recommends  this  solution,  1 :  3000, 
to  begin  with,  and  then  to  cautiously  increase  the  strength. 

Lindstroem^  is  disposed  to  think  that  this  agent  is  valuable  in  acute 
gonorrhoea  when  a  strength  of  solution  of  1  :  4000  or  1  :  2000  is  used. 
The  very  decided  staining  quality  of  this  drug  will  prevent  its  extended 
use,  even  if  found  beneficial  in  very  dilute  solutions. 

Antipyrine. — This  drug,  useful  in  many  cases  of  painful  complications 
and  symptoms  of  gonorrhoea,  has  been  used  by  some  authors  as  an  ingre- 
dient for  injections. 

Audhoui,^  in  several  cases  of  acute  and  chronic  gonorrhoea,  claims 
success  from  the  use  of  injections  of  the  strength  of  2^  per  cent.,  dis- 
solved in  water.  Brindisi^  is  said  to  have  used  the  same  solution  with 
benefit. 

The  paucity  of  its  literature  and  the  absence  of  the  claim  of  specific 
action  for  this  drug  go  to  show  that  it  has  little  if  any  therapeutic  effect. 

Qitric  Acid. — As  a  result  of  the  knowledge  of  the  energetic  action  of 
citric  acid  on  the  bacillus  of  diphtheria,  Pellissier*  has  used  this  drug  in 
acute  gonorrhoea  in  fifteen  cases,  efi'ecting  a  cure  in  from  fifteen  to  eigh- 
teen days.  He  uses  a  solution  (1: 100  of  water)  as  an  injection  six  times 
daily.  For  lavages  the  solution  employed  is  8  grammes  of  citric  acid  to 
1000  grammes  of  water. 

Dermatol,  suspended  in  a  thick  mucilage  made  of  Irish  and  Iceland 
mosses,  was  claimed  by  Vaughan*  to  act  as  a  demulcent  and  to  promptly 
cure  acute  gonorrhoea.  This  is  one  of  the  passing  fancies  in  the  treat- 
ment of  gonorrhoea  which  appears  and  disappears  with  equal  celerity. 

Sozoiodol  pf  zinc  has  been  used  with  benefit  by  Taaks  ^  in  2  or  3  per 
cent,  watery  solutions  as  injections  in  acute  gonorrhoea  in  men  and  Avomen. 
Triedheim  ^  used  this  salt,  as  well  as  sozoiodol  of  potassium  and  sodium, 
and  claims  that  it  distinctly  lessens  the  purulency  of  the  discharge. 

Lysol^  in  1  per  cent,  watery  solution  has  been  used  by  Carballo  with 
the  usual  great  success  peculiar  to  new  remedies. 

Oreoline  is  regarded  by  La  Bosa  ®  as  superior  to  corrosive  sublimate 
and  carbolic  acid  when  used  as  an  injection  (1 :  100  of  water). 

Salicylate  of  Mercury. — Schwimmer^'*  recommends  injections  of  sa- 
licylate of  mercury  in  acute  gonorrhoea,  using  a  watery  solution  of  1 
centigramme  to  100  grammes  of  water,  as  an  injection  three  times  a  day. 
This  is  said  to  cause  the  discharge  to  cease  in  a  few  days.  This  remedy 
proved  efficient  in  Friedheim's  hands." 

Salicylate  of  cadmium  is  considered  by  Cesaris  ^^  an  energetic  antiseptic 
and  astringent,  useful  in  gonorrhoea  as  an  injection  (^ss  to  water  ^viss). 

Quinine  has  been  used  by  several  surgeons,  suspended  in  water  as  an 
injection  in  gonorrhoea,  and  some  claim  good  results  from  its  use. 

1  Wralch,  No.  37,  1890.  '  Gazette  des  Hopitaux,  Sept.  29,  1888. 

3  Med.  News,  April  25,  1891.  *  Bxdl.  de  Therapeutique,  Dec.  15,  1894. 

*  New  York  Med.  Journ.,  April  30,  1892.         ^  Inaug.  Dissert.,  Wurtzburg,  1889. 

'  Op.  cit. 

^  Monatshefie  fur  Prak.  Derm.,  vol.  xvi.,  1893,  p.  492,  and  Boletin  de  Medicina  de  Chile, 
1892. 

8  Giornale  Ital.  delle  Malat.  Ven.  e.  delln  Pelle,  1890,  p.  194. 

1"  Wien.  med.  Wochenschrift,  No.  8,  1889,  p.  281.  "  Op.  cit. 

^^  Bolletino  Chim.-farm.,  1894,  p.  407,  quoted  from  Merck^s  Annual  Beport  for  1894, 
Darmstadt,  1895. 


TREATMENT  OF  ACUTE   URETHRITIS,   OR   GONORRHOEA.       151 

Harmonic'  regards  the  drug  as  a  mild  antiseptic  and  of  benefit  in 
acute  gonorrhoea.  He  used  an  injection  composed  of  subnitrate  of  bis- 
muth 5  grammes,  quinine  1  gramme,  and  water  130  grammes.  The 
average  strength  of  these  injections  should  be  1  or  2  per  cent. 

Ledetsch  ^  used  quinine  in  solution,  1  :  100,  with  brilliant  results.  In 
some  chronic  cases  of  gonorrhoea  the  author  was  astonished  at  the  rapid- 
ity of  cure,  which  resulted  in  a  few  days.  A  slight  burning  sensation  is 
produced. 

JVaphthol  has  been  found  to  have  only  very  slight  antiparasitic  action 
upon  the  gonococcus  by  Critzman.* 

Ergotine  comes  in  for  a  fair  share  of  praise  in  the  treatment  of  acute 
gonorrhoea  by  Roicki.*  The  injection  used  consists  of  30  centigrammes 
of  ergotine  to  300  grammes  of  distilled  water.  The  patient  should  also 
take  internally  two  to  four  pills  of  this  drug,  containing  two  grains  each, 
daily. 

Tannin  has  been  extensively  used  in  gonorrhoea  in  injection  form, 
but  its  therapeutic  action  is  very  limited,  and  it  sometimes  is  very  irri- 
tating. 

Sea-water  is  said  to  have  cured  thirty-two  cases  of  gonorrhoea  when 
injected  into  the  urethra  eight  times  daily.  O'Brien,*  who  is  the  sponsor 
for  this  treatment,  claims  cures  in  about  eight  days.  The  efficacy  of  the 
water  is  said  to  be  due  to  its  alkalinity  and  to  its  antiseptic  and  tonic 
properties,  all  of  which  are  enhanced  if  it  is  slightly  heated. 

Pyridin,  or  tricarboloxylic  acid,  has  been  used  with  prompt  and  good 
effect  in  gonorrhoea  by  Rademacher®  in  a  watery  solution,  ^  a  grain  to 
the  ounce,  as  an  injection  used  three  or  four  times  a  day. 

Silico-jiuoride  of  sodium  is  considered  by  Croskey  ^  to  be  a  valuable 
antiseptic  agent  and  very  effective  in  gonorrhoea  in  a  1 :  1000  solution  in 
water.     Four  injections  daily  should  be  used. 

Pyrogallic  acid,  in  4  per  cent,  solution,  was  used  by  Friedheim  ^  with 
slow  effect,  the  drug  being  sometimes  irritating  even  when  used  in  2  per 
cent,  solution. 

Natrium  chloroborosum  was  used  in  acute  gonorrhoea  by  Friedheim' 
in  5  per  cent,  solution,  with  alleged  good  effect  and  no  irritation. 

Carbonic-acid  water  has  been  exploited  as  an  active  injection  in  acute 
gonorrhoea,  when  used  in  a  cold  state.  It  sometimes  causes  much  irrita- 
tion. 

Thermal  sulphur  waters  have  been  regarded  as  curative  when  injected 
in  acute  gonorrhoea,  particularly  by  the  disinterested  physicians  who  live 
at  the  springs. 

As  examples  of  the  fatuous  methods  of  treatment  recommended  for 
gonorrhoea  the  inhalation  of  ethereal  oils  and  turpentine-vapor  baths  may 
be  mentioned  as  some  of  the  most  conspicuous. 

Bougies,  Antrophores,  Ointments,  Sounds,  Syringes,  and  InsuflBiatorSi — 
Of  late  years  many  authors  have  written  in  praise  of  certain  applications 

^  Annales  Medico-chirurgicales  et  TTierapeutiques,  July,  pp.  219  et  seq.,  1886. 

"  Prager  med.  Woehenschrift,  No.  32,  1887,  p.  275. 

^  Annales  des  Mai.  des  Org.  G^n.-urin.,  vol.  vii.,  1889,  p.  244. 

*  Ibid.,  1891,  p.  725. 

*  British  Med.  Journ.,  Nov.  30,  1889,  p.  1215. 

«  Medical  Herald  (Louisville),  Oct.,  1887,  p.  290. 

'  Med.  Times  and  Register,  Julv  6,  1889.  *  Op.  cit.  »  Op.  cit. 


152 


GONORRHOEA  AND  ITS  COMPLICATIONS. 


to  the  anterior  urethra,  as  far  back  as  the  bulb,  used  in  the  form  of 
bougies,  antrophores,  and  ointments.  These  agents  perhaps  may  be  useful 
in  the  chronic  stage  in  some  cases. 

Bougies  have  as  their  base  lanolin,  vaseline,  and  cocoa-butter,  ren- 
dered comparatively  hard  and  stiff  by  the  admixture  of  a  certain  amount 
of  white  wax.  A  large  number  of  drugs  and  combinations  of  drugs  of  an 
astringent  and  antiseptic  nature  have  been  incorporated  with  these  basic 
substances,  according  to  the  fancy  of  the  inventor  of  a  "new  treatment." 
These  bougies,  as  a  rule,  have  a  calibre  of  about  14  French,  and  they 
may  be  of  any  length,  but  usually  those  of  two  or  three  inches  are  recom- 
mended. The  following  are  the  principal  drugs  used  in  bougieform  in 
chronic  anterior  urethritis  :  nitrate  of  silver,  sulphate  and  sulphocarbolate 
of  zinc,  subnitrate  of  bismuth,  thallin,  quinine,  iodoform,  oil  of  eucalyp- 
tus, corrosive  sublimate,  calomel,  ichthyol,  boric  acid,  and  alum.  These 
bougies  may  be  introduced  into  the  urethra  once  a  day  by  means  of  an 
endoscopic  tube ;  the  end  of  the  penis  is  then  enveloped  in  a  tuft  of  ab- 
sorbent cotton  held  in  place  by  an  India-rubber  elastic  band.  In  Ger- 
many, Senftleben's  ^  urethral  pistol  seems  to  be  in  much  favor.  This 
instrument  consists  of  a  cannula  made  of  celluloid,  into  which  an  obturating 
staff  of  whalebone  is  inserted. 

Antrophores  are  soluble  bougies  composed  of  medicated  gelatin  moulded 
on  a  spiral  wire.  Into  the  gelatinous  mass  any  one  or  several  of  the 
above-mentioned  drugs  may  be  incorporated  as  it  may  suit  suit  the  fancy 
of  the  surgeon.  As  time  goes  on  and  as  new  antiseptic  drugs  are  invented 
or  discovered,  we  shall  no  doubt  have  new  treatments  in  the  shape  of 
bougies  or  antrophores. 

Ointments  have  for  their  bases  lanolin,  vaseline,  cerate,  and  cocoa- 
butter,  and  are  less  firm  in  structure  than  bougies.  The  therapeutic 
agents  have  already  been  named.  These  ointments  for  the  urethra  are 
introduced  into  that  canal  by  means  of  sounds  and  syringes.  In  America 
we  have  used  for  years,  and  sometimes  with  benefit  (when  nitrate  of  silver, 
3ss  to  §j,  was  the  active  agent),  what  is  known  as  the  cupped  sound.     At 


Fig.  62. 


Cupped  sound. 

its  distal  portion  there  are  six  or  eight  cup-shaped  depressions,  into  which 
the  ointment  is  placed  before  the  sound  is  passed.  This  treatment  of 
chronic  gonorrhoea  by  means  of  ointment  introduced  upon  sounds  into  the 
urethra  has  been  advocated  quite  warmly  in  Germany.  Unna^  advises  a 
quite  stiff  ointment,  the  essential  part  of  which  is  nitrate  of  silver.  This 
is  liquefied  in  a  lukewarm-water  bath,  and  the  sounds,  of  which  he  has 
invented  a  complete  set,  are  dipped  in  it  and  then  hung  up  to  cool.  Then 
they  are  introduced  into  the  urethra,  the  warmth  of  which  causes  the  oint- 

^  "Eine  neiie  Methode  der  Tripper  Behandling,"  Monutshefte  fiir  Prcik.  Dei-mat.,  1884, 
vol.  iii.  pp.  281  et  seq. 

2  Ibid.,  vol.  iii.,  1884,  pp.  326  et  seq. 


TREATMENT  OF  ACUTE   URETHRITIS,    OR   GONORRHCEA.      153 

ment  to  melt  and  lubricate  the  parts.  Szaclek^  advocates  Unna's  treat- 
ment in  an  article  showing  its  scope  and  limitations. 

Casper^  has  modified  the  cup-sound,  and  uses  cylindrical  steel  sounds 
with  four  to  six  quite  deep,  narrow  grooves  about  three  inches  long,  which 
begin  about  an  inch  and  a  quarter  from  the  tip,  passing  around  the  curve 
as  far  as  the  straight  portion  of  the  instrument.  With  Unna's  instrument 
the  ointment  rarely  comes  in  contact  with  all  the  mucous  membrane 
traversed  by  the  sound.  With  the  cupped  sound  and  Casper's  sound,  if 
care  is  taken  to  wipe  off  the  instrument  smoothly  after  the  ointment  has 
been  deposited  upon  it,  a  quite  sharply-localized  application  of  the  remedy 
on  the  urethral  walls  may  be  attained. 

In  this  ointment-sound  treatment  there  is  a  combination  of  pressure 
and  dilatation,  with  a  decided  astringent  action.  Cases  must  be  carefully 
selected  upon  which  to  employ  this  treatment,  which  of  necessity  causes 
more  or  less  inflammatory  reaction.  When  there  is  much  hypersemia  with 
thickening,  or  w^here  the  morbid  process  is  quite  extensive,  the  treat- 
ment will  in  all  probability  produce  harm.  When  the  cell-infiltration  is 
considerable  and  the  condensation  of  the  mucous  membrane  well  marked, 
and  there  is  not  much  hyperemia — in  short,  in  certain  sluggish  cases — this 
treatment  may  be  of  decided  benefit.  It  should  only  be  adopted  after  a 
full  study  of  the  case,  and  it  should  be  followed  out  with  great  care  and 
watchfulness. 

Within  recent  years  great  activity  has  been  displayed  in  the  invention 
of  syringes  for  the  deposition  of  ointments  in  the  urethra  as  far  down  as 
the  bulb.  Most  authors  who  introduce  new  ointment-syringes  and  treat- 
ment speak  of  their  methods  as  being  the  rational  one,  the  inference  being 
warranted  that  they  regard  other  methods  as  irrational.  In  order  that  an 
idea  may  be  conveyed  as  to  what  we  have  already  on  hand  in  this  direction, 
I  will  give  the  chief  literature  on  this  subject,  which  may  have  the  good 
effect  of  sparing  us  any  further  additions.  All  ointment-S3a'inges  are 
modifications  of  silver  catheters,  uterine  syringes,  rectal  syringes,  and  the 
ordinary  penis-syringe.  The  simple  fact  is,  that  the  ordinary  uterine 
syringe,  with  its  long  tube,  will  do  all  that  is  needed  of  it  in  this  treat- 
ment, particularly  if  the  tube  be  bent  like  a  steel  sound. 

Tommasoli  ^  has  recently  described  a  syringe  which  is  a  combination 
of  the  penis-syringe,  at  the  end  of  which  is  a  catheter  with  the  open- 
ing on  its  end.  This  author  had  already  invented  a  syringe,  and 
had  further  modified  it  several  years  before.  The  next  inventor  was 
C.  J.  Smith,*  who  has  favored  us  with  a  modification  of  a  rectal  syringe, 
and  he  was  followed  by  Bransford  Lewis, ^  who  attached  vulcanized  soft- 
rubber  stems  to  the  ointment-box  in  order  to  produce  a  minimum  of 
irritation. 

On  old  fad  is  now  being  revived  in  the  shape  of  certain  complicated 
insuflflators  or  powder-blowers.  Rosenburg  ^  described  a  complex  instru- 
ment, called  the  "  urethral  exsiccator,"  by  which  he  throws  into  the  urethra 

^  Archivfur  Derm,  und  Syphilis,  1889,  vol.  xix.  pp.  171  et  seq. 
2  Berl  klin.  Wochenschrift,  1885,  No.  49,  p.  806. 

'  Giornale  lial.  delle  Malat.  Ven.  e  delta  Pelle,  1891,  p.  255;  also  same  journal,  1887,  p. 
270,  and  1889,  p.  283. 

*  Lancet,  Sept.  1,  1888,  p.  418. 

'"  The  Medical  Standard,  Nov.,  1889,  pp.  143  et  seq. 

*  Die  Behandlung  der  Gonorrhoe  nach  neuen  Grundsdtzen,  Berlin,  1 895  (brochure). 


154  GONORRHCEA  AND  ITS  COMPLICATIONS. 

a  powder  called  by  him  "  zymo'idin,"  which  is  composed  of  no  less  than 
seventeen  drugs  having  an  astringent  and  antiseptic  action. 

Still  another  insufflator,  rather  less  complicated  in  structure,  is  ex- 
ploited by  Schalenkamp,'  who  gives  minute  directions  for  the  deposit  by 
it  of  antiseptic  powders  in  the  urethra. 

Future  inventors  should  familiarize  themselves  with  the  mechanism  of 
these  instruments,  lest  they  find  themselves  forestalled  in  some  particular 
feature. 

Separation  of  the  Urethral  Walls  and  Drainage. — A  number  of  writers 
have  advocated  methods  of  treatment  of  gonorrhoea  the  essential  feature 
of  which  is  to  interpose  some  substance  or  instrument  in  the  urethra,  and 
thus  keep  its  walls  apart.  Since  it  is  just  as  important  that  the  young 
practitioner  should  know  what  not  to  do  in  the  treatment  of  gonorrhoea 
as  it  is  for  him  to  know  what  should  be  done,  I  will  give  an  outline  of 
these  procedures,  which  may  have  some  influence  in  deterring  others  from 
experiments  in  this  direction. 

Pitts  ^  recommends  a  method  of  treatment  at  once  unique  and  radical. 
In  order  to  "jugulate  gonorrhoea  in  its  incipiency  "  he  first  causes  the 
patient  to  urinate,  then  washes  out  the  urethra  with  warm  boiled  water, 
and  cocainizes  it  if  sensitive.  If  the  meatus  is  small,  it  must  be  cut  to 
the  full  size  of  the  urethra  to  allow  a  metallic  tube  to  be  passed  five 
inches.  Through  this  tube  a  cotton  tampon,  saturated  in  a  1  :  20,000 
bichloride  solution,  is  passed  well  down  the  urethra.  This  tampon  is  tied 
to  a  silk  thread.  Then  the  urethra  is  again  injected  through  the  tube, 
and  another  tampon  with  silk  thread  is  introduced.  Thus  he  keeps  on 
until  the  urethra  is  filled  up.  The  strings  hang  from  the  urethra,  and  by 
means  of  them  the  tampons  can  be  removed.  The  tampons  should  be  kept 
in  the  urethra  as  long  as  they  can  be  borne,  and  they  should  be  renewed 
every  seven  days.  In  11  cases  a  cure  resulted,  on  an  average,  in  twenty- 
five  days,  without  sequelae.  Nothing  is  said  about  the  interference  with 
urination  thus  induced,  nor  as  to  the  amount  of  discomfort  suiFered  by  the 
patient.  Any  one  who  has  seen  in  practising  endoscopy  of  the  urethra 
how  spasmodically  that  canal  will  contract  on  the  cotton  at  the  end  of  the 
applicator  on  some  occasions,  will  have  convinced  himself  that  tamponing 
of  the  urethral  canal  is  impracticable,  by  reason  of  the  spasmodic  condi- 
tion which  will  follow. 

McVaiP  recommends  an  open  wire  arrangement  which  is  to  be  con- 
stantly worn  by  the  patient,  "  so  that  the  discharge  may  drain  freely  away." 
His  wire  bougies  are  an  inch  and  a  half  long,  but  he  says  that  they 
may  of  necessity  have  to  be  much  longer.  We  have  already  seen  that  in 
no  case  of  acute  gonorrhoea  is  the  morbid  process  limited  to  the  first  inch 
and  a  half  of  the  urethra  longer  than  a  day  or  two ;  hence  these  short 
bougies  would  fail  of  their  purpose  even  if  the  urethra  were  sufficiently 
quiescent  to  allow  their  presence.  To  drain  the  deeper  and  bulbous  por- 
tion of  the  canal  with  these  bougies  is  a  simple  impossibility,  since  they 
would  become  so  bent  at  the  peno-scrotal  angle  that  they  would  fail 
in  aiding  drainage. 

'  "  Die  Insufflation  trockener  Pulver,  etc.,"  Monatshefte  fur  Prak.  Deimat.,  vol.  xx.,  1895, 
pp.  279  et  seq. 

2  Med.  News,  Sept.  27,  1893. 

*  Bj-itish  Med.  Journal,  March  15,  1884,  pp.  306  et  seq. 


TREATMENT  OF  ACUTE   URETHRITIS,    OR   GONORRHCEA.      155 

The  principle  of  urethral  drainage  is  carried  to  an  extreme  in  an  arti- 
cle by  B.  Foster.^  This  author  suggests  that  when  the  diagnosis  of  a 
first  gonorrhoea  is  made  the  patient  should  be  etherized,  propei'ly  pre- 
pared, and  a  button-hole  opening  made  in  the  perineum  and  bladder 
drainage  established.  Then  the  anterior  urethra  should  be  thoroughly 
irrigated  with  appropriate  solutions. 

If  we  could  obtain  the  consent  of  the  majority  of  gonorrhoics  to  this 
radical  treatment,  we  should  have  to  enlarge  our  hospital  facilities  to  an 
extreme  degree. 

The  distention  of  the  urethral  walls  and  their  separation  by  means  of  a 
mild  powder  with  antiseptic  properties  are  the  essential  factors  in  a  mode  of 
treatment  advocated  by  Pixley  and  Zeisler.^  They  use  a  rather  complicated 
instrument,  which  is  really  a  long  metallic  endoscopic  tube  with  an  obtura- 
tor and  a  hollow  spiral  made  of  wire.  After  urination  the  canal  is  flushed 
with  a  permanganate  solution  (1  :  10,000),  then  dried  by  stripping  the 
urethra.  Then  the  tube  is  introduced,  the  patient  being  on  his  back  ;  the 
obturator  is  withdrawn,  the  powder  is  put  in  the  expanded  part  of  the 
instrument,  and  the  spiral  is  then  introduced  and  twisted,  thus  carrying 
the  powder  into  the  urethra.  Boric  acid  may  be  used,  also  a  powder 
composed  of  calomel  1  part,  subcarbonate  of  bismuth  10  parts,  and  boric 
acid  12  parts.  I  gave  this  treatment  a  fair  trial,  and  found  it,  even  when 
employed  with  the  utmost  care,  discomforting  and  even  painful  to  the 
patient,  and  productive  of  no  good  whatever. 

In  the  same  line  with  the  preceding  is  the  following  method :  About 
twenty  years  ago  injections  of  water  mixed  as  thickly  as  possible  with 
clay-earth  were  much  vaunted  by  Gordon^  and  Hewson  as  an  abortive 
treatment  of  gonorrhoea.  The  effect  thus  produced  was  the  deposit  of  an 
inert  substance  in  the  urethra  which  kept  the  walls  apart.  Since  no  one 
but  its  promoters  could  obtain  beneficial  results  from  this  dirty  treatment, 
it  has  remained  unemployed  all  these  years,  and  it  is  to  be  hoped  that  it 
will  not  be  reintroduced. 

^"The  Ideal  Treatment  of  Acute  Gonorrhoea.     Is  it  Justifiable?"  Journal  of  Cutan. 
and  Gen.-urin.  Diseases.,  Sept.,  1894,  pp.  390  et  seq. 
^  Medical  Record,  Jan.  19,  1889,  pp.  64  et  seq. 
^  Am.  Journal  of  Syphilog.  and  Dermat.,  etc.,  Oct.,  1874,  p.  337. 


156  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

CHAPTER    XL 

ACUTE  POSTEKIOR  URETHRITIS,  OR  GONORRHCEA. 

It  is  now  a  well-established  fact,  as  we  have  seen  in  a  previous  chap- 
ter, that  anterior  urethritis  in  between  80  and  90  per  cent,  of  cases  within 
the  early  days  of  the  infection  passes  backward  and  involves  the  posterior 
urethra.  When  the  disease  reaches  the  bulb  of  the  urethra,  which  it 
does  within  a  few  days  in  acute  attacks,  there  is  then  an  acute  inflamma- 
tion and  profuse  suppuration  in  highly  vascular  tissues.  The  thesis  is 
then  no  longer  tenable  that  such  is  the  tonus  or  the  markedly-contracted 
condition  of  the  compressor  urethrse  muscle  that  the  lumen  of  the  urethra 
is  hair-like  in  calibre,  and  that  the  parts  are,  as  we  may  say,  so  exsan- 
guinated that  the  extension  of  the  infective  process  is  thus  prevented  or 
barred.  Such  is  not  the  case.  The  bulb  in  gonorrhoeal  inflammation 
becomes  a  profusely  suppurating  pouch,  and  from  it,  in  the  majority  of 
cases,  the  morbid  process,  by  cell-to-cell  invasion,  attacks  the  membran- 
ous and  prostatic  urethra. 

In  many  cases  the  onset  of  posterior  urethritis  is  unattended  by  any 
marked  symptoms,  and  it  is  largely  by  reason  of  this  absence  of  symp- 
toms pointing  to  the  deep  extension  of  the  trouble  that  the  opinion  was 
held  that  the  posterior  urethra  is  invaded  only  in  a  minority  of  cases. 

It  has  been  customary  to  speak  of  a  deep  burning  pain  between  the 
testes  and  in  the  perineum  as  symptomatic  of  involvement  of  the  bulbous 
urethra — a  contention  which  is  quite  correct.  But  it  is  equally  certain 
that  this  symptom  occurs  when  the  infective  process  has  invaded  the 
urethra  beyond  the  triangular  ligament.  Its  import  has,  therefore,  fre- 
quently been  misconstrued.  Acute  posterior  urethritis,  moreover,  may 
exist  and  gradually  decline  in  the  manner  and  with  the  same  symptoma- 
tology that  we  have  seen  the  infection  of  the  anterior  urethra  subside. 
In  such  cases  there  has  been  no  suspicion  of  the  invasion  of  the  canal 
beyond  the  bulb,  and  in  all  probability  the  two-glass  test  and  the  lavage 
of  the  anterior  urethra,  followed  by  the  one-  or  two-glass  test,  have  not 
been  resorted  to.  Thus  it  is  that  many  instances  of  involvement  of  the 
posterior  urethra  have  been  unrecognized. 

If  cases  of  acute  gonorrhoea  are  carefully  watched  as  to  their  symp- 
tomatology, and  the  urine  is  properly  examined,  it  will  be  found  that  in 
a  goodly  proportion  the  only  symptoms  of  posterior  urethritis  will  be 
a  slight  burning  deep  in  the  canal,  particularly  after  urinating,  and  a  very 
slight  increase  in  the  number  of  urinations.  In  many  cases  these  symp- 
toms will  only  come  to  light  as  a  result  of  the  care  and  acumen  of  the 
physician,  since  many  patients  say  nothing  about  them  or  fail  to  take 
much  notice  of  them. 

Then  there  are  other  patients  who,  when  the  discharge  is  profuse,  will 
complain  of  the  deep-seated  burning  pain  and  of  an  increased  desire  to 
make  water.  Many  of  these  cases  are  able  to  go  about  and  attend  to  their 
duties  during  the  acute  and  declining  stages  of  their  trouble,  which  is 
gonorrhoea  of  the  totality  of  the  urethra. 


ACUTE  POSTERIOR    URETHRITIS,    OR   GONORRHCEA.  157 

But  the  symptoms  most  strikingly  indicative  of  invasion  of  the  poste- 
rior urethra  are  a  diminution  in  the  amount  of  the  suppuration  or  its 
entire  cessation  (even  when  it  is  profuse  and  also  when  it  is  on  the  decline) 
and  a  decidedly  increased  desire  to  urinate.  In  some  cases  the  cessation 
of  the  discharge  so  pleases  the  patient  that  he  gives  himself  little  concern 
about  the  increased  frequency  of  urination.  In  these  cases  by  the  two- 
glass  test  the  first  and  second  specimens  of  urine  will  be  found  to  be 
opaque  and  to  contain  pus  and  tissue-elements.  If  no  complications 
develop  in  such  cases,  the  trouble  in  the  posterior  urethra  may  be  more  or 
less  severe  for  a  time ;  then  in  most  instances  the  discharge  again  appears, 
either  copious  or  rather  scanty,  at  the  meatus ;  the  patient  feels  much  re- 
lieved, and  the  case  then  behaves  like  one  of  anterior  urethritis  on  the  decline. 

In  many  cases  in  which  a  supposed  anterior  urethritis  is  declining  in 
a  satisfactory  manner  the  patient  will  present  himself  and  complain  of  a 
frequent  and  intense  desire  to  urinate,  together  with  pain  deep  down  in 
the  perineum  at  the  end  of  micturition.  By  questioning  the  patient  the 
mode  of  onset  of  his  trouble  will  be  made  clear.  He  usually  begins  by 
urinating  in  a  normal  manner,  but  at  the  end  of  the  act  he  experiences 
a  dull  pain  and  weight  in  the  perineum  or  a  short,  sharp  spasm.  This 
leads  him  to  think  that  he  has  not  evacuated  the  bladder,  and  he  then 
strains,  but  expels  no  urine,  or  at  most  only  a  few  drops,  the  passage  of 
which  causes  still  more  deeply-seated  pain.  Thus  ushered  in,  the  tenes- 
mus begins  in  varying  degrees  of  severity.  Examination  of  the  urine 
shows  cloudiness  in  both  beakers  when  the  suppuration  is  profuse,  as  it 
usually  is  in  such  cases.  This  desire  to  urinate  may  be  very  frequent 
and  imperative,  or  the  symptoms  may  be  less  pronounced.  In  some  cases 
a  patient  may  go  about,  while  in  others  he  is  forced  to  go  to  bed.  In 
severe  cases  a  further  symptom  is  added  to  the  patient's  discomfort,  and 
this  is  a  more  or  less  profuse  heematuria.  In  most  cases  the  blood  follows 
the  urine,  but  in  some  it  appears  before  it  is  all  voided.  There  may  be 
but  a  few  drops  or  the  quantity  may  be  very  profuse,  in  which  case 
Guyon's  simile  is  warranted,  in  which  he  says  the  patient  has  nose-bleed 
from  the  meatus.  In  some  of  these  cases  of  hsematuria  in  posterior 
urethritis  a  small  worm-like  mass  of  coagulated  blood  may  be  passed  in 
the  first  jet  of  urine.  This  coagulation  is  formed  in  the  intervals  of  uri- 
nation by  the  escape  of  blood  from  the  inflamed  prostatic  urethra.  At 
the  end  of  micturition  the  prostate  and  bladder  sphincters  contract  and 
squeeze  the  inflamed  and  eroded  lining  membrane,  thus  forcing  the  blood 
from  it,  as  we  by  squeezing  force  water  from  a  sponge. 

Strange  as  it  may  seem,  even  in  very  severe  and  acute  cases  there  is 
no  systemic  reaction,  there  is  no  fever,  and  there  is  no  increase  in  the 
frequency  of  the  pulse. 

There  are,  therefore,  four  well-marked  symptoms  and  conditions  of  pos- 
terior urethritis,  as  follows : 

1.  Frequent  and  intense  desire  to  urinate ; 

2.  Pain  in  glans  penis  and  perineum  at  the  end  of  urination ; 

3.  Hsematuria  (sometimes  absent) ; 

4.  Absence  of  systemic  symptoms. 

In  addition  to  the  foregoing  classical  symptoms,  there  are  two  to  which 
attention  was  directed  by  Leprdvost,^  which  are  complete  retention  and 

^  Etude  sur  les  Cystites  blennorrhacjiquei^,  Paris,  1884,  pp.  34  et  seq. 


158  GONORRHCEA  AXD  ITS  COMPLICATIONS. 

incontinence  of  urine.  Temporary  retention  may  occur  in  the  less  severe 
order  of  cases,  due  to  spasm  of  the  compressor  urethrse  muscle,  and  may 
pass  away  without  the  surgeon  having  to  resort  to  the  catheter.  Complete 
retention,  due  to  the  same  cause,  may  occur  in  severe  cases  in  which  there 
is  urethral  stricture,  hypertrophy,  or  abscess  of  the  prostate.  In  these 
cases  prompt  surgical  relief  is  sometimes  imperative. 

By  the  term  "relative  incontinence"  is  understood  a  relaxed  or  insuf- 
ficient condition  of  the  compressor  urethrge  muscle,  which  fails,  even  when 
will-power  is  exercised,  to  keep  back  the  urinary  stream.  This  condition 
is  observed  in  the  more  severe  order  of  cases.  A  sudden  impulse  to  urinate 
overtakes  the  patient,  the  bladder  contracts,  and  some  urine  is  expelled, 
perhaps  in  the  patient's  pantaloons.  Hearing  a  stream  of  water  flowing 
from  a  faucet  or  a  hydrant  or  from  a  watering-cart,  washing  the  hands, 
and  even  the  flow  of  lager  beer  from  the  tap,  sometimes  causes  in  these 
patients  vesical  contraction  and  the  escape  of  urine,  the  compressor  urethrse 
being  enfeebled  and  off'ering  little  or  no  resistance. 

Gruyon  and  Jamin  have  laid  stress  upon  the  intermittent  expulsion  of 
pus  from  the  posterior  into  the  anterior  urethra  when  the  suppuration  is 
profuse  in  the  former.  Without  any  erotic  sensation  the  patient  imagines 
that  he  has  had  a  seminal  emission,  and  he  finds  a  purulent  secretion  flow- 
ing from  the  meatus.  Guiard,^  who  has  paid  particular  attention  to  this 
point  bv  minutely  questioning  all  of  his  patients  as  to  whether  they  have 
experienced  such  excitations,  thinks  that  they  are  very  rare — a  view  with 
which  my  own  experience  is  in  accord. 

In  many  acute  cases  we  also  observe  such  symptoms  as  painless  erec- 
tions and  pollutions.  Pollutions  are  very  signiflcant  of  the  involvement 
of  the  posterior  urethra,  since  they  are  due  to  the  irritation  of  the  inflam- 
matory process  in  the  caput  gallinaginis.  Chordee  is  not  observed,  unless 
the  inflammation  still  remains  in  the  acute  stage  in  the  anterior  urethra. 

In  the  general  run  of  cases  the  increased  desire  to  urinate  only  causes 
discomfort,  and  not  much  pain.  Such  patients  generally  go  about  and 
rest  when  they  can.  In  other  cases  the  patients'  suff'erings  may  be  said 
to  be  quite  severe.  Then,  again,  we  sometimes  see  patients  thus  afilicted 
who  become  objects  of  the  most  profound  sympathy.  While  in  some 
patients  the  desire  to  urinate  may  occur  every  hour  or  so,  in  others  it 
occurs  every  half  hour  or  less.  Then  in  very  bad  cases  the  imperious 
desire  comes  every  five  minutes,  and  in  yet  worse  cases  there  is  no  inter- 
val :  the  patient  sits  over  the  chamber  the  whole  time,  groaning  and  cry- 
ing out  with  pain  and  drenched  in  a  cold  sweat,  passing  a  few  drops  at  a 
time  of  bloody  urine.  The  pain  is  usually  of  a  dull  character,  and  felt  at 
the  end  of  the  act  of  urination.  Some  patients  complain  of  pain  at  the 
end  of  the  penis  before  urination,  as  they  do  with  stone  in  the  bladder. 
This  pain  and  tenesmus  in  severe  cases  radiates  to  the  bladder,  anus, 
lumbar  region,  spermatic  cord,  and  the  hypogastrium.  Sometimes  these 
patients  also  suffer  from  cramps  in  the  legs.  In  many  cases  nocturnal 
exacerbations  ai'e  observed.  In  these  very  bad  cases  of  acute  posterior 
urethritis  the  urine  in  the  second  glass  is  more  cloudy  than  that  in  the 
first.  These  patients  seem  instinctively  to  know  that  they  suffer  less 
when  they  pass  considerable  urine ;  hence  they  drink  large  quantities  of 
water  in  order  to  dilute  the  urine  and  to  render  it  less  irritating. 
^  La  Blennorrhagie  chez  t' Homme,  Paris,  1894,  p.  251. 


ACUTE  POSTERIOR    URETHRITIS,    OR   GONORRHCEA.  159 

When  the  hemorrhage  is  very  severe  it  escapes  in  the  intervals  of 
urination  from  the  posterior  urethra  into  the  bladder,  and  then  the  first, 
and  particularly  the  second,  glass  will  be  found  to  contain  blood  as  well 
as  pus.  In  such  cases  there  is  usually  the  same  terminal  flow  of  blood 
after  urination  as  has  already  been  described. 

Albuminuria^  is  a  symptom  peculiar  to  severe  cases  of  posterior  ure- 
thritis. It  is  severe  in  proportion  to  the  intensity  of  the  tenesmus,  and  is 
said  to  be  caused  by  the  spasmodic  contraction  of  the  orifices  of  the  ureters 
by  the  detrusor  muscles  of  the  bladder,  which  dams  back  the  urine  and 
leads  to  the  escape  of  albumin  from  the  glomeruli  into  the  renal  tubules. 

It  will  be  seen  that  in  inflammation  of  the  posterior  urethra  the  symp- 
toms may  be  slight  and  insignificant,  and  they  may  be  severe,  and  even 
violent  and  atrocious.  The  duration  of  an  attack  of  posterior  urethritis 
is  very  uncertain.  In  the  milder  forms  it  may  last  weeks  and  months, 
according  to  the  care  taken  and  treatment  advised.  In  moderately  severe 
cases  one  or  more  weeks,  even  as  many  as  six,  may  elapse  before  a  condi- 
tion of  comfort  is  established,  even  when  the  treatment  is  correct  and  the 
care  of  the  patient  perfect.  In  the  most  severe  cases  the  duration  is 
indefinite.  Usually  such  a  violent  attack  lasts  two  or  more  weeks,  and 
then  amelioration  occurs  and  the  disease  becomes  less  severe. 

When  posterior  urethritis  complicates  the  condition  incident  to  hyper- 
trophy of  the  prostate,  or  when  middle-aged  or  old  men,  having  stricture 
of  the  urethra,  are  attacked  with  posterior  urethritis,  their  condition  is 
very  often  alarming  and  even  critical.  In  such  cases  the  symptoms  are 
very  severe  and  the  sufi"erings  of  the  patients  very  intense.  This  com- 
bination of  acute  and  chronic  disorder  is  the  more  dangerous  as  it  may 
lead  to  rapidly-ascending  gonorrhoea  and  an  invasion  of  the  kidneys. 

The  first  symptom  pointing  to  improvement  is  the  less  urgent  desire  to 
make  water  and  the  greater  length  of  the  intervals  of  urination.  Then 
the  local  and  radiating  pains  become  less,  and  the  patient  becomes  more 
comfortable  and  hopeful.  The  progress  toward  recovery  in  very  severe 
cases  is  usually  slow  and  may  be  interrupted  by  relapses,  which  are  often 
brought  on  by  indiscretions  of  the  patient  in  the  matter  of  alcoholic  ex- 
cesses, sexual  imprudences,  and  bodily  strains.  In  many  cases  the  disease 
ceases  to  give  the  patient  concern  and  settles  down  into  a  chronic  con- 
dition, in  which  there  may  be  no  subjective  symptoms  whatever.  In  these 
cases  the  discharge  is  small  in  quantity  and  viscid  in  consistency,  and  the 
two-glass  test  fails  to  localize  the  inflammatory  process.  Resort  to  lavage 
of  the  anterior  urethra,  however,  w^ill  show  that  the  posterior  urethra  is 
the  seat  of  chronic  inflammation. 

In  very  acute  cases  of  posterior  urethritis  the  secretion  is  purulent 
and  profuse,  like  that  of  anterior  urethritis,  and  in  it  the  gonococcus  can 
usually  be  readily  discovered.  As  the  process  grows  older  the  pus  becomes 
mixed  with  epithelial  cells  and  is  seen  in  the  form  of  threads.     It  is  very 

'  In  spite  of  many  contributions  on  the  subject  our  knowledge  of  the  pathology  of 
albuminuria  in  the  course  of  gonorrho-a  is  yet  very  limited  and  unsatisfactory.  Balzer 
and  iSouplet  in  a  recent  communication  reach  the  conclusion  that  it  is  due  to  general 
systemic  infection.  The  reader  is  referred  to  the  following  essays  by  these  authors: 
"  Note  sur  I'Albuminurie  liee  ii  la  Blennorrhagie,"  Bulletin  de  la  Societe  fran^aise  de 
Dermatologie  et  de  Syp/iilif/raphie,  vol.  ii.,  1891,  pp.  235etseq. ;  and  "  Nouvelle  Contribu- 
tion al'Etude  de  I'Albuminurie  compliquant  les  Phases  aigueN  de  la  Blennorrhagie," 
Annales  de  Derm,  et  de  Syphiligraphie,  1891,  pp.  113  etseq. 


160  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

difficult  to  find  this  micro-organism  by  means  of  the  microscope  late  in  the 
course  of  posterior  urethritis. 

Invasion  of  the  posterior  urethra  menaces  the  following  parts :  the 
verumontanum,  the  ej  aculatory  ducts,  the  ducts  of  the  seminal  vesicles,  the 
prostatic  ducts,  the  epididymis  and  testes,  the  seminal  vesicles,  and  the 
bladder.  Posterior  urethritis,  therefore,  may  be  the  starting-point  of 
various  complications,  all  of  which  are  painful  and  distressing,  and  some 
of  them  are  more  or  less  dangerous  in  their  results. 

Diagnosis. — Commonly,  the  diagnosis  of  acute  anterior  gonorrhoea  or 
urethritis  is  usually  made  by  the  patient  before  the  physician  is  consulted. 
In  some  instances,  however,  a  correct  conclusion  is  not  reached  at  the  first 
consultation.  Some  cases  of  balanitis,  in  which  the  prepuce  is  rather 
tight,  resemble  gonorrhoea,  for  the  reason  that  besides  the  discharge  the 
meatus  may  be  red  and  swollen,  and  perhaps  there  is  slight  uneasiness 
in  urination.  Retraction  of  the  foreskin  and  cleansing  of  the  parts  will 
permit  a  thorough  examination,  and  then  the  diagnosis  can  be  readily 
made.  In  those  cases  of  balanitis  in  which  the  preputial  orifice  is  very 
small,  even  of  pinhole  size,  more  difficulty  may  be  experienced.  By 
means  of  intrapreputial  injections  the  discharge  may  be  removed ;  the 
parts  then  being  dried,  slight  pressure  upon  the  urethra  from  behind  for- 
ward will  reveal  the  presence  or  absence  of  pus  in  the  canal.  By  means 
of  the  microscope  we  can  find  gonococci  in  the  pus  of  gonorrhoea,  and  it 
is  not  found  in  that  of  balanitis. 

When  the  initial  lesion  of  syphilis  is  developed  on  or  within  the  lips 
of  the  meatus,  a  slight  mucous  discharge  is  present,  and  doubt  as  to  its 
nature  may  exist  up  to  the  period  when  the  diagnosis  of  chancre  is  made. 
The  initial  lesion  may  occur  at  one  or  more  inches  down  the  canal,  and 
give  rise  to  a  discharge  which  is  usually  sero-purulent  and  scanty.  Such 
patients  complain  of  a  localized  uneasiness  and  impediment  to  urination, 
and  examination  reveals  a  circumscribed  thickening  of  the  corpus  spon- 
giosum. In  these  cases  the  endoscope  and  the  microscope  afford  much 
aid. 

Gummatous  infiltration  occurs  at  any  part  of  the  pendulous  urethra, 
and  a  scanty  sero-purulent  discharge  accompanies  its  development.  The 
absence  of  inflammatory  symptoms,  the  localization  of  the  lesion,  and  the 
history  of  the  patient  are  usually  sufficient  for  a  correct  if  perhaps  rather 
delayed  diagnosis. 

The  mucous  fluid  which  exudes  from  the  meatus  when  the  seat  of 
herpes  progenitalis  and  the  presence  of  vesicles  establish  the  case  as  not 
one  of  gonorrhoea. 

The  pus  of  chancroids  of  the  meatus  is  of  a  rusty-brown  color,  difier- 
ing  markedly  from  that  of  gonorrhoea.  The  points  in  the  diagnosis  of 
posterior  urethritis  have  necessarily  been  given  in  the  description  of  that 
condition. 

The  diagnosis  of  acute  posterior  urethritis,  it  may  be  mentioned,  is 
made  by  a  consideration  of  the  acute  attack  in  the  anterior  urethra  and 
the  typical  symptoms  of  deeper  invasion. 

Prognosis. — In  general,  the  prognosis  of  gonorrhoea  is  good,  and  a  cure 
may  be  promised  in  from  three  to  six  or  eight  weeks  if  proper  care  and 
treatment  are  used.  The  disease  is  commonly  very  obstinate  when 
acquired  before  puberty,  particularly  in  scrofulous  and  tuberculous  sub- 


ACUTE  POSTERIOR    URETHRITIS,   OR   GONORRHGEA.  161 

jects.  In  plethoric  persons,  in  high  livers,  and  those  addicted  to  drink, 
in  rheumatic  and  gouty  subjects,  gonorrhoea  is  frequently  very  persistent. 
In  those  who  are  overworked,  the  subjects  of  mental  worry,  and  those  of 
neuropathic  tendency  the  disease  is  often  very  tedious.  Even  in  healthy 
subjects,  in  many  cases,  the  inflammatory  process  is  very  rebellious,  and 
shows  a  tendency  to  become  localized  in  some  part  of  the  urethra,  and 
there  tax  the  bearer's  patience  and  the  surgeon's  skill.  By  reason  of  its 
chronicity  and  its  complications  and  sequelae  gonorrhoea  may  become  a 
serious,  dangerous,  and  even  lethal  affection ;  therefore  its  seriousness 
should  not  be  underestimated. 

Treatment  of  Acute  Posterior  Urethritis. — In  many  cases,  where  the 
totality  of  the  urethra  is  involved,  the  treatment  of  the  posterior  segment 
requires  nothing  more  than  the  regular  treatment  for  acute  anterior 
urethritis,  which  has  already  been  described. 

In  the  milder  forms  of  acute  posterior  urethritis  it  is  well  to  stop  the 
use  of  antiblennorrhagics  and  the  employment  of  injections  into  the 
anterior  urethra  if  they  give  evidence  of  producing  irritation. 

At  first,  in  the  severe  class  of  cases,  no  local  treatment  should  be  used. 
The  patient  should  be  put  to  bed  and  placed  on  a  milk  diet,  and  he  should 
take  the  alkaline  and  hyoscyamus  mixture.  His  bowels  should  be  kept 
loose  by  the  use  of  mild  cathartics.  In  many  mild  and  in  some  severe 
cases  the  following  mixture  will  produce  much  comfort. 

3^    Fl.  ext.  tritici  repent, 

Fl.  ext.  uvse-ursi,  da.  ^iss  ; 

Liq.  potassse,  §ss ; 

Tr.  opii,  gtt.  Ixiv  to  xcvj  ; 

Aquae,  ad  5iv. 

Dose,  one  teaspoonful  every  three  or  four  hours  in  a  wine-glass  of 
water.  It  is  well,  in  the  milder  order  of  cases,  to  give  laudanum  in  small 
doses  without  producing  any  heaviness  and  sleepiness,  since  it  calms  and 
soothes  the  patient  and  improves  his  morale,  which  is  sometimes  much 
disturbed  by  the  frequency  of  urination,  tenesmus,  and  hgematuria.  In 
the  very  severe  cases  hot  sitz-baths,  hot-water  bags  to  the  perineum  and 
perhaps  over  the  pubis,  together  with  tolerably  strong  suppositories  of 
morphine  and  belladonna,  may  be  used  according  to  the  indications.  In 
many  cases  warm  enemata  to  clear  the  rectum,  followed  by  an  injection 
of  cold  water,  Avill  be  very  beneficial.  It  is  a  good  rule  to  see  that  the 
bowels  are  rendered  free  once  a  day.  Patients  usually  like  large 
quantities  of  water;  therefore  Apollinaris,  Stafford,  Poland,  and  other 
waters  which  have  a  mildly  demulcent  effect  may  be  freely  allowed.  In 
these  cases  a  moderate  amount  of  alkali  is  usually  beneficial,  but  too  much 
should  not  be  given.  Therefore  Vichy  and  mineral  waters  should  not  be 
allowed  when  the  patient  is  taking  an  alkaline  mixture.  Flaxseed, 
sassafras-pith,  and  slippery-elm  teas  may  also  be  given,  moderately  sweet- 
ened and  nicely  flavored. 

As  in  anterior  so   in   posterior  urethritis,  we   should   resort  to   local 

medication  just  as  soon  as  we  can  do  so  without  discomfort  to  the  patient 

and  increase  of  the  inflammation.     It  is  well,  therefore,  to  begin  with 

irrigations  of  Avarm  boric-acid  water,  as   directed  in  the  section  on  the 

11 


162  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

Treatment  of  Acute  Anterior  Urethritis,  and  then  to  progress  in  the  ordinary 
cases  on  the  lines  laid  down  there. 

In  the  severe  cases  it  is  well  to  begin  with  nitrate  of  silver  in  much 
dilution  as  early  as  possible,  and  to  increase  the  strength  of  the  solution, 
which  should  always  be  hot,  until  it  reaches  1 :  8000  or  1 :  4000.  By 
this  time  the  tenesmus  will  be  much  lessened,  the  irritation  less  frequent, 
and  the  haematuria  less  copious.  When  these  favorable  symptoms  are 
progressing  it  is  well  to  use  caution  and  not  to  abruptly  increase  the 
strength  of  the  irrigation.  Later  on  warm  irrigations  of  alum,  of  sulphate 
of  zinc,  and  of  permanganate  of  potassa  may  perhaps  be  useful  in  giving 
the  parts  a  rest  from  the  action  of  the  nitrate  of  silver.  Under  favorable 
conditions  a  cure  is  produced. 

Under  no  circumstances  should  sounds  or  bougies  be  passed  into  the 
bladder  at  these  times,  since  very  much  harm  may  be  produced  by  them. 
In  the  declining  stage  of  these  mild  cases  the  antiblennorrhagics  in  mod- 
erate  doses  may  be  given  for  a  time,  but  they  should  never  be  pushed. 
The  fluid  extracts  of  kava-kava  and  of  buchu  are  sometimes  of  seeming 
benefit  in  the  declining  stage  of  acute  posterior  urethritis. 

In  some  very  bad  cases  in  which  the  tenesmus  is  dreadful  in  its 
severity  and  the  hsematuria  is  copious,  when  other  methods  of  treatment 
have  failed  to  give  relief,  very  often  results  little  less  than  miraculous 
will  be  produced  by  the  instillation  (see  section  on  Treatment  of  Chronic 
Urethritis)  of  a  few  drops  of  a  solution  of  nitrate  of  silver ;  1 :  1000  or 
1 :  500  may  be  given,  care  being  taken  that  the  urethra  is  not  harmed  by 
the  passage  of  the  catheter.  In  using  this  treatment  it  is  well  to  be  very 
careful  to  throw  up  only  a  few  drops  at  first,  and  then  watch  the  result. 
If,  as  sometimes  happens,  the  patient's  sufferings  are  calmed,  on  the  next 
day  or  on  the  second  day  an  injection  of  a  larger  quantity  may  be  admin- 
istered. Usually  in  these  cases  good  will  be  produced  by  the  1 :  500 
solution,  and  caution  should  be  exercised  in  going  higher  than  that  stand- 
ard. When  the  crisis  is  Avell  over,  mild  boric-acid  irrigation  may  be 
given,  and  further  than  that  the  cases  should  be  treated  according  to  the 
directions  given  in  this  chapter  and  in  that  on  the  treatment  of  acute 
anterior  urethritis.  When  there  is  bladder  complication  in  these  cases  the 
treatment  is  in  the  main  similar.  (See  chapter  on  Urethro-cystitis  and 
Cystitis.) 

In  middle-aged  and  old  men  with  stricture  and  prostatic  hypertrophy 
we  sometimes  see  acute  anterior  and  posterior  urethritis.  In  these  cases 
the  sufferings  are  very  great,  and  they  are  much  intensified  by  the  chronic 
impediments  to  urination.  In  some  cases  I  have  had  to  resort  to  aspira- 
tion until  the  severity  of  the  urethral  symptoms  had  subsided ;  then  I 
went  on  with  the  usual  local  treatment  as  soon  as  I  could  get  into  the 
bladder  with  a  very  small  catheter.  Each  case  of  this  kind  will  present 
its  special  features,  which  should  govern  the  surgeon  in  his  efforts  for 
relief. 


URETHRITIS  IN  YOUNG  BOYS.  163 

CHAPTER    XII. 

URETHRITIS   IN  YOUNG  BOYS. 

Until  within  recent  years  our  knowledge  of  urethral  discharges  in 
male  infants  and  young  boys  was  very  vague,  and  all  cases  thus  affected 
were  regarded  by  writers  on  venereal  diseases,  surgery,  and  pediatrics  as 
evidences  of  catarrhal  urethritis.  To-day,  though  there  are  many  points 
still  unsettled,  our  knowledge  is  much  broader  and  more  precise.  Pre- 
vious to  the  year  1885  attention  had  not  been  drawn  to  the  possibility 
of  acute  suppuration  in  the  urethrse  of  young  male  children  originating 
in  gonorrhoeal  pus.  Up  to  that  date  the  underlying  causes  of  this  ure- 
thritis in  the  young  were  said  to  be  masturbation,  friction  of  the  clothes, 
mechanical  and  chemical  irritants  (foreign  bodies  in  the  urethra,  catheters, 
the  passage  of  vesical  and  renal  calculi  and  urine  containing  an  excess 
of  uric  acid),  and  certain  skin  diseases — pediculosis,  scabies,  and  eczema. 
There  can  be  no  doubt  that  chronic  masturbation  may  cause  a  subacute 
urethritis,  but  this  as  a  cause  cannot,  as  a  rule,  be  assigned  in  the  cases 
of  babies  in  arms.  The  various  irritants  and  traumatisms  above  men- 
tioned may  produce  a  urethritis,  but  its  course,  like  that  of  the  analogous 
condition  in  the  adult,  will  be  subacute  and  its  duration  short. 

This  being  the  condition  of  medical  opinion  prior  to  1885,  new  light 
was  thrown  on  the  subject  by  Cseri^  of  Buda-Pesth  in  a  paper  which  may 
be  said  to  be  the  starting-point  of  our  present  broader  views.  Cseri  re- 
ported the  cases  of  two  boys,  aged  four  and  five  years,  who  had  a  profuse 
purulent  discharge.  Though  the  parents  of  these  children  were  informed 
of  the  infectiousness  of  the  disease,  a  fortnight  later  they  brought  an  eight- 
year-old  girl  to  Cseri  suffering  from  purulent  vulvo-vaginitis.  In  speci- 
mens of  the  discharge  taken  from  these  cases  a  micro-organism  exactly 
similar  in  all  particulars  to  the  gonococcus  was  found.  ,  Cseri  therefore 
claimed  the  infectious  nature  of  these  cases.  Though  Cseri's  conclusions , 
have  been  confirmed  by  Rdna,^  and  though  there  is  ample  evidence  to-day 
that  there  is  a  not  infrequently  occurring  purulent  urethritis  of  infectious 
character  in  young  male  children,  we  must  not  now  go  to  the  extreme  in 
saying  that  all  urethral  suppurations  in  these  young  subjects  are  of  gon- 
orrhoeal origin. 

My  own  experience  leads  me  to  confirm  the  statement  made  by  Kop- 
lik,^  that  there  is  a  simple  non-specific  (certainly  as  to  its  origin)  inflam- 
mation of  the  meatus  and  the  anterior  portion  of  the  urethra.  I  have 
seen  cases  in  which  a  mild  urethritis  of  the  distal  part  of  the  penis  orig- 
inated in  balano-posthitis  resulting  from  great  uncleanliness.  In  like 
manner  the  hypergemia  caused  by  pediculosis,  scabies,  and  eczema  of  the 
penis  and  glans  may  cause  a  mild  form  of  purulent  urethritis  in  children, 

^  "  Zur  Aetiologie  der  Infecticisen  Vulvo-vaginitis  bei  Kindern,"  Wien.  med.  Wochen- 
schr.,  vol.  XXXV.,  1885,  pp.  707-739. 

^  "  Ueber  Aetiologie  und  Wesen  der  '  Urethritis  Catarrhalis '  der  Kinder  Milnnlichen 
Geschlechtes,"  Archiv  filr  Derm,  und  Syph.,  1893,  pp.  149  et  seq. 

*  "  Urogenital  Blennorrhcea  in  Children,"  Journ.  Cut.  and  Gen.  Diseases,  1893,  pp.  263 
et  seq. 


164  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

as  they  do  in  the  adult.  Koplik  thinks  that  in  the  act  of  crawlinoj  chil- 
dren may  get  filth  on  these  organs,  and  from  this  infection  may  result. 
I  have  several  times  seen  in  boys  from  ten  to  thirteen  years  old  well- 
marked  subacute  urethritis  concomitant  with  balano-posthitis  which 
originated  in  efforts  to  retract  the  prepuce  for  the  first  time  and  to  break 
up  adhesions.  In  these  cases  dirt,  retained  smegma,  and  urine  undoubt- 
edly played  a  prominent  causative  part. 

The  symptoms  of  mild  urethritis  in  young  male  children  are  heat, 
swelling,  pain  on  urination,  and  a  scanty  purulent  discharge.  This  secre- 
tion may  become  encrusted  on  the  glans  or  meatus,  and  when  the  crusts 
are  removed  a  superficially  eroded  surface  may  be  left. 

The  course  of  this  disease  is  tolerably  mild  and  its  duration  short,  pro- 
vided the  exciting  causes  are  removed. 

Gonorrhoeal  urethritis  in  infants  and  young  boys  is  not  infrequently 
met  with,  particularly  in  the  lower  classes  of  society  living  in  localities 
where  children  are  closely  herded  together  with  adults.  The  disease  is 
found  in  an  endemic,  quasi-epidemic,  and  sporadic  form. 

Little  is  known  as  to  the  very  early  stages  of  this  infection,  and 
there  are  no  reliable  facts  as  to  the  period  of  incubation. 

The  symptoms  are  similar  to  those  of  acute  gonorrhoea  in  the  male. 
The  disease  begins  violently  in  heat,  redness,  and  swelling  of  the  penis, 
from  which  there  is  a  profuse  discharge  of  pus.  The  morbid  process 
begins  in  the  fossa  navicularis,  and  promptly  runs  down  to  the  bulb  and 
into  the  posterior  urethra.  There  is  pain  on  urination,  besides  constant 
burning  sensation  in  the  urethra,  and  there  may  be  painful  nocturnal 
erections.  In  the  early  stage,  by  the  two-glass  test,  the  urine  is  found  to 
be  turbid  in  the  first  cylinder  and  clear  in  the  second.  But  in  most  cases 
the  posterior  urethra  becomes  involved,  and  then  the  urine  in  both  cylin- 
ders is  turbid.  With  the  invasion  of  the  posterior  urethra  the  symptoms 
resemble  those  of  the  adult  similarly  attacked.  There  is  tenesmus,  which 
which  may  be  very  severe  and  occur  as  often  as  every  quarter  of  an  hour 
in  bad  cases.  In  milder  cases  the  desire  to  make  water  may  occur  every 
hour  or  at  longer  intervals.  Sometimes  mild  and  even  severe  hemorrhage 
may  occur  at  the  end  of  the  act  of  urination.  This  disease  runs  the  same 
persistent  and  rebellious  course  in  the  young  that  it  does  in  the  adult,  and 
one  or  more  months  may  elapse  before  cure  is  effected. 

The  complications  may  be  balano-posthitis,  lymphangitis,  epididymitis, 
orchitis,  and  vaginalitis.  In  some  cases  chronic  posterior  urethritis  is  a 
result. 

The  virulent  form  of  urethritis  in  the  young  may  lead  to  stricture  of 
the  urethra.  Rona  reports  two  such  cases.  In  one,  a  boy  aged  seven- 
teen, the  stricture  probably  began  in  an  infection  at  the  age  of  ten.  The 
second  case  was  that  of  a  medical  student  of  twenty-one,  who  also  was 
infected  in  his  tenth  year.  It  is  very  probable  that  to  virulent  urethritis 
occurring  in  early  life  may  be  attributed  many  of  the  cases  of  stricture  in 
boys  and  young  men  in  whom  a  history  of  recent  gonorrhoea  cannot  be 
obtained. 

Etiology. — Enough  has  already  been  said  of  the  probable  causes  of 
mild  catarrhal  urethritis  in  young  male  subjects.  It  is  often  difficult,  and 
even  impossible,  to  ascertain  the  cause  and  mode  of  origin  of  virulent  gon- 
orrhoea in  the  infant  under  two  years  of  age,  but  the  facts  presented  by 


CHRONIC   URETHRITIS,    OR   GONORRHCEA.  165 

most  cases  warrant  the  opinion  that  the  child  had  been  tampered  with  by 
an  older  person  and  thus  infected.  Since  intromission  of  the  organ  is  not 
absolutely  necessary  for  infection,  it  is  probable  that  in  some  of  these 
cases  depraved  women  suffering  from  gonorrhoea  place  the  child's  penis 
in  their  vulva.  Such  instances  have  been  known.  Rdna  records  four- 
teen cases  of  virulent  urethritis  in  young  boys,  and  others  can  be  found 
in  medical  literature,  in  some  of  which  the  infection  was  derived  from  an 
infected  female  child  or  young  girl.  Then,  again,  the  disease  has  appeared 
among  a  number  of  boys  without  the  aid  of  a  female,  and  OAving  to  their 
ignorance,  indisposition  to  talk,  or  to  their  persistent  lying  the  mode  of 
origin  has  not  been  learned.  Crandall  ^  reports  the  cases  of  a  brother  six 
and  a  sister  eight  years  old  who  suffered  from  gonorrhoea.  The  sister 
claimed  that  she  was  contaminated  by  her  brother,  while  the  latter  asserted 
that  the  girl  infected  him,  and  that  she  had  been  infected  by  a  young  man. 
Usually,  then,  in  these  cases  of  precocious  depravity  there  is  much  diffi- 
culty in  learning  their  origin ;  in  some,  however,  the  boys  are  shameless 
and  barefaced,  and  readily  and  sometimes  proudly  assert  that  they  were 
contaminated  by  a  girl. 

Treatment. — Simple  catarrhal  urethritis  will  promptly  cease  by  the 
exercise  of  cleanliness  and  the  use  of  a  mild  lead  injection.  The  treat- 
ment of  virulent  urethritis  of  male  infants  and  young  boys  should  be  that 
laid  down  for  adults.  The  doses,  however,  should  be  adjusted  to  the 
patient's  age,  and  the  strength  of  the  injections  should  be  tempered  in 
accord  with  the  greater  delicacy  of  the  young  suff"erer's  tissues. 


CHAPTER   XIII. 

CHRONIC  URETHRITIS,   OR  GONORRHCEA,  ANTERIOR  AND 

POSTERIOR. 

In  the  terminal  stage  of  gonorrhoea  the  inflammatory  process  in  very 
many  cases  becomes  localized  in  some  part  of  the  urethra,  and  there 
remains  in  a  latent  or  dormant  state.  There  are  a  number  of  conditions 
which  tend  to  render  the  course  of  gonorrhoea  chronic.  In  the  first  place, 
there  is  the  natural  tendency  of  the  disease  to  linger  indefinitely  in  the 
tissues.  As  we  have  already  seen,  gonorrhoea  is  not  a  simple  superficial 
catarrhal  condition,  but  a  strongly-marked  exudative  and  catarrhal  inflam- 
mation which  is  very  rebellious  to  our  best-directed  eff"orts  in  treatment. 
Then,  again,  many  patients  consider  themselves  cured  just  as  soon  as  the 
discharge  ceases,  and  will  submit  to  no  further  treatment,  though  exami- 
nation of  the  urine  shows  the  presence  of  tissue-exudates.  Another  and 
a  prolific  cause  of  chronic  gonorrhoea — or  gleet,  as  it  is  called — is  sexual 
and  alcoholic  indulgence  during  the  decline  of  the  chronic  stage.  Still 
another  cause  of  the  indefinite  perpetuation  of  the  disease  is  a  too  active 
1  New  York  Med.  Joiirn.,  April,  26,  1890. 


166  GONOBBHCEA  AXD  ITS  COMPLICATIONS. 

and  protracted  treatment,  either  by  antiblennorrhagics  or  injections,  or  by 
both  combined.  Many  an  obstinate  gleet  has  thus  been  induced  by  the 
intemperate  use  of  drugs. 

It  is  out  of  the  question,  in  the  vast  majority  of  cases,  to  induce 
patients  suffering  from  gonorrhoea  to  spare  their  physical  forces.  This 
is  particularly  the  case  in  the  declining  stage.  In  the  better  class  of 
intelligent  patients  we  can  in  many  instances  control  them  to  a  certain 
extent,  and  cause  them  to  avoid  athletic  exercises,  horseback  riding,  bi- 
cycling, and  other  violent  exercise.  Among  working-men,  wage-earners, 
however,  the  daily  necessities  demand  the  daily  toil,  and  in  many  of 
these  cases  the  physical  exercise  tends  to  cause  gonorrhoea  to  become 
chronic.  The  tissues  of  some  subjects  are  more  vulnerable  than  those 
of  others;  this  particularly  applies  to  weak,  debilitated  subjects,  the  scrof- 
ulous, and  the  tuberculous. 

In  former  years  gleet,  also  called  goutte  militaire,  was  looked  upon  as 
a  chronic  inflammatory  process  seated  in  some  portion  of  the  anterior 
urethra.  Its  symptoms  are  the  morning  drops — the  pus-accumulation  of 
the  night — which  may  be  small  in  quantity  and  greenish-white  in  color. 
There  may  be  a  minute  drop,  a  large  pea-sized  drop,  or  three  or  more 
drops.  In  other  cases  there  is  simply  gluing  of  the  lips  of  the  meatus 
together,  on  the  separation  of  which  a  film  of  glairy  muco-pus  is  seen. 
In  other  cases  there  is  not  sufiBcient  secretion  to  produce  a  drop.  In  a 
third  class  of  cases  there  is  simply  increased  moisture  at  the  meatus,  and 
a  scanty  colorless  secretion,  like  glycerin,  may  be  forced  out  by  a  little 
pressure. 

It  is  well  to  mention  that  some  ovei'-anxious  patients,  who  in  time 
past  have  suffered  from  gonorrhoea,  alarmed  about  themselves,  come  to  the 
surgeon,  stand  before  him.  and  by  firm  pressure  and  milking  of  the  glans 
and  meatus  cause  to  exude  a  slight  clear  mucous'  secretion,  which  they 
think  is  gleet.  In  very  many  instances  their  only  trouble  is  the  hyper- 
aemia  induced  by  their  own  violent  manipulations,  which  result  in  a  slight 
increase  of  the  normal  mucus. 

There  can  be  no  doubt  that  in  most  cases  of  the  morning  drop  there 
is  an  inflammatory  focus  in  the  anterior  urethra,  but  it  does  not  by  any 
means  follow  that  the  posterior  urethra  is  healthy,  since  it  is  frequently 
the  more  active  focus  of  trouble.  In  former  years  gleet  meant,  in  general 
terms,  chronic  anterior  urethritis,  and  the  treatment  was  based  on  that 
diagnosis.  To-day  we  know  that  chronic  gonorrhoea  of  the  posterior 
urethra  is  a  quite  common  affection,  and  that  it  may  exist  alone  or  in 
combination  with  localized  anterior  urethritis. 

Chronic  gonorrhoea  or  urethritis,  then,  may  be  seated  in  some  part  of 
the  pendulous  urethra,  particularly  at  the  peno-scrotal  junction  or  anterior 
to  it,  in  the  bulbous  portion,  and  in  the  posterior  urethra.  A  frequent 
combination  is  -posterior  urethritis  with  inflammation  of  the  bulbous 
urethra.  Chronic  inflammation  of  the  urethra  at  the  peno-scrotal  junc- 
tion may  exist  alone  or  in  combination  with  posterior  urethritis. 

There  are  certain  features  of  these  localized  forms  of  chronic  urethritis 
which  demand  mention. 

In  general  terms  it  may  be  said  that  the  morning  drop  is  indicative  of 
trouble  in  the  pendulous  urethra,  the  secretion  of  which  flows  toward  the 
meatus   during  the   night.     During   the   day  the   secretion  may  not   be 


CHRONIC  URETHRITIS,   OR   GONORRHCEA.  167 

noticeable,  owing  to  the  quite  frequent  flushing  of  the  urethra  by  the 
urine.  In  some  cases  the  lips  may  be  glued  together  during  the  day 
by  the  scanty  secretion  which  gravitates  downward  in  the  intervals  of 
urination. 

In  many  of  these  cases  of  chronic  anterior  urethritis  all  discharge 
ceases  to  be  seen  at  the  meatus,  and  the  true  state  of  affairs  can  only  be 
ascertained  by  the  examination  of  the  urine,  or  by  the  use  of  the  endo- 
scope. If  distinctly  limited  to  the  anterior  urethra,  the  urine  in  the  first 
glass  will  contain  threads  or  masses  of  tissue-products,  and  that  in  the 
second  glass  will  be  clear.  In  all  cases,  however,  the  examination  should 
be  pushed  still  farther :  the  anterior  urethra  should  be  carefully  and  fully 
irrigated,  and  then  the  urine  should  be  passed  into  one  or  two  glasses. 
In  the  fluid  which  has  been  used  in  irrigation  will  be  found  the  products 
of  inflammation  of  the  anterior  urethra,  and  in  the  first  glass  those  of  the 
posterior  urethra  if  it  is  the  seat  of  inflammation. 

In  the  bulbous  urethra  the  gonorrhoeal  process  shows  a  marked  tend- 
ency to  become  chronic,  and  its  persistency  causes  it  to  be  very  rebel- 
lious to  treatment.  In  this  part  of  the  urethra  the  vascular  supply  is  so 
great,  the  tissues  are  so  succulent,  and  we  may  say  relaxed,  that  every 
condition  favorable  to  chronic  inflammation  is  there  present. 

Chronic  urethritis  of  the  bulbous  urethra  may  give  rise  to  no  secretion 
visible  at  the  meatus.  Then,  again,  the  pus  may  be  so  copious  and  fluid 
in  consistence  that  it  may  glue  up  the  meatus  in  the  morning  and  perhaps 
during  the  day,  or  may  escape  once  a  day  or  oftener  as  a  decided  drop. 
Owing  to  the  fact  that  the  bulbous  portion  is  in  direct  continuity  with  the 
membranous  urethra,  this  portion  may  be  the  seat  of  hypergemia  or  in- 
flammation in  bulbous  urethritis.  In  these  cases  washing  out  the  anterior 
urethra,  and  then  examining  the  urine  passed  in  a  vessel,  may  not  give 
exact  information  as  to  the  seat  of  the  lesion.  In  this  event  the  parts 
may  be  examined  by  means  of  the  endoscope,  which  should  be  used  with 
great  delicacy  and  as  little  backward  and  forward  motion  as  possible. 
In  this  way  the  seat  of  the  affection  may  be  definitely  ascertained. 

A  chronic  discharge,  usually  small  in  amount  and  viscid  in  consistence, 
may  be  developed  as  a  result  of  chronic  gonorrhoeal  inflammation  of  the 
glands  of  Littre  and  the  crypts  of  Morgagni.  In  these  cases  the  lacuna 
magna  and  other  large  follicles  may  be  the  seat  of  inflammation.  Chronic 
follicular  urethritis  is  usually  uncomplicated  with  posterior  urethritis.  It 
is  found  on  the  lips  of  the  meatus,  just  within  that  orifice,  and  as  far  down 
as  the  bulb. 

Chronic  inflammation  of  Cowper's  glands  has  been  known  to  cause 
a  discharge  into  the  urethra  which  Avas  intermittent  in  character.  In 
some  cases  of  chronic  anterior  urethritis  the  patient  suffers  no  inconve- 
nience whatever.  In  a  few  cases  the  patients  complain  of  pain  localized 
at  some  part  of  the  urethra. 

Chronic  posterior  urethritis  follows  in  many  cases  the  subsidence  of 
the  acute  process.  Owing  to  the  complexity  of  structure  of  the  posterior 
urethra  the  symptomatology  of  this  affection  is  often  quite  well  marked. 
When  there  is  simply  uncomplicated  chronic  inflammation  of  the  mucous 
membrane  the  symptoms  may  be  negative  or  very  slight  in  character. 
But  when  the  prostatic  sinuses,  the  orifices  of  the  ejaculatory  ducts,  the 
utriculus   masculinus,   and   the   caput   gallinaginis   are,  together   or   in 


168  GONORBHCEA   AND  ITS  COMPLICATIONS. 

part,  the  seat  of  trouble,  we  find  a  varied  group  of  symptoms  referable 
to  the  sexual  sphere. 

In  chronic  urethritis  distinctly  limited  to  the  posterior  urethra  there 
is  usually  no  escape  of  pus  into  the  anterior  portion,  for  the  reason  that 
it  is  small  in  quantity  and  viscid  in  consistency.  There  are,  however, 
border-line  cases  in  the  extreme  terminal  stage  of  the  acute  affection 
in  which  the  pus  is  still  rather  copious,  and  it  escapes  through  the  mem- 
branous urethra  and  passes  toward  the  glans.  We  have  already  seen 
that  the  compressor  urethras  muscle  does  not  usually  contract  the  lumen 
of  the  urethra  to  a  hair-sized  calibre,  and  that  in  general  it  is  a  mode- 
rately patulous  canal  at  this  point.  There  certainly  is  not,  in  the 
majority  of  cases,  such  a  tonicity  of  the  compressor  urethrse  muscle  as 
will  keep  back  a  quite  copious  discharge.^  While  in  many  cases,  owing 
to  its  small  quantity,  the  pus  may  be  retained  in  the  posterior  urethra 
by  the  cut-off  muscle,  in  some  cases  it  certainly  is  not  thus  dammed 
backward.  The  cases  of  chronic  posterior  urethritis  in  which  a  discharge 
reaches  the  meatus  are  very  rare,  but  they  occur. 

In  very  many  cases  of  posterior  urethritis,  there  being  no  visible 
discharge  and  the  patients  complaining  of  no  symptoms  referable  to  the 
deep  urethra,  the  affection  remains  dormant,  latent,  and  unrecognized. 
Thus  the  cases  may  drag  on  for  one  or  more,  and  even  five,  ten,  and 
twenty,  years  without  giving  any  indication  of  lurking  trouble.  In  some 
of  these  cases  an  exacerbation  occurs,  and  then  the  patient  realizes  that 
he  has  had  an  uncured  gonorrhoea. 

In  some  instances  the  exacerbation  of  the  posterior  urethritis  is  sub- 
acute in  character,  attended  only  with  mild  or  insignificant  symptoms, 
and  its  presence  would  not  be  suspected  or  sought  for  had  not  an  attack 
of  epididymitis  or  epididymo-orchitis  developed  as  a  complication.  In 
many  cases  of  this  deep-seated  urethritis,  in  which  epididymitis  or  epi- 
didymo-orchitis was  developed  in  the  initial  attack,  recrudescences  in 
the  testicular  trouble  are  frequently  developed  at  late  and  remote  periods 
as  a  result  of  an  exacerbation  in  the  posterior  urethra. 

In  somewhat  rare  instances  chronic  posterior  urethritis,  usually  as 
a  result  of  excesses,  becomes  developed  into  a  true  acute  attack  with  all 
its  symptoms  and  its  discomforts.  It  may  thus  run  its  course,  but  in 
some  cases  the  inflammatory  process  extends  forward  into  the  anterior 
urethra,  which  also  becomes  the  seat  of  an  acute  phlegmasia.  In  these 
cases,  when  the  discharge  is  well  established  in  the  anterior  urethra, 
the  sufferings  of  the  patient,  experienced  when  the  posterior  segment 
alone  was  affected,  cease,  and  the  case  then  takes  on  the  features  of 
a  gonorrhoea  of  the  totality  of  the  urethra  in  its  declining  stage. 

What  has  already  been  said  as  to  the  means  of  recognizing  the  exist- 
ence of  acute  posterior  urethritis  applies  with  equal  force  to  the  diagno- 
sis of  the  chronic  affection.  In  this  connection  it  is  well  to  remember 
that  small  comma-like  fleecy  plugs  or  threads,  which  are  thought  to  be 
formed  in  the  excretory  ducts  of  the  prostatic  glands  and  voided  with 
the  last  drops  of  urine,  being  pressed  out  by  muscular  and  prostatic 
contraction,  are  quite  diagnostic  of  chronic  posterior  urethritis. 

*  This  is  well  shown  in  some  cases  of  chronic  prostatorrhoea  in  which  the  mucus 
constantly  dribbles  from  the  meatus,  and  of  which  patients  make  much  complaint. 


CHRONIC  URETHRITIS,   OR   GONORRHCEA.  169 

The  symptoms  of  chronic  posterior  urethritis  are  many  and  varied, 
mild  and  severe. 

This  affection  was  formerly  rather  vaguely  understood,  and  to  it  the 
names  neuralgia  of  the  bladder,  neuralgia  of  the  neck  of  the  bladder, 
irritability  of  the  bladder,  cystite  du  coi,  and  contracture  du  col  de  la 
vessie  have  been  given.  In  the  light  of  modern  study  all  these  names 
may  be  dispensed  with,  and  the  term  "chronic  posterior  urethritis" 
may  be  retained. 

Cases  of  this  affection  may  be,  for  purposes  of  study,  separated  intO' 
groups  according  to  the  nature  and  severity  of  their  symptoms. 

There  is  found  in  practice  a  goodly  number  of  cases  in  which  a  fre- 
quent desire  to  urinate  and  some  uneasiness  at  the  end  of  the  act,  and 
sometimes  at  its  beginning,  are  the  only  symptoms  complained  of.  In 
some  of  these  cases  the  increased  frequency  in  urination  is  not  much 
above  normal ;  in  others  it  is  well  marked.  In  some  cases  the  pain  is 
slight  and  dull,  or  of  a  quick,  stabbing,  but  very  ephemeral  character. 
In  others  it  is  dull,  heavy,  perhaps  spasmodic,  and  radiates  into  the- 
rectum,  pelvis,  testes,  and  groins.  In  these  cases  the  act  of  urination 
may  go  on  smoothly,  or  it  may  be  interrupted  by  slight  or  severe  spasm 
of  the  compressor  urethree  muscle  or  of  the  detrusor  vesicae  muscles. 
This  condition  has  been  called  "  cysto-spasmus."  It  is  liable  to  occur 
after  coitus  or  difficult  defecation.  In  other  cases  there  is  no  disturb- 
ance of  urination  at  all,  but  patients  complain  of  dull  or  aching  pain 
in  the  perineum,  deep  in  the  pelvis  and  prostate,  and  in  the  rectum. 
Sometimes  these  patients  complain  of  pain  over  the  pubis  and  of  uneasy, 
vague  pains  in  the  cord  and  testes.  In  some  cases  mild  and  even  severe 
neuralgic  pains  are  complained  of  in  the  loins,  groins,  and  thighs. 
(These  painful  symptoms,  particularly  when  severe,  are  fortunately  not 
continuously  present.)  They  vary  from  day  to  day,  so  that  the  patient 
has  intervals  of  comparative  comfort. 

Perhaps  the  most  serious  and,  for  the  physician,  trying  cases  of 
posterior  urethritis  are  those  in  which  there  is  some  disturbance  of  the 
sexual  function.  Some  patients  complain  of  a  severe  stabbing  pain  at 
the  moment  of,  or  after,  ejaculation  of  the  semen.  Others  state  that  all 
pleasurable  sensations  are  either  absent  or  lessened  in  degree  in  sexual 
intercourse,  and  they  are  thereby  much  worried.  In  still  other  cases- 
the  ejaculations  occur  before  intromission  or  shortly  afterward. 

In  some  cases  pollutions  are  frequent,  and  Avith  their  occurrence  a 
diminution  in  the  sexual  appetite  is  felt.  Many  of  the  patients  become 
weak,  nervous,  and  apprehensive.  Their  digestion  becomes  poor,  and 
they  suffer  from  constipation.  Then  the  passage  of  a  hard  fecal  plug 
presses  on  the  prostate  and  expels  the  accumulated  muco-pus,  which 
appears  at  the  meatus,  causing  the  patient  to  think  he  is  losing  semen. 
In  some  of  these  cases  some  of  the  secretion  of  the  seminal  vesicles  is 
at  the  same  expelled,  and  this  also  to  many  is  convincing  proof  that 
they  are  suffering  from  spermatorrhoea.  Occasionally  these  patients  are 
much  alarmed  at  the  occurrence  of  bloody  pollutions,  which  are  due  to 
great  hyperaemia  of  the  ejaculatory  ducts.  In  any  of  these  cases  of 
disturbance  of  the  sexual  function  Ave  are  liable  to  find  more  or  less 
deterioration  of  the  health.  This  may  consist  simply  of  weakness  and 
lassitude,  and  it  may  be  a  condition  of  great  nervousness,  of  melancholia,. 


170  GONORRHOEA  AND  ITS  COMPLICATIONS. 

or  even  of  true  neurasthenia.  Between  these  two  extremes  there  are 
many  degrees  of  bodily  and  mental  debility. 

The  pathological  appearances  of  chronic  urethritis  are  quite  varied, 
and  in  the  main  striking. "  So  little  is  shown  by  the  ocular  examination 
of  post-mortem  specimens  of  urethrge  the  seat  of  chronic  trouble  that 
the  details  will  not  be  given,  particularly  as  the  minute  pathological 
changes  have  already  been  described. 

By  the  use  of  the  endoscope  the  morbid  appearances  of  the  urethra 
-are  well  shown.  In  general  it  may  be  said  exploration  of  the  urethra 
by  the  endoscope  should  be  confined  to  the  anterior  urethra,  which  may 
thus  be  examined  without  damage  and  detriment  to  the  patient.  The 
•condition  of  the  posterior  urethra  can  be  so  well  determined  by  the 
■examination  of  the  urine  and  by  rectal  exploration  of  the  prostate,  and 
in  many  cases  by  a  consideration  of  the  symptoms,  that  endoscopy, 
■which  is  (except  to  skilled  experts)  a  difficult  procedure  and  often  fol- 
lowed by  local  injury,  should  only  exceptionally  be  resorted  to. 

Chronic  urethritis  of  the  follicles  shows  itself  in  small  deep-red  pus- 
oozing  spots  of  the  size  of  a  pinhead  to  that  of  a  pea.  The  lacuna 
magna  and  similar  crypts  may  thus  show  evidence  of  inflammation  or 
the  orifices  of  the  follicles  of  Littre  may  be  involved. 

The  most  constant  morbid  condition  seen  in  chronic  anterior  urethritis 
is  a  rather  deep-red,  even  purplish,  color  of  the  mucous  membrane,  which 
is  more  or  less  thickened.  This  redness  may  involve  a  segment  of  the 
canal  or  a  limited  portion  on  one  or  two  sides  of  the  canal.  In  these 
cases  more  or  less  pus,  thin  or  inspissated,  may  be  seen  in  the  examina- 
tion. Thickened  red  circumscribed  spots  or  plaques  of  chronic  inflam- 
mation are  very  common.  The  next  appearance  quite  commonly  seen 
is  called  by  some  granular  urethritis.  The  membrane  is  thickened,  red, 
■even  purplish  in  streaks,  and  rough  and  studded  with  small  projections, 
which  consist  either  of  epithelial  hyperplasia  or  of  little  eminences 
caused  by  the  growth  of  new  capillary  vessels.  This  condition  is  fre- 
quently found  in  the  bulbous  urethra  and  also  in  the  pendulous  portion. 

A  further  advanced  form  of  this  granular  urethritis  is  called  papillo- 
matous urethritis,  in  w^hich  minute  but  distinctly  defined  raspberry-like 
masses  of  new  growth  are  scattered  over  a  segment  of  the  canal.  In 
3ome  cases  there  may  be  but  one  tuft  of  papilloma,  and  in  others  there 
may  be  many  such.  These  little  new  growths  are  formed  of  round-cell 
infiltrations,  new  capillaries,  and  epithelial  hyperplasia.  They  are  usually 
found  a  foAV  inches  from  the  meatus  and  as  far  down  as  the  bulbous 
expansion  of  the  urethra.  Since  the  most  careful  passage  of  a  soft 
bougie  or  catheter  in  cases  of  papillomatous  urethritis  will  often  cause 
slight  bleeding,  the  occurrence  of  this  symptom  may  lead  to  a  suspicion 
■of  its  cause. 

Erosions  and  ulcerations  of  the  urethra  are  frequentl}'-  the  cause  of 
chronic  urethritis.  In  the  erosive  form  the  mucous  membrane  is  thick- 
ened and  red,  and  in  spots  the  epithelium  is  seen  to  be  lost.  Ulcers  of 
the  urethra  are  usually  small  and  sharply  limited,  and  the  evidence  of 
loss  of  tissue  can  be  clearly  made  out.  The  erosive  form  and  the  ulcer- 
ative form  of  chronic  urethritis  may  coexist,  and  may  involve  only  a 
limited  portion  of  the  urethra.  Then,  again,  we  sometimes  see  involve- 
ment of  a  considerable  segment  of  the  canal  in  redness  and  swelling, 


CHRONIC  URETHRITIS,   OR  GONORRHCEA.  171 

yrhich  is  studded  here  and  there  Avith  erosions  and  ulcers  and  granular 
and  papillomatous  growths. 

Now,  it  must  be  remembered  that  all  these  changes  are  secondary  to 
the  chronic  exudative  process  in  the  submucous  connective  tissue,  which 
is  the  primordial  lesion.  As  a  result  of  this  morbid  process  the  changes 
in  the  mucosa  and  in  its  vessels,  glands,  and  epithelium  result  which  are 
revealed  to  the  eye  by  the  microscope. 

The  morbid  appearances  of  the  mucous  membrane  of  the  posterior 
urethra  are  not  conspicuously  striking.  They  consist  of  thickening, 
more  or  less  papillation,  together  with  increased  redness.  Frequently 
the  caput  gallinaginis  and  the  orifices  of  the  prostatic  ducts  are  seen  to  be 
swollen.  The  underlying  pathological  process  is  precisely  similar  to 
that  of  the  anterior  urethra.  In  the  threads  which  contain  pus  and 
epithelium  of  various  kinds  gonococci  are  rather  infrequently  found. 
In  a  recent  essay  Neisser  ^  claims  that  the  gonococcus  can  be  found  in 
many  cases  of  posterior  urethritis  and  of  chronic  prostatitis  if  the  proper 
measures  are  taken  to  discover  it.  Neisser  washes  out  the  anterior 
urethra  thoroughly  with  boric-acid  water.  Then  a  solution  of  carbolic 
fuchsine  is  throAvn  into  the  posterior  urethra,  and  this  stains  all  tissue- 
products  present  there.  The  patient  then  urinates,  and  thus  frees  the 
posterior  urethra  of  its  tinted  contents.  Then  the  prostate  is  "  stripped," 
after  which  the  patient  urinates,  and  with  the  urination  the  expressed 
contents  of  the  prostatic  follicles  are  carried  aAvay.  Another  method  is 
to  Avash  out  the  posterior  urethra  (presumably  after  urination)  Avith  boric- 
acid  Avater,  which  the  patient  expels  from  the  bladder.  When  this  fluid 
comes  aAvay  clear,  it  is  safe  to  say  that  all  secretion  seated  on  the  mucous 
membrane  of  the  prostatic  urethra  has  been  carried  aAvay.  Then,  some 
boric-acid  water  still  being  in  the  bladder,  the  prostate  is  "stripped," 
and  the  patient  then  expels  the  contents  of  the  bladder  as  well  as  all 
deep-seated  inflammatory  products. 

The  question  of  the  infectiousness  of  the  secretion  of  chronic  gonor- 
rhoea is  one  which  frequently  arises,  and  concerning  Avhich  Ave  have  no 
precise  data.  In  order  to  treat  the  subject  intelligently  Ave  must  study 
the  peculiarities  of  each  case  and  be  guided  by  the  results  obtained.  It 
will  not  suflfice  to  merely  state  generalities,  or  to  harp  on  the  persistence 
of  the  presence  of  the  gonococcus,  or  to  endeavor  to  draAv  conclusions 
from  statistics.  We  knoAv  by  experience  that  in  the  third  to  the  sixth 
month  after  the  decline  of  a  case  of  gonorrhoea  in  many  patients  a  still 
infecting  pus  may  be  found  in  the  urethra.  In  many  other  cases  no 
such  pus  can  be  found  a  month  or  tAvo  after  the  cure  of  gonorrhoea.  It 
folloAvs,  therefore,  that  there  is  danger  of  contamination  of  Avomen,  in 
many  cases,  by  men  Avho  Avere  seemingly  cured  of  gonorrhoea  six  months 
previously.  Consequently,  Ave  must  be  on  our  guard  when  men  having 
Avithin  half  a  year  only  recovered  from  gonorrhoea  ask  our  opinion  as  to 
the  propriety  of  marriage.  In  such  cases  the  urine,  particularly  that  of 
the  early  morning,  should  be  carefully  examined.  If  pus-cells  are  still 
present,  together  Avith  epithelial  cells,  the  patient  should  be  subjected  to 
further  treatment,  even  though  the  gonococcus  cannot  be  discovered  in 
the  microscopic  field. 

1  "  Zur  Bedeutuns  der   Gonorrhoischen   Prostatitis,"    Verhandl.  der  Deut.   Dermatol. 
Gesellschafi,  Wien  and  Leipzig,  1894,  pp.  325  et  seq. 


172  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

My  own  experience  convinces  me  that,  in  general,  after  the  lapse  of 
six  months  from  the  time  of  cure,  provided  there  has  been  no  recurrence, 
it  is  safe  for  a  man  to  marry.  It  is  a  matter  of  common  experience  to 
see  men  who  have  only  one  or  two  months  before  recovered  from  gonor- 
rhoea have  intercourse  with  various  healthy  women  with  absolute  safety 
to  the  latter.  Though  we  can  thus  speak  positively  concerning  these 
cases  where  men  do  as  they  please,  we  must  be  guarded  when  we  are 
called  upon  for  an  opinion  and  do  our  utmost  to  protect  the  innocent. 
There  can  be  no  doubt  that  many  women  escape  infection  by  men  recently 
recovered  from  gonorrhoea  by  reason  of  the  fact  that  the  secretion  is  small 
in  amount  and  is  washed  out  of  the  urethra  in  urination. 

I  am  so  constantly  seeing  men  who  have  chronic  anterior  and  posterior 
urethritis,  who  have  intercourse  over  long  periods  with  women,  wives  and 
mistresses,  without  communicating  gonorrhoea  to  them,  that  I  am  led  to 
the  belief  that  in  very  many  of  these  cases  the  pus  is  inactive  or  effete. 
In  such  cases  the  microscope  often  shows  a  field  covered  with  small  with- 
ered pus-cells  and  large,  flabby  epithelial  cells  studded  with  small  fat- 
globules.  When  I  see  these  features  I  am  generally  pretty  certain  that 
the  secretion  is  not  liable  to  cause  infection.  Exacerbations  of  such  a  low 
grade  of  morbid  process  may,  however,  produce  a  pus  competent  to  infect. 

I  think  it  may  be  stated  without  fear  of  contradiction  that  if  the  vast 
number  of  cases  of  chronic  suppuration  of  the  urethra  which  are  known 
to  exist  in  men  gave  issue  to  infecting  pus,  gonorrhoea  in  women  would 
be  as  common  as  it  is  in  men.  This  certainly  is  not  the  case,  for  there 
are  at  the  very  least  thirty  cases  of  gonorrhoea  in  men  to  one  case  in 
women.     This,  is  under-  rather  than  over-stated. 

To  sum.  up,  we  may  say,  on  general  principles,  that  danger  lurks  in 
all  forms  of  urethral  pus,  particularly  in  that  which  is  found  within  six 
months  after  the  supposed  cure  of  gonorrhoea.  In  older  cases  it  may  be 
dangerous,  but  daily  experience  shows  us  that  for  some  reason  or  other 
women  may  with  impunity  cohabit  with  men  whose  urethras  secrete  pus 
sparingly.  In  many  cases  personal  cleanliness  and  the  salutary  effects  of 
urination  may  be  the  undei'lying  causes  of  this  immunity.  In  this  con- 
nection it  is  well  to  repeat  what  has  already  been  said.  Too  much  stress 
is  laid  by  some  authors  upon  gonococci  and  other  microbes  in  chronic 
urethritis.  In  very  many  cases  the  gonococcus  has  produced  its  path- 
ological results  and  has  disappeared,  leaving  an  inflammation  of  the 
vessels  and  cell-infiltration  behind  it,  which  is  then  uninfluenced  by 
microbes.  This  smouldering  inflammatory  patch  gives  forth  pus  which 
may  not  contain  microbes ;  hence  it  produces  no  bad  result.  This  phoe- 
nix-like character  given  by  many  to  the  gonococcus  is  in  most  cases  a  myth. 

Treatment  of  Chronic  Urethritis,  Anterior  and  Posterior. — When  gon- 
orrhoea, or  urethritis,  has  lasted  three  months,  and  is  then  in  a  decidedly 
subacute  condition,  it  may  be  called  chronic. 

It  must  be  clearly  borne  in  mind  that  only  in  rather  exceptional  cases 
is  the  morbid  process  strictly  limited  to  the  anterior  urethra.  In  very 
many  cases  the  posterior  urethra  is  involved,  and  with  it  usually  the  con- 
tiguous portion  of  the  anterior  urethra,  including  the  bulbous  segment, 
and  even  parts  beyond  that,  may  be  similarly  affected.  In  some  cases  the 
posterior  urethra  alone  is  involved. 

In  the  treatment  of  chronic  gonorrhoea  the  history  of  the  case  must  be 


CHRONIC  URETHRITIS,   OR   GONORRHCEA.  173 

carefully  considered.  Then  it  is  necessary  to  determine  the  seat  and 
extent  of  the  morbid  process  and  its  nature  and  physical  character.  In 
every  case  the  first  diagnostic  points  should  be  obtained  by  the  careful 
examination  of  the  urine.  At  the  first  examination  instruments  for  diag- 
nostic purposes  should  be  guardedly  used. 

The  disease  lurks,  particularly  in  very  chronic  cases,  in  various  parts 
and  exists  under  diff"erent  conditions,  so  that  there  are  scarcely  two  cases 
which  thoroughly  resemble  each  other.  The  consequence,  therefore,  is 
that  there  is  no  specifically  routine  treatment  for  chronic  urethritis,  but 
each  case  must  be  treated  on  the  basis  of  its  morbid  process  and  of  the 
therapeutic  indications  presented  by  it. 

The  duration  of  the  urethritis  has  an  important  bearing  upon  its  treat- 
ment. Let  us  first  consider  the  cases  in  which  the  disease  has  lasted  only 
a  few  months.  Such  patients  may  complain  only  of  the  morning  drop,  or 
they  may  state  that  they  seem  well  so  long  as  they  use  an  injection,  abstain 
from  coitus,  and  do  not  drink  beer  and  alcoholics  or  eat  highly-seasoned 
food.  When  they  cease  injecting  and  indulge  in  creature  comforts  and 
excesses,  the  morning  drop  reappears,  with  perhaps  a  more  or  less  profuse 
discharge  during  the  whole  day.  Examination  of  the  urethra  in  these 
cases  shows  a  catarrhal  and  exudative  condition  from  the  bulb  forward, 
perhaps  nearly  to  the  meatus.  In  many  of  these  cases  the  posterior 
urethra  is  also  involved.  The  morning  urine  is  rather  cloudy,  like 
turbid  cider,  contains  much  mucus,  and  some  long  thin  or  thick  threads 
(sometimes  three  or  four  inches  long).  There  may  or  may  not  be  a  few 
gonococci  present.  In  these  cases  the  best  treatment  is  irrigations  of  the 
posterior  and  anterior  urethrge,  using  at  first  warm  solutions  of  alum  and 
sulphate  of  zinc  after  the  manner  of  Ultzmann,^  beginning  with  a  strength 
of  1  :  500,  and  increasing  according  to  the  result  obtained.  Usually  one 
irrigation  daily  is  sufficient,  but  perhaps  two  may  be  well  borne.  The 
sensations  of  the  patient  and  the  condition  of  the  urine  are  infallible  guides 
as  to  the  required  frequency  of  treatment.  As  a  general  rule,  after  one 
or  two  weeks'  treatment  these  irrigations  seem  to  lose  their  efiicacy,  hav- 
ing done  some  good,  but  not  having  produced  a  cure.  Perhaps  in  these 
conditions  permanganate-of-potas,sa  irrigations  (always  hot),  1  :  1000  or 
1  :  2000,  may  bring  about  a  cure.  If  this  remedy  fails,  we  resort  to 
nitrate  of  silver,  beginning  with  solutions  of  the  strength  of  1  :  16,000  or 
1  :  8000,  and  sometimes  even  weaker ;  and  this  usually  brings  about  a 
cure  if  the  treatment  is  carefully  administered.  If  the  morbid  process  is 
more  severe  in  the  anterior  urethra,  the  bulbous  reflux  catheter  (see  Fig. 
57)  should  be  introduced  as  far  as  the  bulb,  and  one  or  two  syringefuls 
of  the  irrigating  fluid  should  be  injected.  The  posterior  urethra  should 
then  be  similarly  treated.  Sometimes  it  is  necessary  to  finish  Avith  quite 
strong,  deep  injections.  In  these  cases  much  pain  is  frequently  produced 
by  the  passing  of  sounds,  particularly  of  large  ones.  This  fixct  should 
always  be  borne  in  mind,  since  many  patients  thus  treated  suff"er  severely, 
while  in  others  the  disease  is  so  aggravated  that  it  is  most  difficult  to 
cure.  Some  of  these  cases  are  rendered  practically  incurable  even  if 
the  most  judicious  and  prolonged  treatment  is  followed.  Too  much  atten- 
tion cannot  be  paid  to  the  fact  that  in  some  cases  of  chronic  gonorrhoea 
sounds  may  be  productive  of  incalculable  harm. 

'  Pyuria,  etc.,  New  York,  1884,  pp.  64  et  seq. 


174 


GONOBBHCEA  AND  ITS  COMPLICATIONS. 


When  the  disease  is  limited  to  the  bulbous  portion,  where  it  shows  a 
great  tendency  to  remain  indefinitely,  the  retrojections  of  alum,  sulphate 
of  zinc,  and  nitrate  of  silver  may  be  used.  These  injections  will  mate- 
rially modify  the  morbid  process,  and  sometimes  cure  it,  but  they  often 
fail  to  bring  about  a  thorough  cure.  In  that  event  it  is  well  to  make 
direct  local  applications  of  solutions  of  nitrate  of  silver,  beginning  with 
a  solution  of  1  :  2000,  and  perhaps  going  as  high  as  2  :  500.  Guyon' 
and  his  followers  advocate  very  strong  solutions  of  this  drug,  such  as 
1  :  30,  20,  and  10.  My  experience  has  taught  me  that  we  get  better 
results  and  cause  less  pain  by  using  weaker  solutions.  For  the  treat- 
ment of  chronic  gonorrhoea  of  the  bulbous  urethra  Guyon's  syringe  is  a 

Fig.  63. 


Guyon's  svrine:c 


very  useful  instrument.  It  consists  of  a  Pravaz  syringe  with  a  screw 
piston  to  which  is  attached  a  conical  cannula  grooved  screw-like  on  its 
external  surface  to  ensure  its  retention  in  the  expanded  proximal  end 
of  the  bougie  a  houle.     The  bulbs  of  the  bougie  vary  in  size  from  10  to 


Author's  syringe. 

20  French.  By  turning  the  handle  of  the  piston  once  around  two  drops 
are  expelled  from  the  syringe.  It  is  well,  before  the  introduction  of 
the  bougie,  to  turn  the  handle  until  it  is  filled  with  the  liquid  and  all 
air  is  expelled.  A  less  complicated  and  perfectly  effective  syringe  is  the 
one  generally  used  by  me.  There  is  nothing  whatever  original  about 
this  syringe.  It  is  simply  a  well-made  instrument,  very  easily  worked, 
having  a  ring  and  shoulders  for  the  thumb  and  fingers,  and  a  very  con- 
ical nozzle,  which  will  fit  into  any  small  soft  catheter.  The  piston  is 
marked  Avith  numbers  to  regulate  the  drops.  The  injecting  medium  is 
any  well-made  soft-rubber  catheter,  10  to  12  or  14  French,  cut  ofi"  to 
measure  eight  and  a  half  inches  in  length.  When  the  catheter  is  intro- 
duced six  or  six  and  a  half  inches,  its  end  is  in  the  sinus  of  the  bulb,  and 
the  very  slight  impediment  it  encounters  there  shows  the  operator  that 

'  "Le9ons  clin.  sur  les  Urethrites  blennorrhagiques,"  Annales  des  Mai.  des  Org.  G6n.- 
urin.,  vol.  i.,  1883,  pp.  612  et  seq. 


CHRONIC  URETHRITIS,    OR   OONORRHCEA. 


175 


he  is  just  at  the  opening  in  the  triangular  ligament.  This  little  catheter, 
being  slowly  passed,  never  causes  pain  or  irritation.  Then  ten  or  fifteen 
drops  of  the  silver-nitrate  solution  may  be  thrown  into  the  urethra. 
This  treatment  may  sometimes  be  varied  by  using  1,  2,  or  3  per  cent, 
sulphate-of-copper  solution,  or  3  to  6  per  cent,  sulphate-of-thallin  solu- 
tion. This  treatment  may  be  administered  by  the  surgeon  every  five 
days  or  twice  a  week,  and  perhaps  oftener  if  the  indications  of  the  case 
point  to  the  necessity  of  increased  frequency.  In  the  intervals  the 
patient  may  use  mild  stimulant  and  astringent  injections  by  means  of 
the  penis-syringe.  This  form  of  chronic  urethritis  being  very  rebellious, 
it  is  sometimes  necessary  to  pass  an  endoscopic  tube  down  to  the  bulb, 
and,  having  ascertained  the  morbid  appearances,  to  sparingly  apply  on 
cotton  at  the  end  of  an  applicator  or  j^orte  remade  a  strong  solution  of 
silver  nitrate  (gr.    30  to   3J   water). 

In  the  more  chronic  cases  of  anterior  urethritis  we  find  spots,  patches, 
and  areas  of  inflammation  at  the  peno-scrotal  angle  (sometimes  seem- 
ingly caused  by  the  pressure  of  the  suspensory  worn  during  the  declin- 
ing stage)  and  in  the  pendulous  urethra  as  far  as  its  beginning. 

The  first  essential  in  the  treatment  of  these  cases  is  to  locate  the 
trouble  and  to  determine  its  nature.  Now,  in  this  part  we  find  sub- 
epithelial infiltration  with  or  without  a  greater  or  less  epithelial  hyper- 
plasia, erosions,  and  superficial  ulcerations,  always  accompanied  with 
submucous  thickenings  and  follicular  inflammation.  The  thickened 
mucosa  may  be  granular,  villous,  or  papillomatous.  The  urine  can  do 
little  in  enlightening  us  as  to  the  exact  nature  of  the  morbid  process 
unless  it  contains  old  flabby  and  fatty  epithelial  cells,  which  point  to  an 
old  ulcer  which  is  in  too  atonic  a  condition  to  heal  of  itself.  In  these 
cases  much  aid  can  be  obtained  as  to  location  by  the  bougie  a  houle} 
This  instrument  consists  of  conical  or  acorn-shaped  heads  with  a  well- 
marked  sharp  but  gently  rounded  shoulder,  which  is  attached  to  a  flex- 

FiG.  65. 


Boufjie  k  boule. 


ible  gum-elastic  staif.  (See  Fig.  65.)  For  the  cases  under  considera- 
tion we  may  need  these  bougies  a  boule  in  size  ranging  from  18  to  30 
French.  For  strictures  we  may  use  the  smaller  sizes,  which  begin  as 
small  as  8  or  10  French. 

'  The  instruments  made  by  the  J.  EUwood  Lee  Co.  of  Conshohocken,  Pa.,  are  far 
superior  to  any  imported. 


176  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

Now,  it  must  be  distinctly  understood  that  all  of  the  above-mentioned 
inflammatory  conditions  cause  a  greater  or  less  thickening  of  the  urethral 
walls,  and  they  impinge  more  or  less  upon  its  calibre.  There  is  a  very 
prevalent  tendency  now-a-days  to  call  any  condition  which  may  interfere 
with  the  easy  passage  of  the  hougie  a  houle  forward  or  backward  a  stric- 
ture, and  thousands  of  men  have  been  cut  for  stricture  when  they  had 
only  one  or  more  of  the  above-mentioned  conditions.  A  little  thickened 
patch  of  infiltrated  mucous  membrane,  perhaps  seated  on  one  side  of  the 
canal  or  perhaps  encircling  it,  will  prove  an  obstacle  to  the  easy-sliding 
forward  and  backward  of  the  bulb,  and  the  case  might  be  mistaken  for 
one  of  annular  stricture  of  large  calibre.  An  ulcer  or  erosion  with  its 
concomitant  thickening  will  ofi"er  some  resistance,  and  the  bulb  on  its 
return  may  jump  and  jerk  over  it.  The  epithelial  hyperplasias  which 
often  accompany  submucous  infiltration  jut  up  in  the  canal  and  more  or 
less  narrow  its  calibre  and  impair  its  suppleness.  A  swollen  follicle 
may  act  in  a  similar  manner.  Papillomata  will  offer  more  or  less  resist- 
ance, but  as  they  bleed  so  readily,  even  on  gentle  manipulation,  their 
nature  may  be  suspected.  All  inflammatory  conditions  render  the  ure- 
thra, particularly  its  pendulous  portion,  thickened  and  less  supple,  and 
more  or  less  impinge  on  its  calibre  and  destroy  its  expansibility.  Bear- 
ing these  facts  in  mind,  it  is  a  serious  matter  to  decide  without  full, 
painstaking  examinations  that  a  man  has  stricture.  Having  ascertained 
that  there  is  a  localized  chronic  inflammatory  spot  or  area,  the  injection 
of  a  few  drops  of  nitrate-of-silver  solution,  1 :  1000  or  1 :  500,  may  be 
made  twice  a  week  or  oftener.  When  cases  resist  this  treatment,  it  is 
well  to  resort  to  the  endoscope  in  order  to  determine  just  what  condition 
exists.  Erosions,  ulcerations,  granulations,  and  urethral  thickenings 
require  circumscribed  applications  of  solutions  of  nitrate  of  silver  per- 
haps as  strong  as  2  :  500,  and  very  rarely  indeed  stronger — 1  per  cent. 
These  applications  should  be  skilfully  and  carefully  applied,  in  some 
cases  through  the  endoscopic  tube,  in  others  by  means  of  Guyon's 
syringe  or  my  own  syringe.  The  patient  in  the  intervals  of  treat- 
ment may  use  astringent  injections  with  the  penis-syringe.  When  the 
inflammatory  condition  is  just  external  to  the  bulb,  particularly  when 
it  is  seated  in  the  pendulous  urethra  in  cases  where  there  is  not  much 
hypersemia,  much  benefit  can  be  derived  from  the  introduction  of  the 

Fig.  66.  __--=-^ — --r-iiiililll 


FORD  "II       "llllllllllllli" 

Conical  straight  sound. 

straight  steel  sound  and  the  gentle  pressure  or  massage  of  the  urethral 
canal  for  a  few  minutes.  Care  must  be  taken  that  no  violence  be  done. 
In  some  cases  this  procedure  aids  the  nitrate-of-silver  injections  in  the 
absorption,  of  the  effused  cells. 

Inflammation  of  the  urethral  follicles,  particularly  when  several  inches 
down,  is  a  condition  which  resists  treatment  and  is  difficult  to  handle. 
The  parts  must  be  exposed  by  means  of  the  endoscope,  and  touched  with 
a  strong  nitrate-of-silver  solution  on  cotton  at  the  end  of  a  very  fine  silver 
probe,  which,  if  possible,  should  be  gently  pushed  into  the  duct.     Some 


CHRONIC   URETHRITIS,    OR   GONORRHCEA. 


Ill 


authors  recommend  the  destruction  of  the  follicle  by  means  of  a  very 
minute  galvano-cautery  needle.  Great  care  and  circumspection  should  be 
used  when  this  rather  heroic  procedure  is  resorted  to.  After  any  of 
these  applications  it  is  well  to  inject  the  urethra  with  lead-Avater  twice  a 
day. 

Follicular  sinuses  in  the  fossa  navicularis  and  just  within  the  lips  of 
the  meatus  may,  after  thorough  irrigation,  be  injected  with  a  few  drops 

Fig.  67. 


,I,EMAN,N 

Ultzmann's  deep  urethral  syringe. 


of  silver-nitrate  solution  (2 :  500)  by  means  of  the  hypodermic  syringe, 
the  needle  of  which  is  made  blunt  by  the  removal  of  its  point.  In  several 
cases  of  juxta-  and  intra-urethral  sinuses  I  have  produced  a  cure  by  ap- 
plying on  a  small  silver  probe  a  coating  of  nitrate  of  silver  obtained  by 
melting  the  drug  with  heat.     A  few  grains  of  the  silver  salt  are  placed  in 


Fig.  68. 


Ultzmann-Keyes  syringe. 


a  small  platinum  crucible,  Avhich  is  exposed  to  an  alcohol  flame  until 
liquefaction  occurs ;  then  the  probe  is  dipped  into  the  crucible  and  is 
thus  charged. 

In  the  treatment  of  posterior  urethritis  with  or  without  anterior  ure- 
thritis great  care  is  required  to  determine  as  nearly  as  possible  the  exact 
condition  of  affairs.  In  the  more  recent  cases  we  sometimes  find  some 
evidence  of  bladder  incompetence  (the  urine  showing  no  involvement  of 
that  viscus),  which  shows  itself  by  the  escape  of  a  little  (gij  to  5ss  or  more) 
residual  urine  when  the  eye  of  the  catheter  reaches  the  neck  of  the  blad- 
der. In  these  rather  early  cases  mild  irrigations  of  the  astringents  and  of 
permanganate  of  potassa  may  be  used,  and  perhaps  with  benefit.  The 
most  uniformly  effective  agent  here  also  is  the  nitrate  of  silver,  Avhich  may 
at  first  be  used  well  diluted,  1 :  16,000  or  1 :  8000,  in  the  form  of  hot 
irrigations.  These  may  result  in  cure,  but  if  the  result  is  not  perfect  in- 
jections of  the  same  drug  may  be  used.  For  injecting  the  posterior 
urethra  the  Guyon  syringe,  to  my  mind,  is  objectional)le,  for  the  reason 
that  its  bulbs,  particularly  when  the  larger  ones  are  employed,  cause 
more  or  less  spasm  of  the  compressor  urethrte  muscle,  and  as  a  result  an 
uneasy  and  even  painful  sensation  is  left  after  its  withdrawal. 

The  Ultzmann  syringe  and  the  Keyes  modification,  in  which  the 
syringe  is  soldered  to  the  cannula,  and  to  it  two  wings  or  holders  for  the 
fingers  are  added,  unless  used  with  the  greatest  care  often  cause  patients  dis- 
12 


178  GONORRHCEA  AND  ITS  COMPLICATIONS. 

comfort  and  even  pain.  By  them  minute  quantities  of  fluid  may  be  thrown 
into  the  posterior  urethra  with  much  accuracy.  The  introduction  of 
these  instruments  often  provokes  vigorous  spasm  of  the  compressor  urethras 
muscle.  In  my  opinion  the  use  of  these  instruments  should  be  confined 
to  the  purposes  for  which  they  were  originally  intended  by  Ultzmann — 
namely,  to  apply  a  few  drops  of  very  strong  silver-nitrate  solution  to  the 
posterior  urethra  and  verumontanum  in  case  of  sexual  disability,  in  pros- 
tatorrhoea,  and  in  spermatorrhoea.  They  certainly  are  not  instruments  to 
be  used  by  unskilled  hands  or  by  persons  who  use  them  very  infrequently. 
My  preference  is  decidedly  in  favor  of  the  simple  little  syringe  with  the 
small-calibre,  soft-rubber  catheter  already  described.  When  it  is  neces- 
sary to  inject  the  posterior  urethra,  using  the  small  catheter  cut  off  at 
eight  and  a  half  inches,  this  tube  should  be  introduced  about  seven  or 
seven  and  a  half  inches,  when,  in  the  majority  of  cases,  the  eye  of  the 
instrument  will  be  just  at  the  beginning  of  the  prostatic  urethra.  In  men 
with  very  long  urethrse  a  catheter  thus  introduced  might  only  reach  the 
membranous  urethra,  and  then  pressure  on  the  piston  would  not  be  fol- 
lowed by  the  expulsion  of  any  fluid,  owing  to  the  compression  exerted  on 
the  catheter.  In  this  event  it  is  only  necessary  to  push  the  catheter  a 
little  farther  onward,  into  the  prostatic  urethra,  where  no  obstacle  will  be 
encountered.  By  this  syringe  we  can  inject  ten  or  twenty  drops  of  a 
silver-nitrate  solution,  beginning  in  the  more  recent  cases  with  1 :  2000  or 
1 :  1000,  making  an  injection  once  a  day,  every  second  day,  or  at  longer 
intervals,  according  to  the  result  produced  and  the  patient's  sensations. 
It  will  rarely  be  necessary  to  use  stronger  solutions  than  1  :  or  2  :  500. 
As  these  cases  progress  gradual  dilatation  may  afibrd  aid,  provided  great 
care  and  caution  are  used.  If  this  little  operation  causes  pain,  and  if  the 
urine  shows  more  pus-  or  tissue-elements  than  it  did  before,  it  is  well  to 
desist  and  keep  on  with  the  injections. 

For  older  and  very  chronic  cases  of  posterior  urethritis  the  stronger 
silver-nitrate  injections,  1 :  500  or  250,  may  be  used.  In  my  expe- 
rience, fifteen  drops  or  more  of  these  solutions  produce  better  effects 
than  a  more  sparing  injection  of  stronger  solutions.  These  injections 
should  be  given  every  third  or  fourth  day.  They  may,  however,  pro- 
duce benefit  in  some  cases  if  made  more  frequently.  Daily  injections 
are  liable  to  cause  acute  suppuration,  which  means  irritation,  and  that 
must  be  avoided. 

Posterior  urethritis,  accompanied  by  sexual  disability,  premature 
ejaculations,  pollutions,  and  absence  of  erections  and  loss  of  sexual 
desire,  usually  requires  the  injection  of  a  few  drops  of  the  stronger 
solutions  just  mentioned.  In  these  cases  especially  it  is  well  to  care- 
fully examine  the  prostate  per  rectum.  This  organ  is  frequently  found 
rather  swollen  both  laterally  and  toward  the  rectum,  and  the  finger-tip 
may  produce  an  uncomfortable  sensation  and  even  pain.  In  many  of 
these  cases  gentle  repeated  pressure  with  the  finger-tip  on  the  organ 
causes  a  thick,  viscid,  grayish  secretion  to  escape  from  the  meatus,  and 
as  a  result  of  three  or  four  such  treatments  patients  frequently  are 
benefited.  In  these  cases  the  disease  has  invaded  the  prostatic  follicles, 
and  within  them  is  stagnated  muco-pus  which  keeps  up  the  irritation. 

Besides  these  local  measures,  patients  thus  afflicted  need  fresh  air, 
relaxation,  good  hygienic   conditions,  and  attention   should  be  paid  to 


CHRONIC  URETHRITIS,   OR  GONORRHOEA.  179 

their  sexual  hygiene.  In  some  of  these  cases,  where  there  is  much 
hyperesthesia  of  the  posterior  urethra,  accompanied  by  erotic  symptoms, 
much  benefit  may  be  produced  by  the  introduction  of  steel  sounds  pre- 
viously chilled  with  ice.  This  procedure  should  be  cautiously  carried 
out  and  its  effects  carefully  watched.  It  should  not  be  very  frequently 
adopted,  and  at  the  most  two  seances  a  week  should  be  given,  and  on 
these  days  the  deep  injection  should  be  omitted.  If  good  is  going  to 
follow,  the  patient  will  at  once  speak  of  his  improvement.  Should  it 
produce  a  dull  pain  or  an  uneasy  sensation,  its  use  is  contraindicated. 
It  is  always  well  not  to  use  very  large  sounds ;  those  having  a  calibre  of 
20  or  22  French  are  the  best. 

Some  surgeons  may  desire  to  try  other  measures  and  methods  of 
treatment  for  chronic  urethritis,  in  which  event  I  would  refer  them  to 
the  various  views  and  exploitations,  as  well  as  instruments  and  methods, 
detailed  in  the  chapter  on  the  treatment  of  acute  urethritis.  They  cer- 
tainly will  find  food  for  serious  thought  there,  and  perhaps  suggestions 
which  may  be  of  practical  benefit  in  a  deterrent  direction. 

The  Use  of  the  Endoscope. — In  the  treatment  of  chronic  urethritis 
the  endoscope  is  useful  under  certain  sharply-drawn  restrictions.  As  a 
means  of  localizing  an  inflammatory  focus,  of  viewing  surface  appear- 
ances, and  of  allowing  the  use  of  topical  applications  under  free  ocular 
inspection  it  is  often  of  signal  benefit.  It  is  an  instrument  of  reserve 
rather  than  of  routine,  and  it  always  should  be  used  in  a  rational  and 
conservative  manner.  It  is  to  be  regretted  that  it  has  been  used  very 
much  as  a  toy,  and  has  been  to  some  simply  a  surgical  hobby.  There 
are  those  who  have  been  so  unkind  as  to  say  that  some  surgeons  osten- 
tatiously display  and  use  it  as  a  means  of  impressing  patients  with  their 
skill  and  science.  Patients,  however,  as  a  rule,  are  only  profoundly 
impressed  when  science  and  skill  give  them  relief,  and  they  are  corre- 
spondingly disappointed,  and  even  indignant,  when  they  have  been 
submitted  to  discomforting  and  elaborate  manipulations  which  have  done 
them  no  good  and  perhaps  some  harm. 

As  a  general  rule,  it  may  be  said  that  when  in  the  treatment  of 
chronic  anterior  urethritis  the  case  resists  the  usual  methods  properly 
applied,  then  it  is  well  to  use  the  endoscope  to  determine  the  exact  seat 
and  nature  of  the  lesion.  It  is  well  to  sound  a  note  of  warning  as  to 
the  inspection  of  the  posterior  urethra.  It  is  safe  to  say  that  many 
persons  who  cajole  themselves  with  the  idea  that  they  have  inspected 
this  region  have  greatly  deceived  themselves.  It  is  often  very  difficult 
to  efface  the  subpubic  curve  with  the  endoscope  tube,  and  often  much 
damage  is  done  in  the  attempt  or  in  its  accomplishment.  A  skilled  expert 
only  should  make  endoscopic  examinations  of  the  posterior  urethra. 

The  precipitate  use  of  the  endoscope  at  the  first  examination  of  a 
case,  before  the  other  and  less  radical  methods  of  examination  have  been 
tried,  is  to  be  very  much  condemned. 

The  efficient  use  of  this  instrument  requires  much  time,  study,  and 
observation.  The  aim  of  the  surgeon  should  always  be  to  use  such  deli- 
cate care  and  circumspection  that  the  operation  is  made  as  little  trouble- 
some and  painful  to  the  patient  as  possible.  At  the  present  time  the 
tendency  is  to  use  only  the  large  and  complicated  instruments,  and  we 
see  little,  if  any,  mention  of  the  simple  endoscopic  tubes.     These  simple 


180 


GONOBBHCEA  AND  ITS  COMPLICATIONS. 


tubes  can  be  very  readily  introduced,  and  a  good  view  of  the  urethra  as 
far  as  the  bulb  may  be  obtained  by  their  means,  supplemented  by  the 
sun's  rays  or  the  electric  light  thrown  down  their  lumen  by  means  of  a 
hand  or  a  forehead  mirror.  I  strongly  advise  any  one  beginning  the 
study  of  endoscopy  to  employ  the  Weir  meatoscope  or  the  F.  N.  Otis 
endoscopic  tube.  The  first  instrument  will  give  a  clear  view  of  the 
whole  fossa  navicularis,  Avhile  Otis's  tube  will  show  fully  six  inches  of 
the  canal.     By  means  of  endoscopic  tubes  longer  than  those  of  Otis  the 


Weir's  meatoscope. 


urethra  as  far  down  as  the  beginning  of  the  membranous  portion  can  be 
inspected.     Weir's  instrument  (Fig.  69)  is  made  of  hard  rubber,  and  by 


otis's  endoscopic  tube. 


it  fully  two  inches  of  the  canal  can  be  inspected. 
(Fig.  70)  is  of  similar  structure. 


Otis's  instrument 


Urethral  speculum. 


Endoscopic  tubes  being  solid,  and  not  fenestrated,  only  admit  of 
inspection  of  the  urethra  at  their  distal  ends.     For  examination  of  the 


CHRONIC  URETHRITIS,   OR  GONORRHCEA. 


181 


fossa  navicularis  (for  follicular  abscesses  and  sinuses,  suspected  incipient 
gonorrhoea,  chancroids,  and  exceptionally  for  hard  chancres)  the  little 
speculum  designed  by  me  (Fig.  71)  Avill  often  give  material  aid.  For  a 
close  inspection  of  the  urethral  walls  for  about  six  inches  the  speculum 
of  F.  T.  Brown  (Fig.  72)  may  be  satisfactorily  employed.     Care  must 


Brown's  wire  urethral  speculum. 

"be  exercised  in  using  these  two-bladed  specula  that  harm  is  not  done. 
It  is  always  well  to  first  examine  and  familiarize  one's  self  with  the  ap- 
pearances of  the  normal  urethra,  since  by  this  course  the  study  of  abnor- 
mal conditions  is  rendered  much  easier  and  clearer. 

It  would  be  a  waste  of  space  to  give  a  description  of  the  various 
endoscopes  which  have  been  invented.  The  Mathieu  endoscope  (Fig. 
73),  a  very  excellent  one,  will  give  a  clear  view  of  the  canal,  but  will 

Fig.  73. 


Mathieu' s  endoscope. 


not  permit  of  synchronous  examination  and  topical  applications.  By 
its  use,  however,  one  may  obtain  much  knowledge  of  the  morbid  appear- 
ances of  the  urethra. 

The  simplest  of  the  elaborate  instruments,  both  as  to  construction 
and  use,  is  the  perfected  endoscope  of  W.  K.  Otis.     By  its  means  not 


182 


GONOBBHCEA  AND  ITS  COMPLICATIONS. 


only  is  the  canal  rendered  perfectly  visible,  but  under  the  eye  direct 
topical  applications  may  be  made.  Since  the  inventor  can  always 
describe  his  own  instrument  more  clearly  than  another  man,  I  quote 
Dr.  Otis's  words  :  "  This  instrument  consists  of  a  metal  tube  or  cyl- 
inder an  inch  and  a  quarter  in  length  by  half  an  inch  in  diameter, 


Fig.  74. 


W.  K.  Otis's  "perfected"  urethroscope. 


closed  at  one  end.  A  quarter  of  an  inch  from  the  open  end  of  this 
tube  is  a  plano-convex  lens,  so  arranged  that  it  may  be  easily  removed 
for  cleaning.  On  the  inferior  surface,  near  the  closed  end  of  the  tube, 
an  elbow  is  let  in,  a  quarter  of  an  inch  in  length  and  half  an  inch  in 
diameter,  through  which  the  source  of  illumination  (a  small  incandescent 
electric  lamp)  is  introduced,  a  row  of  holes  being  bored  at  its  base  to 
allow  of  ventilation.  The  handle  of  the  instrument  consists  of  a  piece 
of  hard  rubber  an  inch  long  by  half  an  inch  wide,  the  electrical  con- 
nections running  through  it  to  the  lamp,  which  is  placed  on  top.  This 
handle  fits  into  the  elbow  by  means  of  a  bayonet  joint,  bringing  the 
lamp  immediately  behind  the  plane  side  of  the  lens.  A  thumb-screw 
'  switch  '  in  the  handle  places  the  lamp  under  control,  so  that  it  may  be 
turned  on  or  off  at  pleasure. 

"  The  instrument  is  attached  to  the  urethroscopic  tube  by  means  of  a 
stout  wire  an  inch  and  a  half  in  length,  with  hinged  joints  at  each  end, 
which  swing  in  opposite  directions  and  are  furnished  with  set  screws, 
thus  allowing  the  instrument  to  be  put  in  any  position,  though  when 
once  adjusted  it  will  rarely  be  necessary  to  move  it.  If  the  ordinary 
form  of  tube  is  used,  the  distal  end  is  provided  with  a  simple  ring  sliding 
joint ;  but  ....  I  greatly  favor  the  use  of  the  tube  of  Dr.  Klotz. 
I  have  arranged  the  instrument  for  this  form  of  tube. 

"  When  the  instrument  is  in  position  and  the  lamp  illuminated,  a  strong 
beam  of  light  is  thrown  down  the  urethroscopic  tube,  and  the  urethral 
mucous  membrane  is  more  easily  and  clearly  observed  than  with  any 
other  form  of  urethroscope  with  Avhich  I  am  familiar. 

"  The  advantages  of  this  instrument  are — 

"  1.  The  exclusion  of  all  extraneous  light,  the  presence  of  which  is 
a  most  annoying  fault  both  in  the  urethroscope  of  Leiter  and  in  my 
own  improvement  on  it. 


CHRONIC  URETHRITIS,   OR   GONORRHCEA.  183 

"2.  A  very  much  more  ready  access  to  the  urethral  field,  both  to  the 
eye  and  for  instrumental  applications. 

"  3.   Increased  illumination. 

"  4.  By  abandoning  the  funnel  and  sliding  joint  an  inch  and  a  half 
in  distance  is  gained  from  the  source  of  illumination  to  the  distal  end 
of  the  urethroscopic  tube,  increasing  the  illumination  and  alloAving  the 
eye  to  be  placed  just  so  much  nearer  the  mucous  membrane  to  be 
examined. 

"  5.  Its  extreme  compactness  and  lightness,  -weighing  less  than  one 
ounce,  even  when  constructed  of  brass. 

"  6.   Its  great  simplicity,  which  should  ensure  a  moderate  cost."^ 

A  six-cell  electric-light  battery  answers  all  purposes. 

We  have  already  considered  the  features  offered  by  urethrae  (see  page 
170)  the  seat  of  a  chronic  gonorrhoeal  process,  and  therefore  need  but 
to  allude  to  them  now.  In  some  cases  the  discharge  depends  on  a  simple 
red  spot  of  inflammation  with  infiltration,  Avhich  may  be  limited  or  quite 
spread  out.  A  velvety  or  granular  condition  is  not  uncommonly  seen, 
while  spots  of  follicular  inflammation  are  not  uncommon.  Erosions  and 
superficial  ulcerations  are  commonly  encountered,  and  with  the  latter 
lesions  there  is  frequently  a  hyperplasia  of  the  epithelial  strata.  Papil- 
lomatous urethritis  Avill  be  encountered  in  various  degrees  of  develop- 
ment. Sometimes  the  little  new  growths  of  vessels,  connective  tissue, 
and  epithelium  are  of  the  size  of  millet-seeds,  and  they  may  reach  the 
dignity  of  true  vegetations.  Dr.  Briggs"  has  described  and  figured 
some  of  these  lesions  taken  from  an  illustrative  case,  and  has  given  a 
drawing  of  their  microscopic  structure.  Polypoid  growths  are  some- 
what rarely  encountered,  even  of  such  a  size  as  to  materially  obstruct 
the  lumen  of  the  urethral  canal.  Dr.  H.  Goldenberg^  has  written 
instructively  upon  some  personal  cases  in  which  these  growths  were 
found.      He  also  depicts  their  histological  structure. 

The  applications  suitable  for  endoscopic  treatment  are,  in  the  main, 
solutions  of  nitrate  of  silver,  5  :  10  to  100  of  water.  These  should  be 
applied  by  means  of  swab-holders  or  applicators  carrying  a  tuft  of 
absorbent  cotton  moistened  in  the  medicated  fluid.  Strong  solutions 
of  sulphate  of  copper,  5  :  20—100,  may  be  used,  and  in  some  cases  such 
severe  remedies  as  solution  of  perchloride  of  iron,  liquor  hydrargyri  per- 
nitratis,  or  Lugol's  solution,  may,  of  necessity,  be  resorted  to.  These 
latter  solutions  should  always  be  applied  sparingly  and  only  on  the 
morbid  surfaces.  Papillomatous  urethritis  may  require  operative  meas- 
ures if  the  little  growths  cannot  be  scooped  off"  with  the  end  of  the  endo- 
scopic tube.  They,  with  polypoid  growths,  may  sometimes  be  removed 
by  tampon  ecrasement,  which  means  the  introduction  of  a  plug  of  cot- 
ton on  the  end  of  an  applicator,  which  is  pushed  forward  and  backward 
and  rotated  from  side  to  side  until  the  growth  is  detached.  After  this  a 
strong  nitrate-of-silver  application  should  be  made.  In  some  cases  the 
urethral-polypus  forceps  may  be  employed.* 

1  N.  Y.  Med.  Journal,  Dec.  17,  1892. 

"^  Boston  Med.  and  Sure/.  Journal,  Oct.  24,  1889,  pp.  403  et  seq. 

^  N.  Y.Med.  Journal,  May  9,  1891  (with  bibliography),  and  Med.  Record,  Nov.  4, 1891. 

*  The  reader  is  further  referred  to  the  elaborate  works  of  Oberliinder,  Lehrbuch  der 
Urethroscopie,  Leipzig,  1893 ;  of  Griinfeld,  Die  Endonkopie  der  Harnrohre  und  Blase,  Stutt- 
gart, 1887;  of  Berkeley  Hill,  On  Chronic  Urethritis,  London,  1890;  of  Horteloup,  Legons 


184  GONORBHCEA  AND  ITS  COMPLICATIONS. 

CHAPTER    XIY. 
URETHRO-CYSTITIS  AND  CYSTITIS. 

Until  within  the  past  few  years  posterior  urethritis,  acute  and  chronic, 
was  described  as  cystitis,  which  was  said  to  be  a  frequent  complication 
of  gonorrhoea.  To-day  we  have  very  clear  ideas  as  to  the  nature  and 
course  of  posterior  urethritis,  acute  and  chronic  (see  sections  on  these 
subjects),  and  we  know  positively  that  in  very  many  cases  of  these 
troubles  there  is  no  involvement  of  the  bladder  whatever,  the  phleg- 
masia being  quite  sharply  united  to  the  membranous  and  prostatic 
urethra. 

The  inflammatory  process,  however,  may  invade  the  bladder  in  part 
or  in  totality.  In  the  majority  of  cases  only  that  portion  of  the  bladder 
near  the  internal  sphincter,  particularly  on  its  sides  and  also  at  the  base 
or  trigone,  is  attacked.  This  limited  bladder-inflammation,  together  with 
the  posterior  urethritis,  constitutes  what  Finger  very  properly  calls 
^'  urethro-cystitis." 

This  limited  process,  however,  may  extend,  and  in  time  involve  the 
whole  bladder,  in  which  event  there  is  a  true  cystitis  resulting  from 
gonorrhoeal  inflammation. 

The  pathology  of  gonorrhoeal  cystitis  is  not  yet  clearly  demonstrated. 
In  acute  cases  of  posterior  urethritis  the  pus  quite  commonly  contains 
the  gonococcus,  but  as  the  process  grows  old  this  microbe  disappears 
and  other  forms  of  cocci  seem  to  take  its  place.  This  same  condition  is 
observed  in  the  pus  of  urethro-cystitis  and  of  cystitis,  in  the  secretions 
of  which  it  is  impossible  to  find  the  gonococcus,  except  very  rarely  in 
very  small  numbers,  but  which  show  very  plainly  myriads  of  cocci  and 
bacteria.  Much  study  is  necessary  to  clear  up  this  interesting  subject. 
The  theory  of  a  mixed  infection  being  the  cause  of  this  trouble  sug- 
gests itself,  but  it  cannot,  as  yet,  be  strongly  urged. 

Urethro-cystitis  may  be  acute  or  chronic.  When  the  inflammation 
is  still  acute,  and  that  portion  of  the  bladder  near  its  neck  becomes 
swollen  and  red  and  secretes  pus,  the  symptoms  are  those  of  acute 
posterior  urethritis.  (See  section  on  that  subject.)  These  are  mostly 
tenesmus,  pain  at  the  end  of  micturition,  and  perhaps  hsematuria.  Ex- 
amination of  the  urine  shows  opacity  in  the  two  cylinders,  but  instead 
of  the  second  specimen  being  less  cloudy  than  the  first,  as  is  the  case  in 
posterior  urethritis,  it  is  as  cloudy,  and  even  may  be  more  cloudy,  than 
the  first.  In  some  cases,  but  not  in  all,  if  the  patient  urinates  into 
three  glasses,  the  urine  in  the  first,  which  clears  out  the  posterior 
urethra,  will  be  very  cloudy,  the  second  specimen  less  so,  while  the  con- 
tents of  the  third  glass,  which  come  directly  from  the  inflamed  viscus  in 
a  state  of  tonic  contraction,  will  be  very  cloudy,  OAving  to  the  forcible 
extrusion  of  pus  from  the  texture  of  the  mucous  membrane.     If  hemor- 

sur  V  Urethrite  ckronique,  Paris,  1892 ;  and  to  articles  by  Klotz,  .V.  Y.  Med.  Journal,  Nov.  27, 
1886,  and  January  28,  1895,  and  to  the  monograph  of  Burckhardt,  Beitr.  zur  Uin.  Chir., 
Tubingen,  1889-90,  vol.  i.  pp.  261  et  seq. 


VRETHRO-CYSTITIS  AND  CYSTITIS.  185 

rhage  is  small,  only  the  third  portion  will  contain  blood,  but  if  it  is 
copious,  all  three  specimens  will  contain  it. 

The  urine  is  usually  of  acid  reaction,  and  presents  a  milky  or  kero- 
sene-oil-like appearance,  according  as  the  morbid  process  is  mild  and 
superficial  or  severe  and  deep-seated.  Whenever  the  tenesmus  is  great, 
albumin  may  be  present.  Alkalinity  of  the  urine  may  be  caused  by 
heematuria.  When  allowed  to  stand,  as  a  rule  the  tissue-products  do 
not  settle  promptly ;  hence  fully  twenty-four  hours  may  elapse  before 
the  pus,  epithelium,  and  mucus  have  settled  to  the  bottom  of  the  cylin- 
der. Then  we  see  a  grayish  granular  and  quite  thick  layer,  in  which 
are  pus-cells  and  bladder-epithelium  ;  if  hsematuria  exists,  there  is  a  red 
layer  of  blood  over  this,  and  floating,  cloud-like,  over  all  is  the  readily 
movable  mucous  layer. 

Microscopical  examination  of  the  urine  of  urethro-cystitis  shows  a 
conglomeration  of  tissue-products.  The  various  forms  of  epithelial 
cells  derived  from  the  posterior  urethra  Avill  be  found  inextricably  mixed 
with  the  large  flat  bladder-epithelium.  These,  with  pus-cells,  mucous 
corpuscles  (perhaps  a  few  gonococci),  many  and  varied  cocci  and  bac- 
teria, and  blood-corpuscles  cover  the  whole  field.  When  decomposition 
of  the  urine  has  occurred,  it  emits  a  foul  odor,  and  contains,  besides  the 
foregoing  elements,  triple  phosphates  and  myriads  of  bacteria. 

Cystoscopic  examination  in  cases  of  acute  urethro-cystitis  shows  a 
redness  and  swelling  of  the  prostatic  urethra  and  a  thickened  and  quite 
uniformly  deep-red,  velvety  appearance  of  the  portion  of  the  bladder- 
walls  involved.  The  vessels  sometimes  show  very  distinctly  an  arbor- 
escent interlacing  which  is  well  marked. 

Besides  the  prompt  and  acute  invasion  of  the  lower  part  of  the  blad- 
der from  the  posterior  urethra  which  has  just  been  considered,  there  is 
a  subacute  and  chronic  form  which  is  equally  as  common. 

Subacute  urethro-cystitis  may  develop  as  a  result  of  an  exacerbation 
of  chronic  posterior  urethritis.  When  this  occurs,  it  is  usually  as  a 
result  of  sexual  and  alcoholic  excesses,  great  physical  strain,  particularly 
in  horseback  riding,  wrestling,  and  bicycling.  Exposure  to  cold  in  the 
various  ways  incident  to  daily  life  is  also  productive  of  this  extension. 
In  some  cases  long  delay  in  urination,  and  in  others  the  introduction  of 
catheters  or  sounds,  have  caused  the  phlegmasia  to  spread  from  its 
urethral  seat  to  the  bladder-walls. 

In  these  cases  of  chronic  urethro-cystitis  the  symptoms  are  similar, 
but  less  pronounced  than  in  the  acute  form.  As  the  chronicity  of 
the  case  increases,  the  tenesmus,  and  other  symptoms  may  grow  much 
less  and  in  some  chronic  cases  cease  to  exist.  In  some  cases  of  first 
attack,  as  well  as  in  relapses  later  in  the  declining  stage,  patients 
complain  of  a  dull  and  uneasy  sensation  long  after  urination,  and 
they  speak  of  a  feeling  as  if  the  bladder  yet  contained  urine.  The 
catheter  being  passed,  half  an  ounce  to  an  ounce,  or  even  more,  of  urine 
flows  out.  In  these  cases,  owing  to  the  swelling  in  the  mucous  mem- 
brane and  its  subjacent  connective  tissue,  the  bladder  is  unable  to  expel 
all  the  urine.  This  uneasy  sensation  is  in  marked  contrast  with  the 
sharp,  sometimes  radiating,  pains  felt  at  the  end  of  urination.  It  is  a 
symptom  of  residual  urine.  As  a  result  of  the  chronic  inflammation,  in 
some  rare  cases  around  and  near  the  bladder-neck,  a  villous  condition  of 


186  GONORRHCEA  AND  ITS  COMPLICATIONS. 

the  mucous  membrane,  as  shown  by  a  quite  thickened  and  velvety  ap- 
pearance, is  produced,  which  gives  rise  to  hsematuria,  particularly  at  the 
end  of  urination.  In  some  of  these  cases  the  existence  of  a  bladder- 
tumor  might  very  properly  be  suspected. 

Acute  cystitis — meaning  inflammation  of  the  whole  of  the  mucous 
membrane  of  the  bladder — is  a  very  rare  complication  of  gonorrhoea, 
since  acute  posterior  urethritis,  even  when  it  invades  the  bladder,  usually 
only  involves  an  inch  or  two,  or  perhaps  more,  of  tissue  near  the  inter- 
nal sphincter.  Very  exceptionally  the  phlegmasia  extends  and  involves 
the  totality  of  the  mucous  membrane.  In  these  cases  the  symptoms  are 
still  those  of  acute  posterior  urethritis,  besides  which  there  may  be  pain 
over  the  symphysis  pubis,  malaise,  and  fever.  The  urine  is  very  opaque 
and  contains  bladder-epithelium,  pus,  and  bacteria. 

When  the  urine  is  tested  in  these  cases,  the  second  and  third  speci- 
mens are  even  cloudier  than  the  first.  In  the  early  stages  the  urine  is 
acid  and  has  no  foul  smell ;  later  it  may  be  alkaline  and  offensive. 

This  form  of  cystitis  may  end  in  one  or  two  months,  but  there  is  a 
marked  tendency  in  these  cases  for  the  process  to  become  subacute  and 
chronic.  Chronic  gonorrhoeal  cystitis  is  a  very  persistent  affection,  and 
often  resists  the  most  intelligent  treatment  directed  against  it.  Usually, 
with  the  involvement  of  the  whole  bladder,  the  symptoms  of  posterior 
urethritis  cease,  except  perhaps  that  a  little  increased  frequency  of  uri- 
nation remains.  In  the  older  cases  we  frequently  hear  patients  com- 
plain of  a  burning  or  scalding  pain  on  urination,  with  uneasiness  some- 
times amounting  to  a  paroxysm  of  pain  at  the  end  of  the  act.  Urina- 
tion may  be  quite  or  very  frequent  both  during  the  day  and  the  night. 
With  the  continuance  of  the  cystitis,  the  morbid  process,  which  at  first 
was  superficial,  involves  the  deeper  parts  of  the  mucous  membrane,  and 
forms  what  is  called  "parenchymatous  cystitis."  Progressing  farther, 
ulceration  of  the  bladder  may  result  or  the  morbid  process  may  extend 
up  the  ureters  and  involve  the  kidney  and  its  pelvis.  In  cases  of  chronic 
parenchymatous  cystitis  the  urine  is  usually  alkaline,  and  has  a  very 
foul,  even  feculent,  smell. 

The  diagnosis  of  gonorrhoeal  cystitis  is  to  be  made  by  a  study  of  the 
history  of  the  case  and  of  its  symptoms,  together  with  examination  of 
the  urine.  The  history  and  symptoms  have  already  been  fully  given. 
The  urine  varies  according  to  the  severity  and  chronicity  of  the  cystitis. 
It  may  be  simply  purulent  urine  of  acid  reaction  or  alkaline  and  fetid. 
The  three-glass  test  will  show  cloudiness  in  each  specimen,  more  par- 
ticularly in  the  last.  In  this  connection  it  is  important  to  remember 
that  alkaline  urine  from  phosphates,  carbonates,  and  urates  very  com- 
monly has  the  cloudy  look  of  purulent  urine,  but  its  nature  is  soon 
revealed  by  the  simple  method  recommended  by  Ultzmann.  If  the 
cloudiness  is  due  to  urates  or  uric  acid,  it  vanishes  by  the  use  of  heat. 
If  it  is  due  to  phosphates,  carbonates,  or  pus,  heat  increases  the  turbid- 
ity, but  a  few  drops  of  acetic  acid  will  clear  up  phosphaturia  and  carbo- 
nuria  (the  latter  with  much  effervescence),  while,  if  the  opacity  then 
remains,  it  is  caused  by  pus  or  bacteria. 

In  all  cases  the  microscope  should  be  constantly  used  in  the  exami- 
nation of  the  urine,  and  the  following  features  will  generally  be  found 
reliable  guides  in  diagnosis:  If  the  cystitis  is  still  rather  young  and  the 


URETHRO-CYSTITIS  AND   CYSTITIS.  187 

urine  is  still  acid,  on  its  examination  various  forms  of  urethral  epithe- 
lium, bladder-epithelium,  and  pus  will  be  discovered.  This  combination, 
the  history  being  in  accord,  will  usually  warrant  a  diagnosis  of  urethro- 
cystitis, partial  or  general.  When  the  process  is  old  and  the  urine 
alkaline,  and,  as  it  then  usually  is,  of  foul  smell,  withered-up  pus-cells, 
bladder-epithelium,  and  triple  phosphate  will  dominate  the  field  and 
establish  the  diagnosis.  The  absence  of  casts  and  renal  epithelium  will 
show  that  the  morbid  process  is  still  confined  to  the  bladder. 

Treatment. — In  acute  urethro-cystitis  and  cystitis  the  patient  should 
at  once  assume  the  recumbent  position.  A  plain,  bland  diet  of  bread 
and  milk,  and  rice  and  Indian  meal  with  milk,  should  be  ordered.  The 
bowels  should  at  once  be  acted  upon  and  kept  mildly  relaxed.  Pain 
may  be  relieved  by  suppositories  or  by  opium  by  the  mouth  or  morphine 
by  hypodermic  injection.  If  there  is  much  suprapubic  pain,  an  ice-bag 
may  be  applied  and  kept  on  if  it  affords  comfort.  In  some  cases  a  hot- 
water  bag  or  hot  flaxseed  poultice  will  be  indicated.  Hot  sitz-baths  and 
full  hot  baths  may  give  comfort. 

In  the  very  acute  stage  all  treatment  by  injections  should  be  stopped. 

The  older  practitioners  placed  much  reliance  upon  flaxseed  and  slip- 
pery-elm tea,  taken  quite  hot  and  copiously.  They  are  certainly  very 
acceptable  to  many  patients,  particularly  if  sweetened  a  little  and  flavored 
with  a  little  lemon-  or  orange-peel.  They  undoubtedly  act  in  a  beneficial 
manner  in  diluting  the  urine.  Infusions  of  buchu  and  of  uva-ursi  some- 
times seem  beneficial.  The  fluid  extract  of  triticum  repens  and  of  kava- 
kava  also  may  be  used,  either  alone  or  in  combination.  Thirty  drops 
of  each  in  plenty  of  water,  with  two  or  three  drops  of  laudanum  when 
the  pain  is  severe,  may  be  given  every  three  or  four  hours.  When 
opium  in  any  form  is  administered,  the  condition  of  the  bowels  must  be 
carefully  looked  after  and  constipation  avoided,  either  by  the  use  of 
enemata  or  of  aperients  or  cathartics. 

In  some  cases  alkalies  produce  a  soothing  effect.  Bicarbonate  of 
potassa  and  citrate  of  potassa  in  thirty-grain  doses,  dissolved  in  water 
or  carbonic  water,  may  be  given  three  times  a  day.  With  the  decline 
of  the  acute  and  the  onset  of  the  subacute  or  chronic  stage  the  use  of 
antiblennorrhagics,  cubebs,  copaiba,  and  oil  of  santal,  may  be  of  signal 
service  in  some  cases,  whereas  in  others  they  may  cause  actual  discom- 
fort. Their  effect,  then,  should  be  carefully  watched,  and  if  they  give 
decided  relief  they  may  be  continued;  if  not,  discarded.  Injections 
into  the  bladder  of  warm  solutions  of  boracic  acid  and  of  Thiersch's 
mild  solution  may  give  comfort  to  the  patient. 

In  the  subacute  and  chronic  stages  the  most  reliance  is  to  be  placed 
on  the  action  of  solutions  of  nitrate  of  silver,  used  at  first  very  w'eak 
and  increased  as  the  treatment  is  continued.  In  many  cases  much 
benefit  follows  the  injection  into  the  posterior  urethra  of  a  hand-sjn'inge- 
ful  of  a  warm  solution  of  nitrate  of  silver  (1 :  16,000,  and  as  strong  as 
1:4000).  This  agent  irrigates  the  posterior  urethra  and  passes  into 
the  bladder,  the  lower  part  of  which  it  acts  favorably  upon.  It  may  be 
retained  for  half  an  hour,  and  then  voided,  and  as  it  passes  out  it  again 
favorably  affects  the  morbid  surfaces.  Such  an  irrigation  may  be  made 
daily,  but  the  sensations  of  the  patient  must  be  the  guide  in  deciding 
its  frequency.       As  the  case  progresses  the  strength  of  the  solution 


188  QONOBEHCEA  ASD  ITS  COMPLICATIONS. 

should  be  cautiously  increased,  until  toward  the  last  instillations  of 
a  stronger  solution  of  nitrate  of  silver  (see  Treatment  of  Posterior 
Urethritis)  are  resorted  to. 

Solutions  of  permanganate  of  potassa  (gr.  j  to  warm  water  gvj  to  5viij) 
also  produce  good  results  in  some  cases.  Resorcin  (gr.  xlv-lxxv  to 
water  ^iij)  may  also  be  injected  into  the  bladder,  as  recommended  by 
Finger. 

Chronic  cystitis  from  gonorrhoea  is  usually  found  in  young  and 
middle-aged  patients.  Cystitis  from  stricture  and  hypertrophy  of  the 
prostate  is  usually  found  in  more  advanced  subjects. 

The  diagnosis  beino;  made,  and  the  absence  of  stricture  being  deter- 
mined,  general  and  local  treatment  should  be  instituted.  The  diet  must 
be  regulated  and  be  confined  to  bland,  easily-digestible  articles.  Coffee, 
spices,  beer,  alcoholics,  are  to  be  interdicted.  As  much  bodily  quiet 
and  ease  as  possible  should  be  observed.  In  these  cases  care  must  be 
exercised  in  the  use  of  alkalies,  which  some  physicians  seem  by  instinct 
to  prescribe  indiscriminately.  The  tendency  is  toward  alkalinity  of  the 
urine,  therefore  we  should  be  on  our  guard. 

When  the  urine  is  alkaline,  dilute  nitric  acid,  dilute  nitro-muriatic 
acid,  and  dilute  muriatic  acid  may  produce  decided  benefit.  Salol,  sa- 
licylate of  sodium,  benzoic  acid,  and  salicine  may  be  of  benefit  in  tend- 
ing to  restore  an  aseptic  condition  of  the  bladder,  Avhich  is  the  chief 
aim  of  treatment. 

Warm  injections  of  boric-acid-water,  of  Thiersch's  mild  solution,  and 
of  borax  and  water,  to  all  of  which  a  little  laudanum  may  be  added, 
may  be  of  benefit  for  a  time.  Then  the  indications  are  for  the  use  of 
more  decidedly  active  injections,  such  as  nitrate  of  silver,  permanganate 
of  potassa,  and  in  some  cases  of  alum  and  sulphate  of  zinc  in  combina- 
tion. The  strength  of  these  solutions  should  be  adapted  to  the  case, 
and  their  action  should  be  carefully  watched.  In  some  cases  benefit 
follows  the  injection  of  solutions  of  bichloride  of  mercury.  It  is  well  to 
begin  with  the  strength  of  1  part  to  30,000,  and  increase  if  progress  is 
made,  or  desist  if  a  feeling  of  discomfort  is  produced. 

These  cases  are  frequently  very  trying  to  the  patient  and  to  the 
surgeon,  whose  therapeutic  armamentarium  they  sorely  tax. 

As  a  last  resort,  perineal  section  should  be  performed  and  the  blad- 
der washed  out  and  drained.  Boric  solutions  and  Thiersch's  solution 
may  then  efi"ect  a  cure,  but  it  may  be  necessary  to  resort  to  nitrate  of 
silver,  permanganate  of  potassa,  or  bichloride  of  mercury. 


MEMBRANOUS  DESQUAMATIVE   URETHRITIS  189 


CHAPTER     XV. 

MEMBRANOUS  DESQUAMATIVE  URETHRITIS. 

Under  the  foregoing  title  a  number  of  cases  have  been  described  in 
which  patients  have  passed  membranous  flakes  or  cylinders  or  casts 
from  their  urethrse.  In  the  cases  thus  far  reported  we  find  a  marked 
variation  in  the  character  of  the  membranes  and  in  the  subjective  and 
objective  symptoms  of  the  patient  passing  them. 

Griinfeld^  by  means  of  the  endoscope  found  that  in  the  anterior  and 
posterior  urethra  the  walls  were  covered  with  grayish-white  strips  of 
membrane  parallel  with  the  long  axis  of  the  canal.  He  sometimes 
found  casts  of  the  urethra,  but  only  in  the  anterior  portion.  The  cases 
examined  Avere  those  of  acute  gonorrhoea.  In  like  manner  Rdna^  saw 
in  two  cases  of  acute  gonorrhoea  some  whitish  layers  of  tough  membrane, 
which  under  the  microscope  showed  the  elements  of  croupous  membrane. 
In  these  cases  the  fossa  navicularis  alone  was  involved. 

These  cases,  therefore,  are  illustrative  of  croupous  inflammation  oc- 
curring in  acute  gonorrhoea,  and  limited  to  the  fossa  navicularis  and 
to  the  anterior  and  posterior  urethra.  In  all  acute  gonorrhoeas  there  is 
more  or  less  croupous  exudation,  which  passes  out  as  detritus  in  the  pus. 

Zeissl^  reports  a  case  in  which  flakes  and  cylinders  one  and  a  half 
inches  long  were  passed  from  the  urethra  of  a  patient  who  suffered  from 
violent  pain  in  the  perineum.  The  author  considered  the  case  to  be 
one  of  croupous  inflammation  in  a  chronic  catarrhal  process  caused 
probably  by  strong  injections. 

Oberlander  describes  an  inflammation  of  the  urethra  in  Avhich  small 
layers  of  a  croupous  membrane  are  found.  The  affection  is  subacute  in 
character  and  unattended  with  pain.  These  flakes  may  be  thrown  off 
for  many  months.  They  gradually  grow  thinner  in  structure,  and 
finally  disappear.  Oberlander  thinks  that  this  urethral  inflammation  is 
similar  to  that  seen  in  the  mouth  and  called  "leukoplakia  buccalis." 

Zeissl's  and  Oberlander's  observations  go  to  show  that  there  is  a 
chronic  form  of  desquamative  croupous  urethritis. 

Two  very  interesting  cases  have  been  reported  by  Pajor,*  in  which 
patients  suffering  from  chronic  gonorrhoea  and  certain  peculiar  nervous 
phenomena  passed  true  epithelial  tubes  and  flakes  from  the  urethra. 

The  first  case  was  that  of  a  soldier  who  had  gonorrhoea  at  nineteen, 
which  was  followed  by  orchitis,  pollutions,  and  cystitis.  Nine  years 
later  he  suffered  from  neurasthenia  sexualis,  pollutions,  burning  in  the 
perineum,  and  itching  in  the  anus,  anaesthesia  of  the  right  half  of  the 
penis,  and  trembling  of  the  muscles  of  the  neck  and  extremities,  and 
general  prostration.  Endoscopic  examination  showed  that  the  mucous 
membrane  was  hard  and  rough  from  the  prostatic  urethra  to  the  fossa 

^  Die  Endoscopie  der  Harnrbhre  und  Blase,  1881,  p.  120. 
'^  "  Adatok  a  buja-sborhetegs,"  Orvosi  fietilap.,  ]  884. 
^  Zeitschrift  der  Gem'lhchafl  der  Aerzte,  Wien,  1852,  i.,  quoted  by  Pajor. 
*  "  Urethritis  meinbranacea  Desquamativa,"  Archiv  fur  Derm,  and  Syph.,  1889,  pp.  3 
et  seq. 


190  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

navicularis,  so  the  surface  was  touched  Avith  a  1  per  cent,  tincture  of 
iodine.  Two  such  applications  seemed  to  give  the  patient  relief.  He 
then  passed  a  fine  milk-white  membranous  tube  about  four  inches  long, 
resembling  the  delicate  inner  membrane  of  an  egg.  Fine  folds  or 
creases  ran  both  longitudinally  and  laterally  in  this  membrane,  and  gave 
it  the  appearance  of  a  snake's  skin.  This  patient  passed  other  shreds, 
but  was  soon  cured  by  the  local  treatment  both  of  his  urethral  trouble 
and  of  the  various  other  morbid  phenomena  mentioned. 

In  the  second  case  the  man  had  suifered  for  ten  years  Avith  chronic 
gonorrhoea,  and  he  entered  the  hospital  complaining  of  frequent  stran- 
gury, pain  in  the  urethra  running  to  the  groins,  and  a  profuse  grayish- 
white  discharge.  The  endoscope  showed  that  the  mucous  membrane  of 
the  urethra,  from  the  membranous  division  to  the  middle  of  the  pendu- 
lous portion,  was  of  a  whitish  color.  Applications  were  made  of  tincture 
of  iodine,  nitrate  of  silver,  and  lead-water.  A  few  days  later  the  patient 
passed  a  similar  membrane  to  that  of  the  preceding  case.  This  was 
repeated  three  times ;  then  the  strangury  and  discharge  ceased,  and  the 
patient  was  reported  as  improved.  Histological  examination  of  these 
membranes  showed  that  they  were  composed  of  stratified  pavement  epi- 
thelium with  large  nuclei,  round-cells,  and  wandering  cells. 

The  points  of  interest  to  be  emphasized  in  these  cases  of  Pajor  are 
the  peculiar  symptoms  and  the  formation  of  true  epithelial  cylinders. 
In  these  cases  the  morbid  process  involved  both  the  anterior  and  poste- 
rior urethra  at  the  same  time. 

In  the  cases  of  Grrunfeld,  Rona,  Zeissl,  and  Oberlander  the  urethra 
was  involved  more  or  less  in  its  continuity  and  in  regions  and  spots. 

Though  a  fcAV  cases  will  not  warrant  sharply-drawn  conclusions,  these 
seem  to  point  to  the  conclusion  that  there  is  a  croupous  urethritis  and  a 
Avell-defined  epithelial  desquamative  urethritis,  the  one  being  acute,  the 
other  chronic. 


CHAPTEE    XVI. 

EXTERNAL  URETHRITIS,  PREPUTIAL  FOLLICULITIS,  JUXTA- 
URETHRAL  SINUSES,  AND  FOLLICULAR  ABSCESSES  DUE  TO 
GONORRHOEA. 

Under  the  title  "  external  urethritis  "  we  understand  several  varieties 
of  chronic  inflammation  which  have  their  origin  in  gonorrhoea,  are  seated 
in  the  follicles  and  crypts  of  the  external  surfaces  of  the  penis,  and  are 
of  a  very  chronic  and  relapsing  character. 

Inflammation  of  the  Preputial  Follicles. 

During  the  course  of  acute  gonorrhoea  or  following  such  an  attack 
we  sometimes  see  running  in  the  long  axis  of  the  penis,  between  the 


EXTERNAL    URETHRITIS,   ETC.  191 

two  layers  of  the  prepuce,  a  little  line  of  inflammatory  tissue,  the  end 
of  which  is  usually  on  the  free  border  of  the  prepuce  or  just  within  its 
mucous  layer.  Careful  inspection  will  usually  show  that  this  little  line 
ends  in  a  minute  opening  of  the  size  of  a  pin's  head  or  of  a  pinhole, 
but  sometimes  it  may  not  be  visible  except  by  the  use  of  a  magnifying 
glass.  Pressure  on  this  little  blind  canal  usually  causes  a  small  droplet 
of  greenish  or  grayish  pus  to  exude  from  it.  This  sinus-like  lesion 
may  be  only  about  half  an  inch  long,  and  it  Avill  rarely  be  seen  longer 
than  an  inch.  The  calibre  of  these  lesions  varies,  since  in  some  only 
a  horsehair  can  be  introduced,  while  in  others  a  very  thin  probe  passes 
by  means  of  gentle  manipulation.  Sometimes  these  little  tubes,  which 
are  really  long  abscesses,  are  of  a  deep  even  a  dull  red,  but  as  they 
grow  older  they  lose  their  color  wholly  or  in  part,  and  are  then  recog- 
nized by  touch  as  small  firm  cords  between  the  skin  and  mucous  mem- 
brane. They  may  thus  remain  months,  and  even  years,  when  untreated. 
At  times  they  give  issue  to  no  discharge ;  then,  again,  particularly  after 
sexual  excess,  they  become  red  and  a  little  painful,  and  pus  may  be 
expressed  from  them.  These  little  sinus-abscesses  are  usually  seen  on 
the  sides  of  the  prepuce,  sometimes  down  toward  the  frsenum,  and  again 
on  the  median  line  corresponding  to  the  dorsum  of  the  penis. 

This  may  be  said  to  be  the  first  form  of  gonorrhoeal  preputial  follicu- 
litis. There  is,  however,  a  second  form,  in  all  probability  an  intensifi- 
cation of  the  first  form,  in  which  we  find  a  little  cherry-stone-sized  nodule 
or  abscess-cavity  situated  between  the  two  layers  of  the  prepuce  in  about 
the  same  position  as  that  of  the  first  form.  In  some  cases  I  have  seen 
these  little  round  or  oval  abscess-cavities  have  a  well-marked  outlet  duct. 
In  other  instances  the  opening  leads  almost  at  once  to  the  abscess-cavity. 
This  lesion  usually  runs  a  chronic  and  uneventful  course,  but  in  some 
cases  there  are  remissions  and  exacerbations  of  inflammation  in  greater 
or  less  degree.  In  many  cases  at  their  onset  these  little  tumors  are  the 
seat  of  pain,  heat,  and  swelling  of  the  contiguous  tissues.  This  prodro- 
mal inflammation  usually  subsides  in  a  few  days  or  in  a  week  or  two, 
and  the  afi"ection  then  passes  into  the  chronic  condition  above  described. 
In  short,  it  may  be  stated  that  in  all  forms  of  follicular  inflammation 
about  the  penis  the  course  of  the  disease  may  resemble  gonorrhoea  in  its 
acute  development,  merging  into  subacute  and  chronic  conditions. 

Usually  there  is  but  one  follicular  abscess;  very  rarely  two  are  found. 
During  the  exacerbations  of  these  chronic  sinuses  and  abscess-cavities 
there  is  danger  of  auto-infection  of  the  urethra.  They  may  at  these 
times  also  be  the  source  of  infection  of  women. 

It  is  therefore  a  follicular  abscess,  which  may  be  of  conical  shape  or 
its  surface  may  be  flattened.  These  lesions  are  peculiar  in  the  fact 
that  they  are  localized  and  circumscribed  abscesses,  and  are  not  usually 
attended  with  the  diffiise  spreading  of  the  process  into  the  connective 
tissue  which  we  find  in  periurethral  abscesses. 

There  is  still  a  third  form  of  preputial  abscess.  During  an  attack  of 
gonorrhoea  a  small  red  spot  is  sometimes  seen  on  either  side  of  the  frse- 
num  in  the  foss?e  formed  by  its  prominence  and  the  folding  over  of  the 
mucous  layer  of  the  prepuce  where  it  covers  the  glans.  This  little  red 
nodular  spot  soon  becomes  enlarged  and  elevated,  of  the  size  of  a  pea  or 
larger,  and  at  its  apex  a  minute  opening  may  be  seen.     An  abscess  of 


192  QONOBBHCEA  AND  ITS  COMPLICATIONS. 

this  kind  may  burst  and  heal  up,  or  after  the  pus  has  been  discharged 
and  the  inflammation  has  subsided  it  may  be  again  infected  by  the 
urethral  discharge,  and  again  be  the  seat  of  abscess.  This  process  may 
be  repeated  several  times.     Besides  this  nodular  lesion  of  the  frsenum 

Fig.  75. 


Follicular  abscess  of  the  prepuce  near  the  frsenum,  due  to  gonorrhoea. 

there  is  sometimes  present  there  a  tube-like  or  sinus-like  lesion,  such  as 
is  found  in  the  prepuce.  This  blind  sinus  is  affected,  as  the  other 
lesions  are,  by  varying  degrees  of  suppuration.  In  some  cases,  after 
the  evacuation  of  the  pus,  usually  by  pressure  or  perhaps  by  a  slight 
incision,  the  morbid  process  ceases  and  the  part  again  becomes  healthy. 
In  other  cases,  however,  the  abscess  is  very  persistent  and  rebellious  to 
treatment.  It  seemingly  heals,  and  then  only  a  little  hard  nodule  of 
fibrous  tissue  seems  to  be  left.  This  is  usually  so  small  that  the  dangers 
incident  to  its  existence  do  not  occur  to  a  person  unfamiliar  with  it. 
Then,  most  unexpectedly,  perhaps  as  a  result  of  gonorrhoea,  of  sexual 
excess,  or  want  of  cleanliness,  the  abscess-process  occurs  again.  This 
may  again  seemingly  pass  away,  and  again  break  out  anew  after  a  short 
or  long  interval.  This  morbid  condition  may  exist  over  a  period  of 
many  years.  Then,  again,  in  some  cases  the  nodule  grows  larger  and 
deeper,  and  perforation  of  the  urethra  may  occur,  the  process  not  being 
in  any  way  chancroidal.  I  have  seen  several  fistulse  thus  produced,  a 
part  of  the  urine  passing  through  them  ;  and  the  possibility  of  this  occur- 
rence has  taught  me  always  to  deal  promptly  and  radically  with  these 
not-infrequently-occurring  frpenal  abscesses  and  nodules.  Persons  hav- 
ing a  long,  tight,  or  a  straight  prepuce  or  one  with  a  small  orifice  are 
the  ones  Avho  suffer  most  from  the  chronicity  and  ofttime  recurrence  of 
these  little  lesions.  Then,  again,  persons  who  for  any  reason  suffer 
from  balano-posthitis  or  who  are  frequently  the  victims  of  gonorrhoea 
are  peculiarly  liable  to  these  abscesses,  with  their  annoying  exacerba- 
tions and  remissions.  It  is  not  uncommon  for  one  of  these  abscesses  to 
become  active,  and  for  its  pus  to  infect  the  urethra  of  its  bearer,  with- 
out any  infection  in  coitus. 

In  the  present  state  of  our  knowledge  it  is  impossible  to  definitely 
say  just  what  structure  is  involved  in  the  chronic  suppurative  process 
in  the  prepuce.  Odmansson'  thinks  that  they  originate  in  closed  and 
dilated  lymph-channels  which  have  opened  upon  the  skin   or  mucous 

^  "  Om  urethritis  externa,  silrskildt  hos  mannen  ocli  oni  cystabildningar  a  forhuden," 
Nord.  Med.  Ark.,  xvii.,  No.  5,  1885. 


EXTERNAL    URETHRITIS,   ETC.  193 

membrane.  He  claims  that  he  has  found  small  lymph-crypts  in  the 
prepuce.  These  statements  are  seemingly  not  based  on  histological 
study,  and  have  not  been  generally  accepted.  Careful  histological  studies 
of  these  preputial  sinuses  and  abscesses  have  been  made,  in  all,  in  five 
cases  by  Touton,'  Jadassohn,^  Fabry, ^  and  Pick,*  and  they  reach  the 
conclusion  that  the  structures  they  removed  and  studied  were  in  all 
probability  sebaceous  or  Tyson's  glands,  so  altered  by  the  morbid  pro- 
cess that  an  absolutely  certain  opinion  could  not  be  formed.  Neither 
of  these  observers  thought  the  lesion  occurred  in  the  diverticula  of  the 
skin,  the  cysterna  of  Von  During,  or  in  invaginations  of  the  epithelium. 
As  a  result  of  the  investigations  of  these  four  observers  it  seems  settled 
that  an  acute  suppurative  process  is  set  up  by  the  gonococcus,  and  that 
this  pathogenic  agent  retains  its  virulence  for  a  longer  or  shorter  period. 
After  a  time,  however,  it  disappears,  and  then  the  chronic  suppurative 
process  is  kept  alive  by  the  ordinary  microbes  of  suppuration. 

Suppuration  of  Follicles  of  the  Cutaneous  Investment  of  the  Penis. 

We  sometimes  see  on  the  under  surface  of  the  penis,  along  the  raph^ 
even  as  far  back  as  the  scrotum,  small  suppurating  sinuses  and  follicles 
which  usually  have  a  well-marked  outlet  which  is  directed  forward  toward 
the  glans  penis.  Sometimes  these  lesions  are  tube-like,  and  again  they 
feel  like  minute  nodules.  They  may  be  seen  in  an  active  state,  but 
usually  they  are  shown  to  the  surgeon  when  there  is  no  complicating 
hypersemia  and  only  the  slight  discharge  on  pressure  from  the  outlet 
duct.  There  is,  as  a  rule,  one  such  lesion,  but  sometimes  there  are  two, 
rarely  more. 

The  structures  involved  in  these  cases  are  undoubtedly  sebaceous  fol- 
licles, and  they  are  usually  associated  with  hair-follicles.  Similar  fol- 
licular inflammation  may  be  found  along  the  dorsum  of  the  penis,  on 
the  middle  line,  as  far  as  the  symphysis  pubis.  One  or  more  follicles 
may  be  involved.  When  inflamed,  any  of  these  follicular  swellings  may 
to  a  superficial  observer  look  like  chancre  or  chancroid.  Jadassohn 
thinks  that  these  cutaneous  follicular  abscesses  are  caused  by  the  gono- 
coccus. It  is  probable  that  in  some  cases  the  pyogenic  microbes  are  the 
cause  of  them. 

Juxta -urethral  Sinuses. 

Not  infrequently  patients  present  themselves  to  the  surgeon  com- 
plaining of  a  slight  but  persistent  discharge,  Avhich  they  say  comes  from 
one  or  both  lips  of  the  meatus.  Sometimes  the  affected  part  is  distinctly 
red,  and  again  it  may  appear  normal  in  tint.  It  sometimes  happens 
that  a  distinct  opening  can  be  seen,  and  it  is  usually  of  the  size  of  a 

'  "Ueber  Folliculitis  prseputialis  et  paraurethralis  gonorrhoica,  etc.,"  Arckiv  fiir  Derm, 
und  Syphili%  vol.  xxi.,  1889,  pp.  15  et  seq.,  and  "  Weitere  Beitriige  zur  Lehre  von  der 
Gonorrhoischen  Erkrankungen  der  Talgdriisen  am  Penis,  etc,"  Berlin,  klin.  Wochemchriff, 
No.  51,  1892,  pp.  1.303  et  seq.  These  essays  of  Toiiton  contain  elaborate  and  interesting 
studies  as  to  the  mode  of  invasion  of  the  gonococci  in  epithelial  tissues. 

a  "Ueber  die  Gonorrhcie  der  Paraurethralen  und  Prilputialen  Giinge,"  Deut.  med. 
Wochevschrift,  1890,  Nos.  25  and  2f). 

^  "Zur  Frage  der  Gonorrhfie  der  Paraurethralen  und  Prilputialen  Giinge,"  Monatshejte 
fiir  Prak.  Derra.,  vol.  xii.,  1891,  pp.  1  et  seq. 

*  "Ueber  ein  Fall  von  Folliculitis  Priiputialis  Gonorrhoica,"  Verhandlungen  der  Deut. 
Dermatol.  Gesellschaft  zu  Frag,  1 889,  pp.  258  et  seq. 
U 


194 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


pin's  head  or  of  a  pinhole.  Very  often  this  opening  is  hidden  in  the 
uneven  papillary  surface  of  the  meatus,  and  the  use  of  a  magnifying 
glass  is  required  to  make  it  clearly  visible.  Usually  pressure  on  the 
glans,  particularly  in  the  morning,  will  cause  a  droplet  of  pus  to  exude, 
and  thus  the  outlet  of  the  sinus  is  revealed.  Then,  again,  in  some  cases 
a  thin,  minute  crust  forms  from  escaping  pus,  and  removal  of  this  crust* 
reveals  the  hidden  orifice.  These  sinuses,  which  have  been  called  by 
my  friend,  Dr.  Otis,^  "follicular  sinuses,"  and  by  several  "  gonorrhoeal 
folliculitis,"  have  been  studied  by  Diday,=^  Harmonic,^  Campana,* 
Jamin,^  and  others.  They  are  usually  seated  on  one  or  both  lips  of  the 
meatus  at  about  a  sixth  or  third  of  an  inch  from  its  inner  margin.  In 
most  cases  the  sinus  is  seated  in  the  middle  of  the  lip  of  the  meatus, 
but  in  some  cases  it  opens  at  the  posterior,  and  quite  rarely  at  the  ante- 
rior, commissure.  There  may  be  one  or  two  such  sinuses  on  one  side, 
which  are  entirely  distinct  from  each  other ;  then,  again,  cases  are  seen 
in  which  it  is  probable  that  the  two  sinuses  are  connected.  These 
morbid  canals  usually  run  backward  parallel  with  the  urethra,  but  in 
some  cases  they  pass  obliquely  backward  and  inward,  and  open  in 
the  fossa  navicularis,  forming  the  meato-navicular  fistula.  I  have  seen 
several  cases  in  which  the  opening  was  just  within  the  lip  of  the  meatus. 
It  is  not  at  all  uncommon  to  find  small  follic- 
ular sinuses  which  open  upon  the  urethra  as  far 
back  as  an  inch  from  the  meatus. 

These  little  lesions  may  exist  for  years,  giving 
issue  to  a  slight  discharge  and  causing  no  uneasi- 
ness of  mind  or  body.  Some  patients  have  them 
and  pay  no  heed  to  them  ;  to  others  they  are  a 
source  of  worry  and  annoyance.  In  some  cases 
we  get  a  clear  history  of  their  onset  during  an 
attack  of  gonorrhoea;  in  others  they  seem  to 
originate  in  balanitis  and  balano-posthitis.  I 
have  seen  several  cases  in  which  these  sinuses 
appeared  and  disappeared  with  each  attack  of 
gonorrhoea.  As  a  rule,  however,  they  remain 
indolent  for  an  indefinite  time,  but  are  liable  to 
periods  of  exacerbation  in  which  they  become 
minute  but  conspicuous  abscesses,  as  may  be  seen  '^''^perfo1i^'fixa?eTba'tk)n°^  ^ 
by  inspection  of  Fig.  76.     The  introduction  of  a 

minute  probe  shows  that  these  sinuses  vary  in  length  from  one-third  to 
one-half  an  inch,  and,  very  exceptionally,  a  little  longer. 

It  sometimes  happens  that  these  follicular  lesions  of  the  meatus  appear 
at  the  same  time  that  those  of  the  frsenum  do.     This  is  well  shown  in  a 


Fig.  76. 


1  Stricture  nf  the  Male  Urethra,  etc.,  New  York,  1878,  pp.  9  et  seq. 

2  "  De  la  Blennor-rhagie  des  Follicules  muqueux  dn  Meat,  de  I'Urethre  chez  I'Homme," 
Guz.  hebdom.  de  Med.  et  de  Chir.,  1860,  vol.  vii.  pp.  725  et  seq. 

3  "  Des  Folliculites  blennorrhagiques  de  rHomme,"  Annates  Med.-Chir.  de  Marlmeau, 
Sept.,  188.3. 

*  "  FoUicolite  blennorrhagica,"  Gior.  Ital.  delle  Mai.  Ven.  e  delta  Pelte,  1884,  pp.  193 
et  seq. 

5  "Des  Fistules  juxta-urethrales  du  ^leat,"  Annates  des  Mai.  des  Organ.  Gihi.-urm., 
Yol.  iv.,  1886,  pp.  409  et  seq. 


EXTERNAL    URETHRITIS,   ETC.  195 

case  reported  by  Molinie/  in  which  there  was  a  sinus  on  each  lip  of  the 
meatus,  and  one  near  the  fr?enum.  All  these  sinuses  made  their  appear- 
ance on  the  third  day  of  an  attack  of  acute  gonorrhoea. 

These  suppurating  canals  may  be  the  cause  of  auto-infection,  and  in 
some  cases  they  may  secrete  gonococci-containing  pus  by  which  the 
female  may  be  contapainated. 

Much  has  been  written  as  to  the  bacteriology  of  these  juxta-urethral 
lesions,  but  true  scientific  knowledge  concerning  them  is  not  in  our 
possession.  According  to  my  reading  and  study,  the  case  may  to-day 
be  stated  as  follows :  It  is  probable  that  during  and  for  some  time  after 
an  attack  of  true  gonorrhoea  these  sinuses  give  forth  a  gonococci-con- 
taining pus,  and  that  in  their  chronic  condition  this  secretion  contains 
the  ordinary  pus-microbes.  Arising  as  they  do  both  during  gonorrhoea 
and  simple  balano-posthitis,  it  is  probable  that  in  some  cases  they  have 
as  a  morbific  agent  the  gonococcus,  and  in  others  the  ordinary  pus- 
microbes. 

No  histological  examinations  of  these  sinuses  have  yet  been  made. 
It  is  probable  that  they  originate  in  a  persistent  Tyson's  gland  or  in  a 
misplaced  Littre's  follicle. 

Treatment. — In  the  treatment  of  the  preputial  follicular  lesions  the 
best  course  is  thorough  extirpation  as  soon  as  possible.  If  the  surround- 
ing tissues  are  in  a  state  of  hypersemia,  it  is  well  by  pressure  or.  the  use 
of  the  knife  to  let  pus  out,  and  then  reduce  inflammation  by  the  use  of 
antiseptic  lotions.  Usually  there  is  such  a  redundance  of  tissue  in  the 
prepuce  that  thorough  removal  of  the  morbid  parts  is  possible  without 
any  damage  to  the  penis.  In  the  fosste  of  the  frsenum,  however,  these 
lesions  are  sometimes  imbedded  deep  in  the  tissues  and  are  adherent  to 
to  the  corpus  spongiosum.  In  such  cases  the  curette  may  often  be  freely 
used  to  advantage.  Each  case  will  present  its  peculiar  surgical  indi- 
cations, and  upon  these  the  judgment  of  the  surgeon  must  be  based. 
It  is  well  to  remember  that  in  some  cases  these  lesions  of  the  frsenum 
are  kept  in  an  active  state  by  balano-posthitis,  and  that  after  circum- 
cision the  source  of  irritation  ceases  and  the  part  soon  gets  well.  Cir- 
cumcision, therefore,  is  of  benefit  in  some  cases. 

When  there  are  two  follicular  abscesses,  one  on  each  side  of  the 
frasnum,  it  will  be  necessary  to  carefully  dissect  them  out,  and  perhaps 
at  the  same  time  remove  that  fibrous  cord. 

In  some  cases  in  the  subacute  stage  gentle,  firm  pressure  of  the  lesion 
once  a  day  will  express  the  contents,  and  in  the  end  may  cause  healing. 

Prompt  and  radical  measures  may  be  adopted  for  the  cure  of  suppu- 
rative follicles  of  the  integument  of  the  penis.  After  careful  asepsis 
the  lesion  may  be  incised  and  thoroughly  curetted.  It  will  then  heal 
readily  under  antiseptic  dressings. 

The  treatment  of  juxta-urethral  sinuses  is  much  more  difficult.  It 
is  sometimes  expedient  to  enlarge  the  sinus  Avith  a  very  small  bistoury, 
and  then  endeavor  to  obtain  healing  from  the  bottom  by  means  of 
stimulating  injections  and,  if  possible,  a  minute  tampon.  The  ordinary 
hypodermic  needle,  blunted  by  the  removal  of  its  point,  is  very  useful 
in  the  treatment  of  these  cases.     After  careful  cleansing  and  antisepsis 

^  "  Folliculite  glandulaire  blennorrhagique,"  Journal  des  Mai.  Cut.  et  Syphil.,  March, 
1893,  p.  165. 


196  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

a  drop  or  two  of  a  3  or  4  per  cent,  nitrate-of-silver  solution  may  be 
injected  every  second  day.  I  have  seen  good  results  from  the  intro- 
duction of  a  fine  probe  coated  with  pure  nitrate  of  silver  which  had 
previously  been  melted   by  heat. 

It  is  important  to  remember  that  not  infrequently  these  lesions  heal 
spontaneously  as  a  result  of  daily  firm  but  gentle  pressure  ;  therefore  it 
is  not  well  to  commence  an  active  treatment  until  evidence  of  chronicity 
is  assured. 

Martineau  claims  that  he  cured  many  cases  of  follicular  lesions  about 
the  penis  by  applying  the  galvano-cautery  cold  to  the  mouth  of  the  folli- 
cle, and  then  suddenly  turning  it  on  to  a  white  heat.  If  used  at  all 
near  the  meatus,  great  care  and  judgment  must  be  exercised. 


CHAPTER   XVII. 

PERI-URETHRAL    ABSCESSES. 


Abscesses  of  medium  and  large  size  are  not  infrequently  found  upon 
the  penis  near  the  frsenum  and  along  the  course  of  the  organ  as  far  back 
as  the  peno-scrotal  angle.  It  must  be  borne  in  mind  that  these  lesions 
are  of  greater  extent  and  severity  than  those  described  in  the  preceding 
chapter  as  follicular  inflammations. 

Peri-urethral  phlegmon  or  abscess  near  the  fr^enura  is  usually  a  con- 
comitant of  acute  gonorrhoea  or  it  may  occur  in  the  chronic  stage  of 
that  process.  In  some  cases,  in  primary  attacks,  it  appears  during  the 
height  of  the  urethral  suppuration,  in  others  toward  the  period  of 
decline,  and  only  exceptionally  in  the  later  stage.  It  usually  begins 
as  a  red  and  tender  spot  on  one  side  of  the  fr^enum.  This  inflammatory 
condition  may  increase  rapidly,  and  again  its  growth  may  be  rather 
slow.  In  either  event  it  is  soon  seen  that  an  abscess  is  in  process  of 
formation.  These  abscesses  are  in  general  round  and  globular,  but  their 
shape  is  determined  by  the  topographical  arrangement  of  the  frsBnum 
and  the  tissues  forming  its  fossae  and  the  prepuce.  Sometimes  the 
tumor  is  round,  and  again  it  may  be  oval  shape.  In  Fig.  77  an  oval 
abscess  of  the  left  frsenal  fossse  is  well  shown.  In  this  case  the  inflam- 
matory process  was  very  active  and  gave  rise  to  oedema,  which  produced 
moderate  paraphimosis. 

Perhaps  in  the  majority  of  cases  these  abscesses  occur  unilaterally 
and  are  tolerabl}^  well  circumscribed.  When  of  goodly  size  the  inflam- 
matory oedema  which  accompanies  the  suppurative  process  may  involve 
the  tissues  on  the  unafi'ected  side  of  the  penis.  This  is  also  well  shown 
in  Fig.  77. 

Then,  again,  in  somewhat  exceptional  cases  an  abscess  forms  in  one 
frsenal  fossa,  increases  rapidly  and  extensively,  and,  passing  under  the 


PERI-URETHRAL   ABSCESSES. 


197 


frjBnum,  involves  the  other  fossa  in  the  suppurating  process.     This  is 
■well  shoAvn  in  Fig.  78,  in  which  all  the  connective  tissue  at  the  under 


Fig. 


Fig.  78. 


Abscess  near  the  franum,  producing 
moderate  paraphimosis. 


Abscess  near  the  frsenum,  involving  both 
fossee. 


The  frgenum  then 


Fig.  79. 


part  of  the  glans  is  involved  in  abscess-formation, 
divides  the  abscess  into  two  lobes. 

It  also  happens,  somewhat  rarely,  that 
the  tissues  of  each  fossa  of  the  fraenum 
become  affected  separately,  in  which  event 
there  are  two  distinct  abscesses.  This  oc- 
currence is  well  shown  in  Fig.  79. 

In  any  of  these  cases  the  patient  ex- 
periences more  or  less  pain  at  the  part  in- 
volved. In  somewhat  rare  instances  there 
is  constitutional  disturbance,  as  shown  by 
chills,  fever,  and  loss  of  appetite.  The 
pressure  of  the  tumor  upon  the  urethra 
may  affect  the  force  and  shape  of  the 
stream  of  urine  or  occasion  dysuria 
amounting  even  to  retention. 

It  is  not  definitely  known  how  and 
where  the  suppurative  process  begins  in 
these  cases.     It  certainly  originates  in  the 

pus  of  acute  or  chronic  gonorrhoea.  I  have  paid  particular  attention  to 
this  point,  and  as  a  result  of  careful  inquiry  I  can  say  that  I  never  saw 
an  abscess  of  the  frsenum  without  there  being  obtainable  a  history  of 
gonorrhoea  more  or  less  recent.  It  may  be  that  this  affection  begins,  as 
does  that  described  in  the  previous  chapter  (page  193),  in  a  follicle  or 
crypt.  If  that  is  the  case,  the  walls  of  these  structures  are  soon  de- 
stroyed,  and  a  diffuse  cellular-tissue  abscess  is  produced.      Clinically, 


Abscess  111  each  fossa  of  the  fraenum. 


198  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

however,  we  have  the  two  forms  of  lesions  as  I  have  described  them — 
the  one  quite  circumscribed  and  probably  of  follicular  or  cryptic  origin, 
the  other  a  diffuse  cellular-tissue  abscess,  which  may  possibly  have  had 
its  origin  in  an  infected  follicle  or  crypt.  When  incised  and  properly 
treated  these  abscesses  may  heal  up  promptly.  In  some  cases,  however, 
particularly  when  proper  care  has  not  been  taken,  the  abscess-cavity  con- 
tracts into  a  small,  firm,  inflammatory  nodule  which  remains  indefinitely. 
This  inflammatory  nodule  sometimes  redevelops  into  an  abscess  with 
each  recurrent  attack  of  gonorrhoea.  I  have  seen  cases  in  which  they 
led  to  the  formation  of  a  urethral  fistula. 

Abscesses  of  the  Follicles  of  the  Urethra. — These  lesions 
begin  as  inflammatory  foci  either  in  Littre's  follicles  or  the  crypts  of 
Morgagni.  During  the  acute  and  declining  stages  of  gonorrhoea  we 
frequently  feel  with  the  finger-tips  one  or  more  or  many  little  millet-seed 
and  even  larger  nodules  in  the  corpus  spongiosum.  These  little  circum- 
scribed swellings  are  undoubtedly  swollen  follicles.  In  most  cases,  for 
the  reason  that  we  find  gonococci  in  the  pus  coincidently  with  the  follic- 
ular inflammation,  it  is  fair  to  assume  that  the  morbid  process  is  caused 
by  those  microbes.  Follicular  inflammation  occurring  after  the  cure  of 
gonorrhoea — a  not  very  frequent  condition — may  be  due  to  the  action  of 
other  microbes,  perhaps  the  streptococci  or  staphylococci.  It  may  be 
stated  quite  positively  that  in  most  of  the  cases  of  gonorrhoeic  follicular 
inflammation  resolution  takes  place  synchronously  with  the  cessation  of 
the  major  process. 

Follicular  abscesses  of  the  urethra  may  develop  m  the  fossa  navicu- 
lars. These  suppurations  are  here,  as  a  rule,  not  of  large  extent,  the 
abscess  being  usually  of  the  size  of  a  pea.  The  smallness  of  the  follicu- 
lar abscess  in  this  region  is  probably  due  to  the  density  of  the  tissues 
and  to  the  absence  of  much  connective  tissue.  Usually,  when  the  pro- 
cess is  complete,  pus  is  discharged  into  the  urethra,  and  a  short  sinus 

Fig.  80. 


Abscess  of  the  follicles  of  the  urethra. 


leading  to  a  small  cavity  is  left.  This  may  heal  of  itself  or  may  require 
local  treatment.  In  somewhat  rare  cases  the  abscess  of  the  fossa  navicu- 
laris  extends  deeply  into  the  tissues  and  opens  on  the  outside  in  either 
fossa  of  the  frasnum.  In  this  event  there  is  much  danger  of  a  perma- 
nent urethral  fistula.      Careful  treatment,   aided    by  naUire,   or  nature 


PERI-  URETHRAL  ABSCESSES. 


199 


alone,  may  close  up  the  wound,  but  there  is  always  a  strong  probability 
that  the  fistula  will  be  permanent. 

Farther  down  the  urethral  canal  follicular  abscesses  are  not  at  all 
uncommon.  They  begin  as  small,  round,  painful  swellings,  which  in 
their  early  stage  are  easily  circumscribed  by  the  fingers.     They  usually 


Fig.  81. 


Unilateral  abscess  of  tlie  follicles  of  the  urethra. 

go  on  more  or  less  promptly  to  suppuration,  which  is  attended  by  much 
inflammatory  oedema  of  the  corpus  spongiosum  and  the  connective  tissue 
external  to  it.  In  Fig.  80  is  well  shown  a  follicular  abscess  which 
began  about  one  inch  behind  the  fossa  navicularis. 

Occasionally  the  follicular  abscess  is  seated  on  one  side  of  the  penis, 

Fig.  82. 


Large  abscess  of  the  follicles  of  the  urethra  during  gonorrhoea. 

though  the  inflammatory  oedema  may  extend  to  the  other  side.  This  is 
well  shown  in  Fig.  81,  in  which  the  abscess  was  seated  about  an  inch 
and  a  half  from  the  meatus.     The  two  preceding  figures  (80  and  81) 


200 


GONOBBH(EA   AND  ITS  COMPLICATIONS. 


will  give  a  good  general  idea  of  the  size  of  these  lesions.  But  these 
abscesses  in  the  pendulous  portion  of  the  penis  sometimes  become  very 
large — a  fact  well  brought  out  by  the  appearance  presented  by  Fig.  82. 
It  will  be  seen  that  the  phlegmonous  process  complicated  an  acute 
attack  of  gonorrhoea. 

In  quite  rare  instances  the  abscess  increases  sloAvly  and  without 
marked  inflammatory  symptoms.  The  swelling  becomes  more  and  more 
salient  above  the  tegumentary  level  of  the  penis,  until  in  the  end  a  well- 
marked  pedunculated  tumor  or  abscess-formation  is  produced.  This 
feature  is  clearly  portrayed  in  Fig.  83.     In  this  connection  it  may  be 

Fig.  83. 


Chronic  pedunculated  abscess  of  urethra. 


Abscess  of  the  follicles  of  the  urethra 
(tenth  attack.) 


interesting  to  remark  that  I  once  saw  a  pea-sized  sebaceous  tumor  or  wen 
on  the  under  middle  part  of  the  pendulous  portion  of  the  urethra.  As  a 
result  of  irritation  the  integument  over  this  wen  was  inflamed  and  tender, 
and  the  appearances  were  strikingly  suggestive  of  follicular  abscess  of 
the  penis. 

The  tendency  to  relapse  observed  in  these  follicular  urethral  lesions 
is  shown  in  Fig.  84,  in  which  a  large  swelling  (the  tenth  of  a  series)  of 
the  middle  of  the  under  part  of  the  penis  is  portrayed.  As  is  common 
in  these  relapsing  phlegmons,  the  inflammatory  process  was  not  very 
acute,  though  there  was  considerable  suppuration. 

In  most  of  these  cases  of  follicular  suppuration  of  the  urethra  the 
swelling  is  out  of  all  proportion  to  the  amount  of  suppuration.  There 
is,  as  a  rule,  very  much  inflammatory  oedema,  but  the  suppurating  cavity 
usually  contains  from  half  a  drachm  to  a  drachm  of  pus.  In  very  large 
phlegmons  two  or  three  drachms  may  be  found. 

There  are  two  dangers  to  be  looked  for  in  these  cases  of  follicular 
abscess  of  the  urethra.  The  one  is  urethral  fistula ;  the  other  is  the  for- 
mation, after  the  abscess  bursts  into  the  urethra,  of  an  inflammatory  nod- 


PERI-URETHRAL  ABSCESSES.  201 

Tile.  This  inflammatory  nodule  is  always  a  menace  to  the  patient.  It 
resolves  itself  into  a  little  lump,  in  most  cases  easily  felt,  usually  on  the 
lower  wall  of  the  urethra.  In  this  latent  condition  occasionally  it  may 
be  so  small  and  insignificant  that  it  can  be  scarcely  felt,  but  during 
erection  its  presence  is  readily  made  out.  It  may  thus  remain  for  months 
or  years.  But,  as  a  rule,  with  every  recurrence  of  gonorrhoea  the  sup- 
purative process  lights  up  again  and  a  new  abscess  is  formed.  This  may 
occur  again  and  again  for  many  years.  I  have  seen  as  many  as  twelve 
recurrences  of  this  process.  In  many  cases  in  these  repeated  attacks 
the  swelling  is  about  of  the  same  severity  in  each.  In  some  cases,  how- 
ever, the  abscess-formation  becomes  more  intense,  and  pus  is  discharged 
externally  through  the  inflamed  and  eroded  skin.  In  these  unfortunate 
cases  a  urethral  fistula  remains,  which  is  usually  permanent  and  requires 
for  its  relief  a  plastic  operation.  In  favorable  cases  the  inflammatory 
nodule  undergoes  contraction,  and  finally  ends  in  a  small  cicatrix. 

In  many  of  these  cases  of  follicular  phlegmon  of  the  urethra  the  mor- 
bid process  is  limited  to  the  urethral  wall  proper,  and  it  is  in  these 
cases,  even  when  suppuration  occurs,  that  resolution  and  cure  commonly 
result.  In  the  more  severe  cases  the  follicular  abscess  increases  beyond 
the  urethral  tissue  proper  into  the  connective  tissue  between  it  and  the 
corpus  spongiosum.  It  may  continue  still  farther  and  involve  more  or 
less  or  all  of  the  corpus  spongiosum.  As  the  suppurative  process  thus 
progresses  outwardly,  in  most  cases  a  wise  provision  of  Nature  occurs. 
With  the  establishment  of  the  suppurative  process  in  the  deep  part  of 
the  urethral  wall,  or  in  the  contiguous  connective  tissue,  or  in  this  and 
in  the  corpus  spongiosum,  an  adhesive  inflammation  obliterates  the  little 
follicular  cavity  in  the  urethral  wall,  the  damage  is  repaired,  and  the 
then  outlying  abscess  is  shut  off  from  all  communication  Avith  the  ure- 
thra. This  abscess  then  has  as  its  base  the  healed  urethral  wall,  while 
its  sides  and  roof  are  formed  by  the  infected  tissues  of  the  corpus  spon- 
giosum, the  subcutaneous  connective  tissue,  and  the  skin  itself. 

In  some  cases,  unfortunately,  this  walling  off"  of  the  abscess-cavity 
by  adhesive  inflammation  does  not  occur,  and  then  there  is  much  reason 
for  apprehension  that  a  permanent  fistula  will  follow  the  resolution  of 
the  inflammatory  process.  Even  should  urine  escape  in  these  cases,  all 
hope  need  not  be  given  up,  since  sometimes,  most  unexpectedly,  healing 
takes  place,  the  urethra  is  not  left  perforated,  and  we  find  at  the  seat  of 
the  trouble  a  little  line  or  nodule  of  firm  structure  which  Ave  know  is  the 
cicatrix.  When,  however,  the  parts  are  well  healed  and  a  sinus  re- 
mains, it  may  usually  be  looked  upon  as  permanent,  unless  relieved  by 
a.  plastic  operation. 

There  is  still  another  condition  which  is  sometimes  observed.  The 
abscess  opens  into  the  urethra,  and  there  is  left  a  cavity  and  an  internal 
blind  fistula  or  sinus  leading  to  it.  In  favorable  cases  the  parts  retract 
until  the  lesion  ends  in  a  little  cicatricial  mass.  But  sometimes  this 
happy  result  is  not  attained,  and  the  cavity  and  its  duct  remain.  Then 
urine  leaks  into  the  wound,  and  sloAvly  or  (juickly  an  abscess  again 
forms.  This  may  occur  again  and  again,  and  may  finally  end  in  a  fistula 
leading  from  the  urethra  to  the  outside.  Then,  again,  even  when 
abscesses  have  repeated  themselves  under  these  conditions  many  times, 
thorough  healing  may  finally  occur. 


202 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


Abscesses  of  Cowper's  G-lands. — These  abscesses,  which  are  not 
common,  begin  in  these  glands,  which  are  seated  between  the  two  layers 
of  the  triangular  ligament.  They  usually  occur  at  about  the  same  period 
as  epididymitis,  during  the  third  or  fourth  week  of  gonorrhoea  or  later. 
Usually  but  one  gland  is  affected,  quite  exceptionally  two  are  involved, 
and  in  this  they  are  similar  to  abscess  of  Bartholin's  gland.  The 
peculiarity  of  these  abscesses  is  that  they  are  seated  on  either  side  of 
the  raphe  or  median  line.  In  their  early  stages  these  phlegmons  are 
felt  as  little  cherry-sized  round  or  oval  swellings  just  at  the  triangular 
ligament.  With  the  development  of  the  abscess-process  the  patient 
experiences  pain,  uneasiness,  and  tension  in  the  perineum  near  the 
bulb,  which  is  aggravated  in  the  sitting  position,  in  walking,  and  by 
pressure  and  friction  of  the  clothes.  With  the  increase  in  the  phleg- 
monous process  the  pain  becomes  severe,  and  in  many  cases  there  are 
chills,  fever,  and  malaise.  Owing  to  the  swelling,  the  urethra  is  not  un- 
frequently  pressed  upon,  and  dysuria,  and  even  retention,  may  result.  As 
the  abscess  increases  in  size  it  pushes  outward  and  forms  a  tense  red 

Fig.  85. 


Abscess  of  Cowper's  gland. 


swelling  in  the  perineum,  or  it  pushes  forward  and  juts  out  at  the  peno- 
scrotal angle.  While  at  first  the  swelling  is  seated  on  one  side  of  the 
raph^,  when  it  becomes  very  extensive  it  encroaches  on  the  opposite  side. 


PERI-URETHRAL  ABSCESSES.  203 

This  condition  is  well  shown  in  Fig.  85.  When  the  abscess  is  very  large, 
as  it  somewhat  rarely  is,  the  whole  perineum  becomes  red  and  swollen. 

In  most  cases  abscess  of  Cowper's  glands  is  an  acute  process,  but  in 
some  it  takes  place  quite  slowly.  Usually  the  swelling  extends  from 
the  bulb  into  the  tissue  beyond,  and  the  abscess  either  opens  or  is 
opened  in  the  perineum  or  in  the  scrotum.  The  further  course  of  these 
abscesses  is  similar  to  that  of  those  just  described.  The  abscess  may 
be  walled  off,  and  then  when  opened  may  be  healed  from  the  bottom,  or 
the  sinus  leading  into  the  urethra  may  remain  patulous,  in  which  case 
there  is  left  a  perineal  or  scrotal  fistula.  In  my  experience,  in  the 
majority  of  cases  the  urethral  wound,  which  consists  of  the  duct  of  the 
gland  in  a  state  of  inflammation,  heals,  and  no  bad  results  are  finally 
left.     In  rather  exceptional  cases  a  fistula  is  left. 

It  sometimes  happens,  particularly  when  the  abscess  is  not  very  large, 
that  it  opens  through  the  duct  into  the  bulb,  and  the  pus  then  escapes 
through  the  urethra.  In  this  event  it  may  happen  that  subsequent  con- 
traction may  obliterate  the  abscess-cavity  and  its  duct.  Then,  again,  it 
is  rather  more  common  to  find  that  considerable  contraction  occurs — 
that  the  morbid  process  becomes  circumscribed  to  a  nutmeg-sized  or  even 
larger  mass,  and  this  may  remain  indolent.  This  condition  is  always 
one  of  ill  omen,  since  it  so  frequently  forms  a  focus  for  the  re-forma- 
tion of  abscesses.  Thus  one  phlegmon  after  another  may  form  and 
burst  into  the  urethra  over  a  period  of  many  years.  Sometimes  this 
recurrence  of  the  phlegmonous  process  is  lighted  up  by  fresh  attacks  of 
gonorrhoea  or  by  exacerbations  of  a  chronic  gonorrhoeal  process.  Then, 
again,  in  many  instances  the  new  suppuration  is  seemingly  due  to  the 
leakage  of  urine  into  the  inflamed  nodule. 

Quite  rarely  still  another  course  may  be  taken  by  the  Cowper's-gland 
abscess.  In  the  original  inflammation  there  may  be  considerable 
oedematous  hyperplasia  of  the  gland  and  tissues  immediately  surround- 
ing it,  and  some  pus  may  be  formed,  but  the  whole  abscess-swelling  is 
of  a  subacute  character,  and  less  in  size  than  a  walnut.  After  the 
escape  of  the  pus  a  nodule  is  left,  which  for  a  time  may  or  may  not 
remain  quiescent.  Then  it  gradually  grows,  and  a  firm  somewhat  pain- 
ful swelling,  without  much  redness,  appears  in  the  perineum.  This 
swelling,  which  is  for  a  long  time  on  one  side  of  the  raphe,  increases 
very  slowly,  occupying  two  and  even  many  months  in  its  course.  It 
presents  a  hard,  firm  structure,  and  fluctuation  cannot  be  detected  for 
a  long  time.  Finally,  the  necessity  for  opening  the  abscess  becomes 
evident,  pus  escapes,  and  usually  a  fistula  leading  to  the  bulbous  urethra 
is  left.  But  even  in  these  cold  chronic  abscesses  the  walling  oflf  of  the 
suppurative  process  may  occur  and  no  fistula  may  be  left. 

In  all  probability,  abscesses  of  Cowper's  glands  begin  originally  by 
infection  from  gonococcus-invasion.  Pellizzari^  cautiously  collected  the 
pus  of  three  peri-urethral  abscesses,  and  in  it  found  the  gonococcus.  In 
three  hospital  cases  of  Cowper's-gland  abscesses,  every  precaution 
against  contamination  having  been  exercised,  in  all  specimens  of  the 
pus  the  gonococcus  in  sparing  quantity  was  found  by  me. 

Treatment. — All  these  forms  of  abscess  should  be  treated  on  general 

i"Il  Diplococco  di  Neisser  negli  ascessi  hlennorrhagici  peri-urethrali/'  Giornale  lial. 
delle  Mai.  Ven.  e  delta  Pelle,  1890,  pp.  134  et  seq. 


204  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

surgical  lines.  Until  the  suppurative  process  is  ripe  it  is  well  to  apply 
cooling  lead-and-opium  or  muriate-of-ammonia  or  carbolic  lotions. 
When  fluctuation  is  felt,  a  good,  liberal,  but  careful  incision  should  be 
made,  and  the  abscess-cavity  should  be  thoroughly  cleansed  with  a  bi- 
chloride solution  or  irrigation  with  carbolic  water.  Then  the  wound 
should  be  dressed  with  iodoform  or  aristol  and  stuffed  with  gauze.  In 
the  event  of  a  fistula  being  left  leading  into  the  urethra,  it  will  be  neces- 
sary to  resort  to  a  plastic  operation  when  the  inflammation  has  fully 
subsided. 

In  cases  of  abscess  of  CoAvper's  glands  it  is  not  well  to  be  too  prompt 
in  operating.  In  these  cases  poultices  do  much  harm  by  causing  a 
spread  of  the  inflammatory  oedema.  The  best  plan  of  treatment  in  the 
developing  stage  of  this  abscess  is  to  keep  the  parts  well  covered  with 
absorbent  cotton  saturated  with  lead-and-opium  wash  or  with  a  2  per 
cent,  carbolic-acid  watery  solution.  It  should  always  be  remembered 
that  sometimes  these  abscesses,  even  when  they  have  attained  the  size 
of  a  large  walnut,  may  gradually  undergo  retrogression  and  finally  dis- 
appear. The  best  rule  for  guidance  is  to  watch  the  case  carefully,  and 
as  soon  as  fluctuation  is  well  made  out  to  incise  the  parts  freely,  and 
then  irrigate  and  dress  the  wound  antiseptically.  In  most  cases  the 
abscess  does  not  perforate  the  urethra,  and  healing  promptly  occurs. 
When  there  is  a  fistula  into  the  urethra,  the  parts  may  often  be  healed 
and  their  integrity  restored  by  careful  and  methodical  packing  of  the 
wound  from  the  bottom.  In  these  somewhat  deep  wounds  balsam-of- 
Peru  gauze  is  often  very  beneficial. 


CHAPTER  XVIII. 
GONORRHCEA  OF  THE  RECTUM. 

Within  the  past  few  years  our  knowledge  of  this  subject  has  been 
much  increased  and  has  been  made  more  precise.  So  many  well- 
authenticated  cases  of  gonorrhoea  of  the  rectum  have  been  reported  that 
no  doubts  are  now  entertained  as  to  the  susceptibility  of  this  gut  to 
the  irritation  of  gonorrhoeal  pus  and  to  the  occurrence  of  a  resulting 
specific  suppurative  process  in  it.  It  is  an  affection  more  or  less  fre- 
quently observed  in  countries  in  which  sodomy  is  practised,  but  instances 
of  it  are  not  frequent  in  the  United  States.  I  have  seen^  in  all,  three 
well-marked  cases,  and  in  the  discharge  from  one  (a  recent  case)  I  found 
gonococci. 

Much  of  the  literature  of  this  subject  is  unsatisfactory  ;  therefore  I 
shall  merely  mention  some  of  the  cases  reported  within  a  few  years : 

Thiry  ^  reports  the  case  of  a  woman,  aged  twenty-four,  who  suffered 
from  weight  and  shooting  pains  in  the  pelvis,  pain  in  defecation,  and  a 

^  "  Kectite  blennorrhagique,  et  cet.,"  Presse  Med.,  Beige,  1882,  xsiv.  pp.  201-203. 


GONORRHCEA    OF  THE  RECTUM.  205 

constant  thick  discharge  from  the  rectum.  She  had  a  funnel-shaped 
anus,  the  folds  of  which  were  obliterated,  and  the  sphincter  was  weak 
and  dilated.  The  lower  portion  of  the  rectum  was  acutely  inflamed  and 
studded  with  bright-red  points  which  bled  freely.  The  follicles  were 
enlarged  and  from  them  pus  escaped.  The  woman  confessed  to  sodomy 
with  men  suffering  with  gonorrhoea. 

Winslow  ^  reports  an  epidemic  of  gonorrhoea  in  a  Baltimore  institu- 
tion for  boys  from  nine  to  twenty-one  years  old,  which  originated  in  the 
following  manner :  A  boy  who  Avas  on  leave  of  absence  contracted  gonor- 
rhoea from  a  girl,  and  was  suffering  from  it  on  his  return  to  his  duties. 
Before  he  was  cured  he  had  anal  coitus  with  another  boy,  who  from  it 
became  infected.  From  this  boy  with  rectal  gonorrhoea  many  other  boys 
contracted  the  disease.  Ten  such  cases  are  recorded,  and  it  is  stated 
that  it  w^as  probable  that  there  were  other  cases  which  were  not 
reported. 

The  most  satisfactory  case  is  that  of  Frisch.^  It  was  of  a  girl  seven- 
teen years  old  who,  fifteen  days  after  unnatural  intercourse,  complained 
of  burning  pain  in  the  rectum,  particularly  during  defecation.  The 
peri-anal  region  was  reddened  and  excoriated,  and  from  the  anus,  nar- 
rowed by  inflammation,  a  thick  greenish-yellow  pus  escaped.  In  this 
secretion  and  in  that  from  the  genitals  myriads  of  gonococci  were 
found. 

Tuttle^  reports  two  cases  of  rectal  gonorrhoea  in  men  and  one  in  a 
woman  due  to  sodomy,  in  the  secretions  of  all  of  which  gonococci  were 
found. 

Cases  of  women  suffering  from  rectal  gonorrhoea  in  which  the  gono- 
coccus  has  been  found  have  been  reported  by  Neisser  and  Bumm.  Cases 
of  auto-infection  with  rectal  gonorrhoea  have  also  been  reported.  Rol- 
let*  reports  the  case  of  a  man  suffering  from  gonorrhoea  who  was  also 
affected  with  constipation.  It  was  his  custom  to  aid  defecation  by 
introducing  his  finger  into  the  rectum.  By  this  manoeuvre  his  finger, 
being  soiled  with  pus  from  his  urethra,  infected  that  organ.  Dock^ 
reports  a  case  of  urethral  inflammation  in  a  male  twenty-five  years  old, 
which,  as  regards  its  gonorrhoea!  nature,  is  not  quite  satisfactory,  but 
which  presented  a  typical  clinical  picture  of  gonorrhoea  of  the  rectum. 
In  this  case  infection  is  supposed  to  have  occurred  by  means  of  a  finger 
soiled  with  gonorrhoeal  pus  which  was  introduced  into  the  rectum  for  the 
insertion  of  suppositories.  Careful  microscopical  examination  showed 
the  presence  of  gonococci. 

Etiology. — It  will  be  seen  from  a  consideration  of  the  foregoing  cases 
that  a  virulent  proctitis  is  not  uncommonly  met  with,  due  to  infection 
with  gonococci-containing  pus.  In  most  of  the  cases  the  infection 
occurs  as  the  result  of  sodomy,  more  frequently  in  women  and  3^oung 
boys,  but  also  in  older  males,  the  active  agent  suffering  at  the  time  from 

^  "  Report  of  an  Epidemic  of  Gonorrhoea  contracted  from  Rectal  Coition,"  31cd.  News, 
Aug.  14,  1886. 

^"Ueber  gonorrhoea  rectalis,"  Verhandl.der  Phys.-med.  Gesellsch.zu  Wurzbtin/, 1S91-92, 
N.  R.,  pp.  167  et  seq. 

'^  "Gonorrha-a  of  the  Rectum,"  N.  Y.  Med.  Journal,  April  3,  1892,  p.  379. 

*  Diciionnnire  eneyclop.  des  Sciences  med.,  art.  "  Anus  (Maladies  v^n^riennes  de 
I'Anus),"  1870,  p.  495. 

^  "Gonorrhoea  of  the  Rectum,"  Medical  Newfi,  March  25,  1893,  p.  325. 


206  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

gonorrhoea.  In  some  cases  the  gonorrhoeal  pus  is  carried  to  the  rectum 
by  means  of  a  soiled  finger.  It  is  claimed  that  in  acute  gonorrhoea  in 
women  the  pus,  escaping  from  the  genitals,  may  infect  the  anus  and 
rectum.  This  accident  is,  of  course,  possible,  but  as  a  broad  general 
rule  it  may  be  stated  that  rectal  gonorrhoea  results  from  the  intromis- 
sion of  an  organ  secreting  or  soiled  with  virulent  pus. 

Symptoms. — The  first  symptom  of  gonorrhoea  of  the  rectum  is  an 
uneasy  sensation,  attended  Avith  more  or  less  heat.  This  may  be  com- 
plained of  within  from  two  to  ten  days  after  contamination.  Heat  and 
burning  increase,  defecation  becomes  painful  and  often  more  frequent, 
and  soon  a  discharge  is  noticed  which  may  at  first  be  watery  or  milky, 
but  which  promptly  becomes  purulent  and  even  streaked  or  mixed  with 
blood.  At  this  time  burning  heat  and  itching  are  felt  in  the  anus, 
Avhich  becomes  red  and  swollen,  and  a  deep  dull,  aching  pain  in  the  rec- 
tum is  felt.  Defecation  becomes  more  and  more  painful,  and  sometimes 
is  so  severe  as  to  be  agonizing.  Frequent  calls  to  stool  keep  the  patient 
in  a  condition  of  apprehension  and  suffering.  The  purulent  and  bloody 
secretions  often  become  offensive  in  smell,  and  ooze  constantly  from  the 
inflamed  and  relaxed  anal  orifice.  In  well-marked  cases  decided  consti- 
tutional reaction  is  observed  at  the  end  of  a  few  days  or  a  week.  The 
patient  looks  haggard  and  worried,  there  is  some  rise  in  temperature, 
the  pulse  is  rapid  and  small,  and  general  malaise  and  debility  are  expe- 
rienced. This  condition  may  last  one  to  three  weeks,  when  amelioration 
is  experienced. 

In  many  cases  this  affection  is  not  attended  with  the  severe  symptoms 
above  described,  and  it  ceases  gradually  under  simple  treatment.  The 
milder  cases  are  usually  those  in  which  the  anal  region  alone  is  involved; 
in  the  more  severe  and  intractable  cases  the  lower  part  of  the  rectum  is 
the  seat  of  inflammation. 

The  objective  symptoms  of  gonorrhoea  of  the  rectum  and  anus  are 
striking.  The  mucous  membrane  becomes  red  and  swollen,  and  in 
patches  excoriated  and  ulcerated,  with  here  and  there  red  mammillations 
corresponding  to  inflamed  follicles ;  a  foul,  tenacious  pus  bathes  the 
rectal  walls  and  escapes  from  the  anal  ring,  which  is  thickened,  red- 
dened, excoriated,  and  perhaps  the  seat  of  several  small-  or  good-sized 
fissures.  In  some  cases  fleshy  tabs  are  developed,  presenting  the  appear- 
ance of  hemorrhoids,  while  in  others,  particularly  those  in  which  treat- 
ment has  not  been  followed,  simple  vegetations  may  develop.  In  passive 
pederasts  and  sodomists  the  anus  is  frequently  of  a  decided  funnel  shape, 
its  folds  are  more  or  less  obliterated,  and  the  tonicity  of  the  sphincter  is 
decidedly  impaired. 

Diagnosis. — It  is  frequently  diificult  to  determine  positively  the  gon- 
orrhoeal nature  of  a  suppurating  rectal  inflammation.  In  some  cases  the 
history  or  concomitant  circumstances  point  to  a  gonorrhoeal  origin.  Very 
many  patients  Avill,  from  motives  of  shame,  deny  any  unnatural  practice 
and  will  endeavor  in  every  way  to  mislead  the  physician.  Others,  again, 
will,  with  barefaced  candor,  promptly  admit  the  shameful  mode  of  origin 
of  their  trouble.  In  women  suffering  synchronously  from  purulent  dis- 
charge from  the  vagina,  urethra,  or  vulva  the  diagnosis  is  often  easy. 
As  a  rule,  the  severity  and  persistency  of  a  rectal  or  anal  suppurating 
process  will  excite  the  suspicions  of  the  physician.     Then,  again,  the 


GONOBBHCEA   OF  THE  RECTUM.  207 

sudden  onset  and  quick,  prompt  development  of  rectal  gonorrhoea  (the 
facts  of  which  can  generally  be  obtained  without  difficulty  from  the 
patient)  will  be  an  aid  in  determining  the  nature  of  the  aifection. 

In  many  cases  a  diagnosis  can  be  readily  made  by  the  microscopic 
examination  of  the  pus,  which  must  be  taken  on  a  platinum-wire  loop 
from  the  surface  most  actively  inflamed.  To  this  end  a  speculum  must 
be  passed  into  the  anus  or  rectum,  as  the  case  may  be.  Pus  which  has 
escaped  from  the  anal  orifice  is  liable  to  be  mixed  with  other  forms  of 
cocci ;  therefore  it  should  never  be  used.  In  the  early  stages  of  an 
acute  process  there  will  usually  be  little  difficulty  in  finding  specimens 
of  pus  in  which  there  are  gonococci.  In  chronic  cases  of  gonorrhoea  of 
the  rectum  a  number  of  forms  of  cocci  will  be  found,  chiefly,  however, 
staphylococci  and  streptococci. 

Erythema,  eczema  madidans,  intertrigo,  and  excoriations  about  the 
anus  may  be  mistaken  by  superficial  observers  for  gonorrhoea  of  the  rec- 
tum. Hemorrhoids  and  vegetations  about  the  anus  sometimes,  as  a 
result  of  uncleanliness,  undergo  inflammation,  which  spreads  to  the  con- 
tiguous skin  and  perhaps  to  the  margin  of  the  anal  orifice.  These  cases 
might  be  looked  upon  as  instances  of  rectal  gonorrhoea. 

Prognosis. — Though  the  course  of  this  aff"ection  is  often  severe  and 
sometimes  alarming,  its  tendency  in  healthy  and  cleanly  persons  is 
toward  recovery.  It  is  stated  that  in  tuberculous  individuals  local 
manifestation  of  their  diathesis  may  occur  and  a  lethal  result  follow.  I 
have  had  no  experience  with  such  cases. 

Treatment. — The  patient  should  be  confined  to  the  house  and  placed 
in  a  recumbent  position.  Warm  sitz-baths  should  be  taken,  and  the 
rectum  should  be  freely  injected  several  times  a  day  with  a  saturated 
solution  of  boracic  acid,  warm  or  cold  according  as  it  is  agreeable  to  the 
patient.  Enemata,  hot  or  cold,  of  lead  and  opium  are  sometimes  very 
soothing  and  efficacious.  Lead- water  and  boric  acid  solution  in  combina- 
tion are  also  of  much  benefit.  It  is  necessary  to  free  the  bowel  of  fteces, 
and  for  this  purpose  castor  oil  or  Epsom  salts  may  be  given.  In  the 
intervals  of  defecation  suppositories  of  morphine  or  opium,  sometimes 
with  iodoform,  may  be  used  if  necessary.  When  the  intensity  of  the 
symptoms  has  passed,  slightly  stimulating  enemata  of  sulphate  of  zinc 
and  laudanum  may  be  used.  Solutions  of  bichloride  of  mercury  have 
not  proved  of  value  as  injections.  Toward  the  cessation  of  the  suppu- 
rating process  solutions  of  nitrate  of  silver  (gr.  j-ij— 3viij-xvj)  may  be 
very  useful.  To  these  solutions  wine  of  opium  or  fluid  extract  of  bella- 
donna may  be  added. 

Gonorrhoea  limited  to  the  region  of  the  anal  orifice  requires  constant 
attention  to  cleanliness  and  sitz-baths,  and  the  application  (when  acute) 
of  lead-and-opium  wash,  and,  later,  of  bland  dusting  powders. 


208  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

CHAPTER    XIX. 
GONORRHCEA  OF  THE  MOUTH. 

Our  knowledge  of  gonorrhoeal  infection  of  the  mouth  is  very  incom- 
plete, and  further  observation  and  careful  clinical  and  bacteriological 
studies  are  necessary  before  a  satisfactory  account  can  be  given  of  it. 
A  study  of  the  cases  thus  far  reported  warrants  the  assumption  that 
there  is  a  specific  inflammation  of  the  mouth  contracted  by  beastly  and 
unnatural  practices,  and  perhaps  caused  by  the  gonococcus.  From  the 
following  cases  an  idea  of  the  clinical  history  of  this  affection  may  be 
obtained. 

One  of  the  earliest  cases  is  reported  by  Baum^s.^  It  was  that  of  a 
workman  in  whom  the  left  half  of  the  lower  lip  was  engorged,  red,  shin- 
ing, and  painful.  The  surface  was  covered  with  whitish  granulations, 
and  from  it  a  scanty  purulent  secretion  exuded.  This  morbid  surface 
looked  like  the  neck  of  the  uterus  when  the  seat  of  gonorrhoea.  The 
patient  stated  that  this  inflammation  came  on  six  or  eight  days  after  he 
had  kissed  the  vulva  of  a  woman  who  he  afterward  learned  was  suffer- 
ing from  gonorrhoea.  The  affection  was  very  rebellious  to  soothing 
treatment. 

Holder^  states  that  mouth-infection  may  occur  from  direct  contact 
with  the  infected  male  genital  organ.  He  relates  the  case  of  Petrasie, 
which  was  that  of  a  young  man  who  had  this  form  of  unnatural  coitus 
with  a  man  suffering  from  urethral  gonorrhoea.  The  day  after  he  had 
pain  in  the  lips  and  gums.  On  the  fourth  day  the  mucous  membrane 
of  the  lips  and  buccal  cavity  became  intensely  red,  the  gums  were  spongy 
and  inclined  to  bleed,  with  a  tendency  to  recede  from  the  teeth,  and  the 
buccal  secretion  was  increased  in  quantity.  Motion  of  the  mouth  was 
painful.  Holder  states  that  the  affection  begins  with  a  sensation  of 
heat  and  dryness  in  the  mouth,  which  at  first  appears  very  red.  Soon 
a  purulent  secretion  flows  from  the  swollen  and  inflamed  parts,  which 
may  be  covered  with  an  aphthous-like  exudation.  The  affection  in  this 
case  was  cured  by  an  alum  gargle  in  eight  days. 

Cutler^  also  reports  a  case  which  is  fully  as  striking  as  Petrasie's, 
It  was  that  of  a  woman  who  had  coitus  ah  ore  with  a  sailor  who  was 
found  to  be  suffering  from  gonorrhoea  ;  the  next  morning  her  mouth  was 
raw  and  sore  and  the  saliva  had  a  horrible  taste.  On  the  second  day 
little  sores  appeared  on  the  lips,  and  on  the  third  day  the  gums  and 
tongue  became  swollen  and  painful.  By  the  fifth  day  the  whole  buccal 
cavity  was  so  inflamed  that  she,  could  not  eat,  and  a  whitish  fluid,  mixed 
with  blood,  having  an  unpleasant  odor  and  taste,  Avas  secreted.  Ex- 
amination shoAved  the  mucous  membrane  of  the  lips  and  cheeks  was 

^  Precis  theorique  et  pratique  sm?'  les  Maladies  veneriennes,  vol.  i.,  Paris,  1840,  pp.  210  et 
seq. 

^  Lehrbuch  der  venerischen  Krankheiten,  Stuttgart,  1851,  p.  288. 

^  "Gonorrhoeal  Infection  of  the  Mouth,"  New  York  Medical  Journal,  Nov.  10,  1888, 
p.  521. 


GONORRHCEA    OF  THE  MOUTH.  209 

thickened,  reddened,  denuded  of  epithelium  in  spots,  and  covered  in 
areas  with  a  false  membrane,  which  was  readily  detached,  leaving  an 
excoriated  surface.  The  gums  Avere  swollen,  retracted  from  the  teeth, 
and  bled  readily  on  pressure.  The  tongue  was  swollen  and  very  tender, 
and  could  only  be  slightly  protruded,  and  then  only  with  much  effort 
and  pain.  The  surface  Avas  red  and  glazed  and  covered  with  small 
ulcers  which  secreted  a  thick  yellow  pus.  The  soft  palate  and  pillars 
of  the  fauces  were  much  inflamed,  but  the  parts  beyond  were  in  a 
normal  condition.  The  breath  was  very  offensive.  There  was  little 
salivation. 

The  mouth-secretion  consisted  of  mucus,  pus-cells,  and  epithelium, 
and  contained  a  large  quantity  of  bacteria.  In  the  false  membrane 
a  micro-organism  resembling  the  gonococcus  was  seen,  but  its  identity 
was  not  fully  established.  Soothing  applications  brought  about  an 
amelioration  of  the  symptoms. 

It  is  unfortunate  that  an  absolutely  satisfactory  microscopical  exami- 
nation was  not  made  of  the  secretions  of  the  man  and  the  woman. 
Much  light  can  in  the  future  be  thrown  on  such  cases  by  the  culture  of 
the  micro-organisms  of  the  secretions.  Whenever  possible  confronta- 
tions should  be  obtained. 

Dohrn^  reports  a  series  of  cases  of  very  young  children,  born  of 
mothers  infected  with  gonorrhoea,  who  presented  a  peculiar  form  of 
purulent  stomatitis  which  he  thinks  is  of  gonorrhoeal  origin.  The  first 
case  was  that  of  an  infant  born  at  term,  in  whom,  when  eight  days  old, 
the  mucous  membrane  of  the  alveolar  borders,  the  dorsum  of  the  tongue, 
and  the  soft  palate  became  inflamed,  eroded,  and  covered  Avith  a  grayish 
coating.  The  affection  ran  an  acute  course  and  was  cured  in  four  weeks. 
Portions  of  the  false  membrane  were  examined  microscopically  and 
cultures  were  made  from  it,  with  the  result,  it  is  claimed,  of  demonstrat- 
ing the  presence  of  the  gonococcus.  The  infant  also  suffered  from  gon- 
orrhoeal ophthalmia. 

Dohrn,  in  association  Avith  Rossinsky,  observed  four  similar  cases, 
all  of  them  in  the  offspring  of  Avomen  suffering  from  gonorrhoea.  Dohrn 
thinks  that  the  mucous  membrane  of  the  mouth  of  infants  is  particularly 
susceptible  to  infection  by  the  gonococcus.  This  particular  subject  also 
needs  further  and  extended  study,  aided  by  careful  microscopical  exami- 
nations and  culture-experiments. 

Menard  ^  claims  that  an  ulcero-membranous  stomatitis  may  occur  in 
patients  profoundly  infected  Avith  gonorrhoea.  In  support  of  this  asser- 
tion he  published  the  histories  of  four  cases.  In  the  first  case  there 
appeared  at  the  tenth  Aveek  of  gonorrhoea,  in  a  man  forty-five  years  old, 
first  a  generalized  erythema,  then  orchitis,  and  finally  ulcero-membran- 
ous stomatitis.  The  second  case  was  that  of  a  young  medical  student 
Avho  had  gonorrhoea  Avhich  Avas  complicated  Avith  monoarticular  hydrar- 
throsis, and  later  by  ulcero-membranous  stomatitis,  Avith  SAvelling  of  the 
parotid  gland  of  one  side  and  painful  enlargement  of  the  submaxillary 
and  cervical  glands.  The  third  case  Avas  that  of  a  man  thirty-five  years 
old,  Avho,  while  suffering  from  old  gonorrhoea,  had  orchitis  and  ulcero- 

^  Mercredi  medical,  .July  15,  1891,  p.  352. 

'■^  "  De  la  Stomatite  ulc^ro-inembraneuse  chez  les  Blennorrhagiques,"  Annales  de  Derm, 
et  Syphiligraphie,  deuxienie  serie,  vol.  x.,  1889,  pp.  G79  et  seq. 
14 


210  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

membranous  stomatitis,  limited  to  the  region  of  the  left  lower  molar 
tooth.  In  the  fourth  case  (that  of  a  soldier  twenty-six  years  old  with 
severe  gonorrhoea)  rheumatism,  orchitis,  and  a  typhoid  condition  of 
short  duration  were  observed,  and  were  followed  by  ulcero-membranous 
stomatitis. 

This  author  claims  this  mouth-lesion  as  a  direct  result  of  gonorrhoeal 
infection,  and  that  it  is  not  a  simple  coincidence.  He  thinks  it  due  to 
blood-infection  by  the  gonococcus.  More  light  is  required  on  this  sub- 
ject, of  which  I  have  no  personal  knowledge. 

In  this  connection  it  is  well  to  record  some  cases  in  which  it  is 
claimed  that  gonorrhoea  was  contracted  by  men  from  the  mouths  of 
women.  These  cases,  however,  lack  many  essential  points  and  do  not 
warrant  dogmatic  conclusions. 

Horand^  reports  the  case  of  a  medical  student  Avho  had  natural 
coitus  with  his  mistress  thirteen  days  prior  to  July  10th.  On  that  day 
he  had  coitus  (which  was  of  short  duration)  with  a  woman  by  the  mouth. 
The  next  day  he  felt  heat  in  the  urethra  and  saw  in  the  meatus  a  drop 
of  white  fluid.  On  the  third  day  the  discharge  was  abundant  and  puru-. 
lent,  and  there  was  pain  on  urination.  At  this  time  gonococci  were 
found  in  the  discharge,  and  in  one  pus-cell  there  were  seventy  of  these 
organisms.  By  the  use  of  injections  the  discharge  disappeared  in  fif- 
teen days,  and  the  man  had  natural  coitus  and  also  by  the  mouth  with 
his  mistress,  without  any  bad  results  to  either.  The  woman  from  whom 
this  infection  was  thought  to  be  derived  was  found  healthy  as  to  her 
genitals  and  mouth.  Horand  thinks  that  infection  occurred  from  the 
presence  in  her  mouth  of  gonorrhoeal  discharge  left  there  from  a  previ- 
ous suction.  The  weak  point  in  this  case  lies  in  the  fact  that  it  was  so 
promptly  and  thoroughly  cured  in  fifteen  days.  As  the  search  for  the 
gonococcus  was  made  as  long  ago  as  1884,  when  the  knowledge  of  it 
was  not  complete  and  its  differentiation  from  other  urethral  microbes 
was  not  known,  the  suspicion  is  warranted  that  the  infection  originated 
in  some  micro-organism  less  virulent  than  the  gonococcus. 

Delefosse^  reports  the  following  case:  A  man,  thirty-nine  years  old, 
having  had  three  attacks  of  gonorrhoea,  but  having  had  no  urethral  dis- 
charge for  seven  years,  submitted  to  prolonged  suction  of  the  penis  by 
a  woman.  Five  days  later  prodromal  symptoms  showed  themselves, 
which  were  followed  by  a  typical  severe  attack  of  gonorrhoea.  No 
examination  of  the  woman  was  made  nor  Avas  the  secretion  examined 
by  means  of  the  microscope. 

^  "  Blennorrhagie  contractee  dans  un  rapport  ab  ore,"  Lyon  Med.,  vol.  1.,  1885,  pp.  279 
et  seq. 

=  "  Sur  un  Cas  de  Blennorrhagie  apres  Snccion  de  la  Verge  sans  Coit,"  Journal  des 
Malad.  cutan.  et  syphil.,  vol.  i.,  1889  and  1890,  pp.  305  et  seq. 


CONGESTION  OF  THE  PROSTATE,  ETC.  211 


CHAPTER  XX. 

CONGESTION  OF  THE  PROSTATE,  ACUTE  PROSTATITIS, 
AND  PROSTATORRHCEA. 

The  most  common  form  of  inflammation  of  the  prostate  in  the  course 
of  gonorrhoea  is  congestion  of  more  or  less  severity.  This  condition 
occurs  with,  and  is  dependent  upon,  acute  posterior  urethritis.  In  the 
latter  condition  the  submucous  connective  tissue  is  the  seat  of  an  acute 
phlegmasia,  and  as  a  result  the  substance  of  the  prostate  becomes 
hyper^emic.  With  this  further  extension  of  the  gonorrhoeal  process  the 
patient  has  still  other  symptoms,  besides  those  of  posterior  urethritis. 
He  complains  of  a  sensation  of  dull  weight  and  pressure  in  the  peri- 
neum deep  in  the  pelvis,  and  an  uneasy  sense  of  fulness  in  the  rectum 
or  anus.  In  severe  cases  rectal  tenesmus  may  add  to  the  patient's  dis- 
comfort. The  vesical  tenesmus  may  be  increased^  and  often  in  defeca- 
tion the  patient  experiences  severe  pain  in  the  prostate  when  the  fecal 
mass  passes  under  it.  When  there  is  much  swelling  the  stools  are  small 
and  ribbon-shaped.  Rectal  examination  reveals  a  swollen  organ,  broader 
than  normal  from  side  to  side,  and  bulging  considerably  into  the  rectum. 
The  finger-tip  reveals  the  fact  that  the  part  is  hot  and  decidedly  painful, 
and  on  its  withdrawal  vesical  and  rectal  tenesmus  frequently  ensues.  In 
many  cases  pollutions  are  a  distressing  symptom. 

In  the  great  majority  of  cases  this  congestion  is  temporary.  It  may 
last  a  few  days  or  two  or  three  weeks ;  usually,  however,  resolution  takes 
place  in  about  ten  days.  With  the  decline  of  the  posterior  urethritis  the 
swelling  and  tenderness  usually  subside.  In  some  cases  the  involution  of 
this  congested  condition  of  the  process  occurs  suddenly  and  unexpectedly 
a  few  days  after  its  onset. 

A  congestion  of  the  prostate  may  be  due  to  violence  from  sounds, 
catheters,  lithotrity  instruments,  to  the  irritation  of  a  stone  in  the  blad- 
der and  of  a  fragment  of  stone,  or  of  small  stones  impacted  in  its  mucous 
membrane,  and  to  stricture.  It  is  not  very  probable,  as  claimed  by  some, 
that  injections  used  by  patients  in  the  anterior  urethra  cause  congestion 
of  the  prostate. 

In  chronic  posterior  urethritis  ephemeral  congestion  of  the  prostate 
may  be  caused  by  sexual  and  alcoholic  excesses,  by  masturbation,  and  by 
violent  exercise,  particularly  in  horseback  riding  and  bicycling. 

Examination  of  the  urine  gives  the  same  results  as  are  seen  in  acute 
posterior  urethritis. 

In  quite  rare  cases  rectal  examination  shows  that  certain  parts  of  the 
prostate  are  more  swollen  and  harder  than  the  rest.  In  this  condition  it 
may  be  that  certain  groups  of  follicles  are  the  seats  of  greater  oedematous 
hyperplasia  than  the  balance  of  the  tissue. 

In  some  cases  of  congestion  of  the  prostate  the  patient  experiences 
difiiculty  in  urination,  and  complains  of  a  sensation  as  if  his  urethra  was 
too  small  to  allow  the  stream  to  pass  through  it  even  with  great  straining. 
It  will  be  seen,  under  these  circumstances,  that  the  stream  is  small  and 


212  GONOBRHCEA   AND  ITS  COMPLICATIONS. 

weak,  even  hesitating  and  intermittent.  In  some  cases,  such  is  the 
swollen  condition  of  the  organ  and  of  its  urethral  mucous  lining  that  the 
patient  cannot  void  his  urine,  and  has  to  be  relieved  by  the  introduction 
of  the  catheter.  In  bad  cases  there  may  be  vesical  and  rectal  tenesmus 
superadded,  and  in  some  there  is  spasm  of  the  compressor  urethrge  muscle. 
Under  these  circumstances  the  patient  often  fails  to  thoroughly  empty  his 
bladder,  and  then  the  residual  urine  accumulates  and  causes  continuous 
vesical  tenesmus.  The  bowels  are  frequently  constipated,  and  when  the 
vesical  tenesmus  comes  on  the  patient  makes  painful  and  often  vain  efforts 
to  free  them. 

Congestion  of  the  prostate  usually  ends  in  resolution,  but  it  may  go  on 
to  abscess-formation. 

Parenchymatous  inflammation  of  the  prostate  may  develop  from  the 
milder  or  congestive  form.  In  this  phlegmasia  there  is  usually  suppura- 
tion in  some  part  of  the  organ — hence  the  name  "  abscess  of  the  prostate" 
— which  may  be  a  tolerably  mild  affection,  and  even  a  severe  and  a  fatal  one. 

The  formation  of  pus  in  the  prostate  is  usually  attended  by  quite  well- 
marked  symptoms,  such  as  chills,  fever,  general  depression,  a  sensation 
of  throbbing  in  that  body,  and  a  feeling  as  if  there  was  a  lump  in  the 
rectum.  There  may  also  be  pain  along  the  urethra  in  the  perineum, 
rectum,  and  lumbar  region.  The  further  symptoms  are  painful  micturi- 
tion and  defecation.  In  some  cases  the  urethral  canal  is  entirely  occluded 
by  the  swelling,  and  the  patient  is  unable  to  pass  any  of  his  urine.  He 
of  necessity  lies  on  his  back  and  flexes  his  thighs,  thereby  avoiding  all 
pressure  on  the  perineum. 

Abscess  of  the  prostate  always  begins  in  one  or  more  follicles,  which 
become  acutely  inflamed.  From  this  focus  the  morbid  process  increases 
and  forms  abscesses  of  various  sizes.  As  a  rule,  the  lateral  lobes  are 
more  frequently  the  seat  of  abscess  than  the  third  portion.  There  may 
be  one  or  two  abscesses,  and  in  exceptional  cases  there  may  be  as  many  as 
from  six  to  twenty.  In  this  event  as  many  different  follicles  have  become 
the  seat  of  abscess  as  there  are  abscesses,  Avhich  are  usually  of  the  size  of 
a  pea  and  even  smaller.  When  the  abscess  is  limited  to  one  lobe  and 
points  toward  the  urethral  canal,  it  may  partly  or  wholly  block  it  up.  The 
introduction  of  a  catheter  then  to  relieve  retention  will  be  accomplished 
with  more  or  less  difficulty,  and  its  point  will  deviate  in  the  opposite  direc- 
tion from  the  lobe  involved.  Rectal  examination  will  reveal  general  en- 
largement of  the  organ,  and  it  may  happen  that  the  surgeon  will  be  able 
to  ascertain  that  the  process  is  unilateral. 

The  size  of  these  abscesses  varies  considerably.  They  may  contain  a 
teaspoonful,  an  ounce,  and  even  as  much  as  eight  ounces,  of  pus.  The 
contents  of  these  abscesses  may  be  pure  pus  free  from  odor,  or  it  may  be 
sero-sanguinolent ;  it  may  be  mixed  with  the  debris  of  the  gland  or  it 
may  be  of  a  very  unhealthy  character  and  very  fetid. 

Abscesses  superficially  seated  in  the  prostate  and  pointing  toward  the 
urethra  cannot,  as  a  rule,  be  clearly  defined  by  rectal  examination,  but 
their  presence  may  be  detected  by  the  passage  of  a  catheter  of  medium 
stiffness.  When  the  abscess  is  deeply  seated  in  the  prostate,  it  can 
generally  be  well  made  out  by  the  finger  in  the  rectum. 

Abscess  of  the  prostate  may  also  form  in  an  insidious  manner,  without 
provoking  any  general  or  local   symptoms   pointing  to  its  existence.     I 


CONGESTION  OF  THE  PROSTATE,   ETC.  213 

have  seen  two  instances  following  gonorrhoea,  in  which,  after  apparent 
cure,  the  patients  on  passing  water  were  surprised  at  the  escape  of  nearly 
an  ounce  of  pus.  In  these  cases  rectal  examination  showed  enlargement 
of  the  organ  with  moderate  tenderness.  Perfect  healing  took  place. 
Pitman  ^  reports  a  case  in  which  prostatitis  followed  gonorrhcea  and  ter- 
minated fatally,  with  an  entire  absence  of  systemic  symptoms  or  of  local 
distress.  At  the  autopsy  an  extensive  abscess,  unsuspected  during  life, 
was  found  between  the  bladder  and  the  rectum. 

As  a  rule,  however,  when  the  abscess  is  fully  formed,  the  constitutional 
symptoms  are  much  more  pronounced  than  at  first.  The  rigors  are 
more  severe  and  are  attended  with  flashes  of  heat ;  there  are  great  thirst, 
restlessness,  and  jactitation,  very  high  fever,  and  sometimes  delirium. 
The  pain  becomes  more  violent  and  the  throbbing  more  distressing,  and 
the  sensation  of  fulness  and  weight  at  the  neck  of  the  bladder  and  in  the 
rectum  and  anus  causes  agony.  These  symptoms,  together  with  the  fre- 
quent scalding  urination,  made  drop  by  drop  or  in  a  thin,  feeble  stream, 
stamp  abscess  of  the  prostate  as  one  of  the  most  acutely  painful  and  dis- 
tressing maladies  known  to  man. 

With  the  bursting  of  the  abscess,  naturally  or  by  operation,  every- 
thing is  changed.  The  patient  is  immediately  relieved  of  his  suffering, 
he  can  urinate  freely,  and  his  febrile  symptoms  soon  disappear.  If  the 
inflamed  tissues  contract  and  efface  the  abscess-cavity,  as  they  commonly 
do,  all  is  well  and  the  patient  is  spared  further  trouble. 

Unfortunately,  however,  prostatic  abscesses  may  open  into  the  bladder, 
the  rectum,  the  vesico-rectal  space,  the  perineum,  and  the  peritoneal  cavity. 
In  this  connection  the  statistics  collected  by  Segond^  are  very  interesting. 
In  102  cases  he  found  the  abscesses  burst  and  burrowed  as  follows :  Into 
the  urethra,  64  times ;  into  the  rectum,  43 ;  into  the  perineum,  15 ;  into 
the  ischio-rectal  fossa,  8  ;  into  the  inguinal  region,  3  ;  through  the  ob- 
turator foramen,  2  ;  through  the  umbilicus,  1 ;  through  the  sciatic  notch, 
1 ;  at  the  edge  of  the  false  ribs,  1 ;  into  the  abdominal  cavity,  1 ;  and 
into  the  cavity  of  Retzius,  1. 

It  will  be  seen  that  in  rather  more  than  one-half  of  the  cases  the 
abscess  burst  into  the  urethra,  and  it  is  safe  to  say  that  at  least  in  a  large 
majority  the  patients  experienced  no  ulterior  trouble. 

When  the  abscess  is  developed  in  the  posterior  portion  of  the  gland  the 
tendency  is  for  it  to  burst  into  the  rectum,  which  is  a  serious  condition. 
It  then  leaves  a  fistulous  tract  which  is  very  difficult  to  heal,  and  which 
allows  the  escape  of  urine  into  the  rectum.  The  pus,  however,  may  bur- 
row downward  and  point  as  a  red  indurated  area  in  the  perineum  anterior 
to  the  anal  orifice.  It  may  also  pass  through  the  ischio-rectal  fossa  and 
appear  in  the  perineum.  It  may  extend  toward  the  scrotum  and  sheath 
of  the  penis,  and  may  pass  down  to  the  thigh  or  upward  to  the  region  of 
the  fiilse  ribs. 

The  other  modes  of  burrowing  are  quite  rare,  but  each  of  them  pre- 
sents its  individual  indications  for  surgical  relief. 

In  the  course  of  these  aberrant  burrowings  many  complications  may 
occur,  and  there  is  always  danger  of  pytieraia. 

^  Lancet,  Am.  ed.,  .Jan.,  1S61,  p.  (iO. 

^  "Des  Absces  chauds  de  la  Prostate  et  dn  Phlegmon  periprostatique,"  Thise  de  Paris, 
1880. 


214  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

The  bursting  of  the  abscess  into  the  peritoneum  always  causes  great 
pelvic  pain  and  very  severe,  even  alarming,  constitutional  symptoms. 
Death  usually  ensues  in  a  day  or  two. 

In  the  progress  of  the  burrowing  process  the  patient  may  experience 
more  or  less  pain  in  the  parts,  which  become  red,  swollen,  and  hard. 

Congestion  and  abscess  of  the  prostate  are  generally  found  in  young 
men  from  twenty-five  to  thirty  years  of  age. 

Abscess  of  the  prostate  is  not  of  frequent  occurrence.  Ballou^  ob- 
served 3  cases  of  it  in  1000  cases  of  all  varieties  of  gonorrhoea.  Even  this 
is  a  large  percentage,  according  to  the  statistics  of  my  clinic  and  of  my 
hospital  services. 

Prognosis. — Abscess  of  the  prostate  is  almost  always  a  painful  afi'ection, 
and  sometimes  a  dangerous  and  even  deadly  one.  In  quite  rare  cases  the 
abscess  when  not  recognized  and  untreated  causes  pyaemia  and  death. 
The  rectal  fistulae  are  very  hard  to  cure,  and  they  cause  much  discom- 
fort and  suffering  to  the  patient,  who  becomes  an  object  of  aversion  to 
those  who  come  in  contact  with  him. 

When  the  patient  is  young,  otherwise  healthy,  and  of  firm  fibre  and 
of  good  habits,  his  chances  of  recovery,  even  when  afflicted  with  bad 
fistulse,  are  usually  good.  In  elderly  and  sickly  individuals  the  prog- 
nosis is  usually  grave. 

Prostatorrhcea. 

As  a  result  of  chronic  posterior  urethritis,  of  stricture  of  the  urethra, 
and  in  subjects  who,  as  a  consequence  of  confirmed  masturbation  and  of 
venereal  excesses,  have  produced  a  hypersemic  condition  of  the  posterior 
urethra,  we  sometimes  see  a  chronic  mucoid  discharge  to  which  the  term 
"  prostatorrhoea  "  is  applied.  This  condition,  which  is  also  called  by  some 
authors  "  chronic  prostatitis,"  is  not  a  common  one,  and  is  mostly  seen  in 
young  and  middle-aged  subjects.  It  may  be  an  affection  of  little  gravity, 
and  then,  again,  it  may  be  attended  with  very  serious  symptoms  and  asso- 
ciated with  a  severe  form  of  neurasthenia.  In  anaemic  and  neurotic 
subjects  it  is  often  a  most  distressing  disorder.  It  is  also  observed  in 
men  with  markedly  strong  sexual  propensities  who  commit  great  excesses, 
and  also  in  those  who  suffer  from  unsatisfied  sexual  desire.  This  affection 
may  be  permanent  and  it  may  be  intermittent  in  character.  Then,  again, 
when  it  persists  in  a  chronic  form  it  may  (generally  owing  to  excesses) 
undergo  exacerbations  of  a  very  high  degree. 

The  most  constant  symptom  is  the  escape  from  the  meatus  of  a  clear 
mucous  fluid  or  of  a  mucus  mixed  with  pus  and  perhaps  a  little  blood. 
This  mucous  fluid  may  be  scant  in  quantity,  only  a  few  drops  appearing 
at  the  meatus  in  a  day.  It  may  also  be  more  copious,  and  keep  the  end 
of  the  penis  in  a  moist  condition  continuously,  and  in  very  pronounced 
cases  the  escape  is  so  excessive  that  patients  complain  of  a  constant  and 
annoying  "dripping,"  which  may  wet  and  stain  a  large  part  of  their  shirt- 
fla23  or  of  the  handkerchief  which  they  instinctively  make  use  of  under 
these  circumstances.  The  escape  of  this  discharge  in  large  quantities 
occurs  frequently  during  the  act  of  defecation,  particularly  when  the 
fecal  bolus  is  hard  and  firm.     In  some  cases  the  escape  of  the  mucus 

1  New  York  Med.  Journ.,  July  25,  1891,  p.  99, 


CONGESTION  OF  THE  PROSTATE,  ETC.  23  5 

causes  a  peculiar  tickling  feeling  in  the  prostate  and  urethra,  while  in 
others  it  produces  pleasurable  voluptuous  and  lascivious  sensations.  Some 
patients  claim  that  they  can  feel  the  escape  of  the  fluid  from  the  prostate 
into  the  urethra.  In  rather  rare  cases  the  escape  of  mucus,  particularly 
after  defecation,  is  attended  with  a  sickening  sensation  of  great  faintness, 
which  may  last  for  several  minutes.  Many  of  these  cases  have  been 
treated  for  spermatorrhoea. 

Riders  of  some  forms  of  bicycles  notice  that  a  clear  viscid  secretion 
escapes  from  the  meatus,  particularly  after  long  and  rough  riding.  Seeing 
that  in  these  cases  there  are  no  symptoms  which  point  to  prostatic  or  ves- 
ical disturbance,  it  seems  probable  that  the  fluid  comes  from  hypersemic 
mucous  follicles  and  Cowper's  glands. 

Although  we  have  no  pathological  knowledge  on  the  subject,  it  seems 
fair  to  assume  that  in  prostatorrhoea  there  is  such  an  atonic  condition  of 
the  compressor  urethrse  muscle  that  it  cannot  prevent  the  escape  of  the 
fluid  into  the  anterior  urethra.  The  next  most  constant  symptom  is  in- 
creased frequency  in  urination,  which  may  be  very  excessive  or  only 
about  twice  as  often  as  the  normal  desire.  There  may  be  decided  un- 
easiness at  the  end  of  the  act,  and  there  may  be  a  slight  pain  or  decided 
scalding  sensation  Avhich  passes  from  the  prostate  to  the  end  of  the  penis. 
In  many  cases  the  stream  is  small  and  weak — a  condition  which  seems  to 
point  to  an  atonic  state  of  the  detrusors.  A  sense  of  dulness  and  weight 
is  often  felt  in  the  prostate  and  in  the  rectum,  and  pain  and  uneasy  sensa- 
tions are  experienced  in  the  perineum,  thighs,  and  lumbo-sacral  regions. 

Some  patients  sufl'er  from  chronic  prostatorrhoea  without  becoming 
much  disturbed  in  mind  by  it.  But  there  are  others  to  whom  this  afi"ec- 
tion  is  little  less  than  a  calamity.  They  become  exceedingly  nervous 
about  their  trouble,  even  to  the  extent  of  melancholy.  They  lose  flesh, 
strength,  and  appetite ;  they  become  irritable  and  incapable  of  mental 
and  physical  exertion.  In  fact,  in  some  cases  the  whole  morale  of  the 
man  seems  lost. 

Besides  these  cases,  in  which  the  trouble  is  of  long  duration,  we  some- 
times see  patients — particularly  continent  young  men — who  are  constantly 
seeing  and  caressing  their  sweethearts  prior  to  marriage,  and  men  who 
fruitlessly  try  and  hope  day  by  day  to  have  connection  with  a  certain 
woman,  who  have  an  acute  attack  of  prostatorrhoea,  even  with  quite  pro- 
nounced mental  and  physical  disturbance.  Intercourse  and  sexual  hy- 
giene, with  tonics  and  fresh  air,  usually  bring  around  these  suff'ering 
swains. 

In  many  cases  of  prostatorrhoea  there  is  more  or  less  disturbance  in 
the  sexual  function.  In  some  subjects  it  is  morbidly  exaggerated;  in 
others  there  is  much  desire,  much  erethism,  many  erections,  but  very 
little  is  accomplished,  owing  to  precipitate  ejaculations.  In  still  other 
subjects  there  is  little  if  any  desire,  even  as  a  result  of  much  excitement, 
and  the  penis  and  scrotum  seem  cold  and  lethargic. 

In  subjects  of  prostatorrhoea  every  new  gonorrhoea  shows  a  tendency 
to  run  back  to  the  posterior  urethra  and  there  pursue  a  severe  course.  As 
a  result  of  the  hypen^emia  the  whole  organ  may  become,  as  time  goes  on, 
much  hypertrophied. 

Rectal  examination  of  cases  of  prostatorrhoea,  which  should  be  made 
from  time  to  time,  reveals  an  enlarged  organ,  usually  jutting  more  or  less 


216  GONOBBH(EA  AND  ITS  COMPLICATIONS. 

backward  on  the  gut,  and  being  decidedly  broader  than  normal.  Some- 
times it  feels  soft,  and  again  it  may  seem  decidedly  indurated.  There  is 
commonly  more  or  less  tenderness,  even  severe  pain,  on  pressure  by  the 
finger-tips.  Urethral  examination,  even  with  a  small  and  not  stiff  instru- 
ment, often  causes  a  great  outcry  from  pain  when  the  tip  passes  through 
the  prostatic  urethra. 

In  the  study  of  cases  of  prostatorrhoea  the  surgeon  must  bear  in  mind 
that  during  intense  sexual  excitement,  with  partial  or  complete  erection, 
without  ejaculation  and  satisfaction,  a  viscid,  glycerin-like  looking  fluid 
very  commonly  escapes  from  the  meatus  in  considerable  quantity.  This 
is  not  a  pathological  secretion  at  all,  but  is  the  product  of  Cowper's  glands 
and  of  the  urethral  follicles,  which  have  become  suddenly  the  seat  of  hy- 
persemia.  The  prostate  is  not  in  any  way  concerned  in  its  development. 
This  symptom  has  often  been  considered  by  patients  and  physicians  as 
due  to  spermatorrhoea.  This  secretion  is  called  urethrorrhoea  ex  Ubidine, 
and  has  its  congener  in  the  flow  of  saliva  produced  by  the  sight  or  odor 
of  a  tempting  meal. 

The  character  of  the  secretion  varies  in  different  cases  and  in  different 
stages  of  the  aff"ection.  If  the  case  is  one  of  simple  uncomplicated  pros- 
tatorrhoea and  seen  early,  we  sometimes  find  under  the  microscope  amy- 
loid bodies  in  concentric  strata,  cylindrical  epithelial  cells  in  double 
stratiform  disposition,  with  their  prolongations  running  into  a  cluster  of 
small  round-cells  (Fiirbringer),  and  small,  fairly  refractive  granules  of 
half  the  size  of  red  corpuscles.  According  to  Fiirbringer,^  the  addition 
of  a  drop  of  a  1  per  cent,  solution  of  acid  phosphate  of  ammonia  to  a  drop 
of  the  prostatic  secretion  placed  on  the  glass  slide  will,  after  a  couple  of 
hours'  contact,  reveal  the  presence  of  what  are  called  "spermatic  crystals," 
and  also  Boettscher's  crystals,  the  basis  of  which  exists  only  in  the  pros- 
tatic secretion.  In  the  majority  of  cases,  however,  there  has  been,  either 
as  a  result  of  gonorrhoea  or  of  instrumental  interference,  infection  of  the 
posterior  urethra,  and  a  purulent  secretion  is  produced.  Under  the  micro- 
scope the  appearances  of  this  secretion  are  similar  to  those  of  posterior 
urethritis.     (See  page  75.) 

When  the  prostatic  secretion  is  viscid  and  small  in  quantity,  the  urine 
in  the  first  glass  will  be  cloudy,  and  the  second  perhaps  quite  clear.  In 
some  cases,  however,  it  will  be  observed  that,  Avhile  the  first  urine  is 
cloudy  and  the  second  specimen  clear,  the  third  will  be  more  or  less  faintly 
cloudy  and  may  appear  milky,  and  the  specimen  Avill  give  forth  the  odor 
of  semen.  In  this  event  it  is  very  probable  that  the  final  contraction  of 
this  prostate  squeezed  its  follicles  quite  forcibly,  and  thus  expelled  some 
of  their  secretion.  Examination  of  this  rather  exceptional  third  specimen 
will  sometimes  reveal  the  appearances  just  described  of  amyloid  bodies, 
cylinder  epithelium,  etc. 

The  condition  of  the  prostate  and  of  its  secretion  may  be  quite  clearly 
made  out  by  the  procedure  advocated  by  Von  Sehlen.^  The  patient 
urinates  into  two  small  glasses,  thus  leaving  some  urine  in  the  bladder. 
He  then  leans  forward,  placing  the  trunk  at  right  angles  with  his  legs 
(Von  Sehlen  prefers  the  genu-pectoral  position),  and  the  surgeon  with  his 

1  Op.  cit. 

^  "  Zur  Diagnostik  und  Therapie  der  Prostatitis  chronica,"  Intern.  Centralbl.  der  Harn- 
und  Sexucd-organe,  vol.  iv.,  1893,  pp.  310  et  seq. 


CONGESTION  OF  THE  PROSTATE,  ETC.  217 

finger  in  the  rectum  kneads  or  massages  the  prostate.  This  operation 
causes  the  escape  of  prostatic  fluid  (if  there  is  any)  into  the  urethra.  The 
patient  then  passes  the  remainder  of  the  urine,  which  carries  all  this 
pressed-out  secretion  into  the  third  glass.  After  settling  the  various  spe- 
cimens of  urine  may  be  examined,  and  their  contents  studied  in  connection 
with  the  clinical  symptoms. 

Treatment. — When,  during  gonorrhoea,  symptoms  of  congestion  of 
the  prostate  are  observed,  the  patient  should  at  once  be  put  to  bed  and 
treated  on  antiphlogistic  principles.  The  bowels  should  be  kept  free  and 
the  diet  should  be  of  gruel  or  bread  and  milk.  In  the  case  of  strong 
individuals  six  or  more  leeches  may  be  applied  just  in  front  of  the  anus, 
and  the  patient  then  put  in  a  hot  sitz-bath.  No  general  rule  can  be  laid 
down  as  to  the  use  of  heat  or  cold.  In  some  cases  heat  gives  marked 
relief,  and  in  others  cold  acts  equally  as  beneficially.  Hot  flaxseed  poul- 
tices or  the  hot-water  bag,  with  the  intervention  of  some  lint  well  moist- 
ened with  water,  may  be  applied  to  the  perineum.  In  these  cases  very 
warm  enemata  act  well  on  the  prostate  and  free  the  rectum  of  fseces.  In 
case  cold  is  more  grateful,  an  India-rubber  bag  filled  with  ice-water  or 
broken  ice  may  be  applied  to  the  perineum,  on  which  a  folded  towel  must 
be  placed  so  that  the  intensity  of  the  cold  may  be  moderated  to  suit  the 
patient's  feelings.  Injections  of  a  few  ounces  of  cold  water  at  intervals 
into  the  rectum,  the  insertion  of  a  small  well-rounded  piece  of  ice  or 
irrigation,  with  the  double  catheter  apparatus  recommended  by  Finger, 
may  be  tried.  From  either  heat  or  cold  much  relief  may  be  obtained. 
All  urethral  injections  being  suspended,  the  patient  may  take  the  potassa- 
and-hyoscyamus  mixture  (see  page  131),  and  drink  freely  of  diluent 
waters  of  various  kinds,  according  to  the  preference  of  the  surgeon. 
Morphine  or  opium  should  be  given  generously,  if  necessary,  by  the 
mouth  or  in  the  form  of  suppository  in  order  to  relieve  pain. 

In  favorable  cases,  which  are  most  common,  resolution  occurs  within 
two  weeks,  and  often  in  a  shorter  time.  When  the  patient  is  up  and 
around  again  he  may  be  much  benefited  by  lavages  of  a  very  mild  solu- 
tion of  nitrate  of  silver,  gr.  j-§viij— §xij,  which  should  be  given  every 
second  day,  and  every  day  if  well  borne  and  beneficial. 

If  during  the  course  of  congestion  of  the  prostate  complete  retention 
of  urine  occurs,  it  should  be  carefully  drawn  off".  For  this  purpose  an 
aseptic  silk  or  lisle-thread  catheter  (which  is  both  flexible  and  at  the 
same  time  firm  and  very  smooth),  of  a  calibre  of  not  more  than  12  or  13 
French  scale,  should  be  introduced  into  the  bladder. 

The  treatment  of  abscess  of  the  prostate  should  be  based  on  general 
surgical  principles,  together  with  the  observance  of  strict  antisepsis. 
The  first  essential  is  to  determine,  if  possible,  in  which  direction  the 
abscess  points.  If  the  inflammatory  swelling  pushes  into  the  urethraj 
the  surgeon  will  very  often  have  timely  warning  by  reason  of  the  difl^culty, 
and  even  impossibility,  of  urination  which  the  patient  experiences.  In 
such  cases  the  catheter  must  of  necessity  be  used,  and,  fortunately,  it  very 
often  causes  the  abscess  to  open  and  discharge.  In  desperate  cases  supra- 
pubic cystotomy  with  direct  puncture  of  the  abscess  has  been  recom- 
mended, but  it  is  a-  question  in  my  mind  whether  a  patient  so  sorely  tried 
as  is  a  man  having  a  severe  prostatic  phlegmon  near  the  urethra  could  un- 
dergo the  manipulation  necessary  for  opening  the  bladder  by  this  route. 


218  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

While  in  general  the  abscess-cavity  in  the  prostate  granulates,  con- 
tracts, and  heals  up  without  leaving  a  marked  if  any  depression,  it  is 
well,  if  the  organ  remains  swollen,  as  determined  by  rectal  examination, 
to  throw  into  the  bladder  hot  boric-acid  solutions  or  hot  Thiersch's  solu- 
tion once  or  twice  a  day. 

When  the  prostatic  abscess  points  toward  the  rectum,  it  is  always  best 
to  open  it  by  an  incision  made  with  a  long  sharp  bistoury  directly  in  the 
median  line,  about  half  an  inch  in  front  of  the  anus.  The  fore  finger  of 
the  left  hand  should  be  placed  in  the  rectum,  while  the  surgeon  makes 
this  incision,  which  before  the  withdrawal  of  the  knife  should  be  made 
sufficiently  large  for  irrigation  and  ample  drainage. 

When  the  abscess  is  so  extensive  that  it  has  produced  oedematous 
swelling  in  the  anterior  wall  of  the  rectum,  it  may  be  punctured  and 
evacuated  by  the  introduction  of  the  long  curved  trocar.  After  this  ope- 
ration it  is  absolutely  necessary  to  prevent  the  reaccumulation  of  pus  by 
gentle  massage  with  the  finger-tip,  and  to  irrigate  the  parts  once  or  twice 
a  day  with  hot  boric-acid  solution  or  Thiersch's  solution. 

The  treatment  of  aberrant  forms  of  prostatic  abscess  should  be  based 
on  the  anatomical  and  pathological  indications  presented  by  each  case. 
Periprostatic  phlegmons  should  be  treated  in  the  same  manner  as  those 
just  considered. 

The  local  treatment  of  prostatorrhoea  is  in  the  main  that  of  chronic 
posterior  urethritis.  When  the  affection  is  in  an  acute  condition,  so  fre- 
quently seen  in  exacerbations,  hot  boric-acid  solution  may  be  of  decided 
benefit.  It  sometimes  happens  that  intravesical  injections,  even  of  the 
blandest  nature,  by  the  way  of  the  posterior  urethra,  give  rise  to  discom- 
fort, in  which  event  they  should  be  stopped,  as  Avell  as  all  other  operative 
interference.  Later  on  lavages  and  instillations  may  be  used  with  benefit. 
It  is  always  well  to  remember  that  in  these  cases  very  strong  solutions 
of  any  kind  do  more  harm  than  good.  Care  also  must  be  taken  in  the 
use  of  sounds,  since  in  these  cases  over-distention  is  often  productive  of 
much  harm   and  suffering. 

In  the  treatment  of  anaemic,  neurotic,  and  neurasthenic  subjects  af- 
fected Avith  prostatorrhoea  all  morbid  indications  should  be  sought  for  and 
efficiently  met.  Sexual  hygiene  is  of  the  very  first  importance,  and  the 
surgeon  should  thoroughly  familiarize  himself  with  all  facts  relating  to  it 
and  institute  appropriate  measures  of  relief.  There  is  such  a  disparity 
of  conditions  in  these  cases  that  further  amplification  would  occupy  too 
much  space.  For  such  cases  good  food,  fresh  air,  relaxation,  and  all  good 
hygienic  surroundings  are  great  aids.  Medication,  good  advice,  and 
encouragement  based  on  common  sense  will  do  much  for  the  relief  and 
cure  of  these  chronic  and  often  trying  cases. 


INFLAMMATION  OF  THE  SEMINAL    VESICLES.  219 

CHAPTER   XXI. 
INFLAMMATION  OF  THE  SEMINAL  VESICLES. 

This  aflFection,  also  called  seminal  vesiculitis  (Dolbeau  and  Le  Dentu), 
spermato-cystitis  (Naumann),  and  gonecystitis  (Gouley),  though  treated 
of  more  or  less  fully  by  Lallemand,  Civiale,  Gosselin,  Fournier,  Rapin, 
and  others,  was  very  little  understood  and  very  frequently  unrecognized 
until  within  the  past  few  years,  and  it  is  mainly  through  the  writings  of 
Mr.  Jordan  Lloyd  ^  that  an  impetus  in  its  study  has  been  inaugurated. 
Mr.  Lloyd  claims  that  this  affection  is  among  the  most  common  of  the 
complications  of  gonorrhoea,  and  that  its  signs  and  symptoms  are  misun- 
derstood or  misinterpreted  and  attributed  to  different  organs  altogether. 

It  is  well  to  bear  in  mind  the  structure,  situation,  and  relations  of  the 
seminal  vesicles.     (See  pages  52  and  53.) 

Seminal  vesiculitis  may  be  acute  or  chronic.  The  acute  form  has 
many  points  of  analogy  with  epididymitis.  Both  affections  are  almost 
always  secondary  to  gonorrhoea  occurring  in  the  third  or  fourth  week,  or 
to  hypersemia  of  the  posterior  urethra  due  to  masturbation  and  venereal 
excesses,  or  to  inflammation  of  this  region  resulting  from  traumatism, 
catheterization,  endoscopy,  and  strong  injections.  In  both  there  is 
inflammation  of  the  mucous  membrane  and  hyperplasia  of  the  connective 
tissue.  In  epididymitis  the  testicle  does  not  swell,  and  in  seminal  vesicu- 
litis the  prostate  is  not  usually  affected.  In  both  cases  suppuration,  in 
the  sense  of  abscess-formation,  is  the  exception  and  resolution  the  rule. 

The  symptoms  of  the  acute  form  of  seminal  vesiculitis  are  quite  simi- 
lar to  those  of  posterior  urethritis  and  to  those  given  as  diagnostic  of  the 
several  varieties  of  prostatitis.  The  patient  first  experiences  pain,  either 
of  a  dull  or  throbbing  character,  or  a  sensation  of  weight,  which  he  refers 
to  the  deep  portion  of  the  pelvis  just  within  the  anus  or  at  the  neck  of 
the  bladder  or  in  the  perineum.  There  is  markedly  increased  frequency  in 
urination,  and  tenesmus  sometimes  mild,  again  quite  decided,  and  in  some 
cases  very  severe.  As  the  bladder  fills  the  painful  symptoms  increase  in 
severity,  and  there  may  be  pain  at  the  end  and  sometimes  at  the  root  of 
the  penis.  There  may  be  fever,  chills,  and  malaise.  All  these  symptoms 
may  be  present  in  posterior  urethritis,  so  that  the  crucial  test  in  diagnosis 
is  palpation  of  the  prostate  and  seminal  vesicles  by  means  of  the  finger 
in  the  rectum.  If  the  case  is  one  of  acute  posterior  urethritis,  the  pros- 
tate will  be  tender,  even  painful,  on  pressure,  and  perhaps  swollen.  If 
seminal  vesiculitis  is  present  and  explored  for  early,  one  or  both  vesicles 
will  be  found  to  be  much  enlarged  in  all  directions  in  the  shape  of  a  dis- 
tended leech,  hot,  brawny,  and  exquisitely  tender.     In  a  few  days  the 

^  "  On  Inflammatory  Disease  of  the  Seminal  Vesicles,"  Brit.  Med.  Journ.,  vol.  i.,  1889, 
pp.  882-884,  and  on  "Spermato-cystitis  (Inflammation  of  the  Seminal  Vesicles),"  Lancet, 
Oct..  31,  1891,  pp.  974  et  seq.  The  reader  is  also  referred  to  an  admirable  chapter  on  the 
seminal  vesicles  and  their  pathology  by  Professor  Gouley  in  his  IJiseruses  of  the  Urinary 
Apparatus,  New  York,  1892,  pp.  263  et  seq.,  and  to  the  essay  of  Gu^lliot,  Des  Vesieules 
seminales,  Anatomie  et  Pathologie,  Paris,  1883.  In  this  essay  will  be  found  a  good  bibli- 
ography of  the  whole  subject  up  to  the  time  of  publication. 


220  GONORRHOEA  AND  ITS  COMPLICATIONS. 

swelling  may  still  further  increase,  and  then  moderate  fluctuation  may 
be  felt.  In  some  of  these  cases  the  patient  presents  a  pitiable  spectacle. 
He  suffers  from  pain  in  the  perineum,  rectum,  bladder,  and  at  the  top  of 
the  sacrum.  He  has  frequent  desire  to  urinate,  and  the  act  is  attended 
"with  much  pain,  or,  again,  in  some  cases,  there  is  very  distressing  dysuria. 
Defecation  is  very  painful,  and  perhaps  complicated  with  rectal  tenesmus, 
and  may  be  attended  with  vesical  spasms ;  sleep  is  heavy  and  unrefresh- 
ing,  and  often  during  the  night  painful  erections  and  pollutions,  perhaps 
bloody,  may  add  to  the  patient's  suff"erings.  The  urine  may  contain  pus 
and  epithelial  cells,  but  these  tissue-elements  may  be  absent  for  hours  or 
for  days,  during  which  the  urine  is  clear  ;  and  in  this  feature  acute  semi- 
nal vesiculitis  diff"ers  from  acute  posterior  urethritis,  in  which  the  dis- 
charge of  pus  or  blood  is  constantly  seen.  At  the  onset,  and  early  in  the 
course,  of  seminal  vesiculitis  the  gonorrhoeal  discharge  may  disappear 
entirely,  and  in  this  it  resembles  epididymitis.  But  in  a  short  time  the 
discharge  reappears,  and  it  may  be  more  or  less  bloody.  In  seminal 
vesiculitis  the  blood  is  mixed  with  the  pus  or  the  latter  is  streaked  with 
it,  whereas  in  posterior  urethritis  the  blood  follows  the  act  of  urination, 
or  there  may  be  a  worm-like  thread  of  coagulated  blood  with  the  first  jet 
of  the  urine. 

The  inflammatory  stage  of  seminal  vesiculitis  usually  pursues  a  course 
similar  to  that  of  epididymitis,  and  at  the  end  of  a  week  or  ten  days  the 
symptoms  become  ameliorated  and  resolution  gradually  sets  in.  In  all 
probability,  in  many  cases  the  parts  sooner  or  later  become  normal  again. 
In  some  cases  after  resolution  of  the  vesicular  inflammation  the  urethral 
discharge  reappears,  while  in  others  the  urethra  is  left  in  a  healthy  condi- 
tion. In  this  acute  stage  of  inflammation  the  morbid  process  resembles 
that  of  gonorrhoea  in  the  redness  and  swelling  of  the  mucous  membrane 
and  in  the  submucous  cell-increase.  When,  however,  the  phlegmasia 
becomes  intense,  a  true  suppurative  process  or  abscess  forms,  in  which 
event  the  local  and  general  symptoms  are  more  pronounced  and  the  suffer- 
ings of  the  patient  greater.  Rectal  exploration  then  reveals  a  large  boggy, 
painful  SAvelling  at  the  base  of  the  bladder,  beyond  and  to  the  outer  edge 
of  the  prostate.  This  swelling  is  very  large  when  both  vesicles  are 
involved. 

Dr.  Gouley's  remarks  on  this  subject  are  very  pertinent.  He  says: 
"  If  the  swelling  is  in  the  form  of  a  single,  hard,  oblong  tumor  extending 
from  the  base  of  the  prostate  upward,  backward,  and  outward,  the  pre- 
sumption is  that  the  phlegmasic  process  has  not  extended  beyond  the 
proper  capsule  of  one  vesicle.  If,  however,  there  is  a  diff'use,  doughy 
swelling  extending  beyond  the  median  line,  it  is  likely  that  both  vesicles 
are  involved,  that  perforation  of  their  walls  has  taken  place,  and  that  the 
ambient  connective  tissue  is  infiltrated." 

While  the  ejaculatory  duct  of  the  seminal  vesicle  remains  patulous 
the  contained  pus  may  escape,  or  perhaps  may  be  milked,  by  means  of  the 
finger-tip,  into  the  urethra,  in  which  event  full  resolution  without  ulterior 
bad  results  may  occur.  If,  however,  the  duct  becomes  occluded  by  the 
swelling  of  its  mucous  membrane  or  by  being  plugged  up  by  sympexia  or 
masses  of  mucus  dislodged  from  the  diverticula  of  the  vesicle,  the  abscess 
may  attain  a  very  large  size,  and  the  pus  may  perforate  its  wall  and  burst 
into  the  ischio-rectal  fossa  or  around  the  rectum  into  the  bladder,  the 


INFLAMMATION  OF  THE  SEMINAL   VESICLES.  221 

rectum,  and  the  peritoneum,  sometimes  causing  death,  and  generally  lead- 
ing to  the  formation  of  fistulous  tracts  which  are  very  difficult  to  cure. 

Mr.  Mitchell  Henry  ^  reports  the  case  of  a  sailor  who  simply  com- 
plained of  pain  in  the  loins  and  hip,  the  joint  of  which  Avas  painful  on 
motion.  The  urine  was  loaded  with  pus  and  blood.  Acute  peritonitis 
developed  and  caused  death.  At  the  autopsy  an  abscess  of  the  left  semi- 
nal vesicle  was  found,  the  pus  of  which  had  first  burst  into  the  bladder 
and  then  into  the  peritoneum.  A  similar  case  was  reported  to  Mr.  Henry 
by  Mr.  Cock. 

Velpeau  ^  reported  the  case  of  a  young  man  suffering  from  gonorrhoea 
who  had  abscess  of  the  seminal  vesicles  which  perforated  the  recto-vesical 
cul-de-sac,  causing  peritonitis  and  death.  A  similar  case  is  reported  by 
Peter,^  in  which  peritonitis  originated  in  an  abscess  of  the  seminal  vesicle. 

It  is  probable  that  seminal  vesiculitis  may  eventuate  in  hydrocele  of 
these  diverticula.  Dr.  N.  R.  Smith  *  reports  the  case  of  a  man  having  a 
pyriform  tumor  occupying  the  cavity  of  the  pelvis  and  extending  above  the 
umbilicus.  This  tumor  was  situated  behind  the  bladder  and  in  front  of 
the  rectum.  It  was  regarded  at  first  as  a  distended  bladder.  A  catheter 
being  passed,  an  ounce  of  perfectly  normal  urine  was  obtained.  On  push- 
ing the  catheter  upward  and  forward  the  tumor  glided  upward.  The 
finger  in  the  rectum  found  a  normal  prostate,  and  on  its  left  an  elastic 
tumor,  pressure  on  which  caused  motion  of  its  fluid  to  be  appreciable  on 
the  abdomen.  Ten  pints  of  a  brown  serous  fluid  were  drawn.  The 
cyst  disappeared  after  two  tappings.  Dr.  Ralph  ^  describes  a  similar  case 
in  which  this  condition  was  verified  at  the  autopsy. 

Mr.  Lloyd  states  that  the  abscess  never  ruptures  into  both  bladder  and 
rectum.  In  any  of  these  very  painful  events  examination  of  the  parts  is 
necessary,  and  from  it  the  line  of  operative  procedure  will  be  arrived  at. 
The  intimate  relations  of  the  vas  deferens,  the  ejaculatory  duct,  and  the 
seminal  vesicles  are  such  that  the  last  structures  and  the  testicles  may  be 
involved  at  the  same  time.  It  is  probable  that  in  many  cases  seminal 
vesiculitis  and  epididymitis  coexist,  but  that  the  violence  of  the  svmp- 
toms  of  the  testicular  trouble  masks  that  of  the  vesicular  affection.  It  is 
also  very  probable  that  the  intrapelvic  pain  which  so  frequently  accom- 
panies acute  epididymitis,  and  which  we  have  been  taught  is  due  to  a 
complicating  phlegmasia  of  the  pelvic  part  of  the  vas  deferens,  is  some- 
times really  symptomatic  of  involvement  of  the  seminal  vesicle.  There 
is  a  field  for  observation  in  this  direction,  and  much  may  be  learned  from 
digital  exploration  of  the  rectum  in  cases  of  acute  testicular  inflammation. 
The  statement  of  Mr.  Lloyd  that  this  affection  is  a  common  accompani- 
ment of  gonorrhoeal  epididymitis  needs  confirmation. 

It  can  be  readily  understood,  after  a  consideration  of  the  foregoing 
facts,  why  acute  seminal  vesiculitis  has  often  been  wrongly  diagnosticated  as 
posterior  urethritis,  as  acute  prostatitis,  and  by  many,  under  the  influence 
of  old  ideas,  as  inflammation  of  the  vesical  neck  and  floor  of  the  bladder. 

Chronic  Seminal  Vesiculitis. 

This  form  of  seminal  vesiculitis  may  result  from  the  non-occurrence 

1  Med.-Chir.  Transactions,  vol.  xxiii.  p.  307.  ^  Med.-Chir.  Rev.,  1857,  vol.  i.  p.  270. 

^  L'  Union  medirxde,  1836,  x.  p.  562.  *  Lancet,  vol.  ii.,  1872,  p.  559. 

*  Ibid.,  vol.  ii.,  1876,  p.  782. 


222  GONORBHGEA  AND  ITS  COMPLICATIONS. 

of  resolution  in  the  acute  affection,  and  in  this  event  the  clinical  his- 
tory is  tolerably  clear  and  striking.  But  in  the  majority  of  cases  of 
chronic  seminal  vesiculitis  it  begins  as  a  low-grade  inflammatory  pro- 
cess in  persons,  particularly  of  neurotic  or  neurasthenic  types,  who  may 
suff'er  from  chronic  subacute  posterior  urethritis  or  chronic  prostatitis,  and! 
in  confirmed  masturbators  and  in  those  given  to  excessive  venery  and 
alcoholics.  The  difficulty  in  the  study  of  the  chronic  form  of  seminal 
vesiculitis  is  that  in  many  cases  the  symptoms  are  so  few  and  so  vague, 
and  point  so  indefinitely,  if  at  all,  to  trouble  in  these  vesicles,  that  often- 
times their  origin  is  not  suspected  by  the  physician.  Then,  again,  cases 
are  seen  in  which  the  symptoms  are  very  clearly  and  strongly  marked,  yet 
they  may  be  with  seemingly  good  reason  attributed  to  trouble  in  the  pos- 
terior urethra  and  in  the  prostate. 

Cases  of  seminal  vesiculitis  which  follow  quite  directly  a  recent  or 
more  or  less  remote  attack  of  gonorrhoea  very  often  present  such  a  group 
of  symptoms  that  the  surgeon  is  led  to  suspect  their  origin  in  inflammation 
of  the  seminal  vesicles,  particularly  if  no  trouble  is  found  in  the  posterior 
urethra.  Such  patients  state  that  since  an  attack  of  gonorrhoea  or  a 
relapse  they  have  not  felt  well  as  regards  their  sexual  organs.  Some 
complain  that  they  are  sexually  weak,  that  they  have  little  desire,  or  that 
they  have  premature  and  perhaps  painful  ejaculations,  which  in  some  cases 
are  mixed  with  blood.  Others,  again,  are  subject  to  a  constant  slight  or 
profuse  discharge  Avhich  is  of  a  mucous  or  muco-purulent  character. 
Again,  this  form  of  discharge  may  be  intermittent.  There  may  be,  how- 
ever, a  decided  chronic  seminal  vesiculitis  without  any  discharge  which  is 
perceptible.  Not  infrequently  patients  having  a  history  of  one  or  more 
attacks  of  gonorrhoea  state  that  they  suff'er  with  a  mild  or  moderately 
severe,  even  burning,  pain  or  itching,  or  a  sense  of  weight  in  the  course 
of  the  urethra,  in  the  perineum,  bladder,  anus,  and.  rectum.  In  addition 
to  this  they  often  give  a  history  of  sexual  erethism  with  or  without  grati- 
fication in  coitus,  and  sometimes  of  increased  desire,  while  little  relief, 
and  even  aggravation  of  symptoms,  may  follow  the  sexual  act. 

Gouley  lays  stress  on  the  occurrence  of  painful  spasmodic  contracture 
of  the  anal  sphincter  both  in  acute  and  chronic  seminal  vesiculitis.  He 
very  rightly  calls  attention  to  spermatic  colic  due  in  all  probability  to  the 
lodgement  of  sympexia,  retained  semen,  and  mucous  masses  or  plugs  in 
the  duct  of  the  vesicle. 

In  the  cases  of  pronounced  masturbators,  in  those  given  to  excessive 
sexual  indulgence,  particularly  with  the  addition  of  alcoholic  excesses, 
chronic  seminal  vesiculitis  may  sometimes  be  found.  These  cases  are 
often  those  of  anaemic,  neurotic,  and  neurasthenic  subjects  who  respond 
very  indifferently  to  treatment.  Such  patients  may  complain  of  some 
pain  or  disturbance  in  the  urethra,  bladder,  anus,  or  rectum,  and  they 
may  present  a  discharge ;  then,  again,  all  these  symptoms  may  be  Avanting. 
Most  of  them,  however,  give  a  history  of  a  disturbance  in  the  sexual 
function  similar  to  those  just  detailed.  These  disturbances  are  mainly 
of  two  forms  :  first,  those  of  lowered  poAver,  and,  second,  those  of  erethism 
of  the  sexual  organs.  In  the  first  order  of  cases  we  find  absence  or  in- 
completeness of  erections,  pollutions  from  slight  causes,  Avithout  enlarge- 
ment of  the  penis.  In  these  cases  there  is  often  a  haunting  desire  for 
erection,  with  no  response.     Very  often  these  patients  suffer  from  a  con- 


INFLAMMATION  OF  THE  SEMINAL   VESICLES.  223 

stant  dribbling  of  a  dirty  gray  or  brownish  mucus,  Avhicli  may  during  the 
day  be  so  copious  as  to  saturate  one  or  two  pocket  handkerchiefs.  Then, 
again,  some  of  these  patients  have  no  such  discharge,  but  an  emission  of 
a  thin,  gray,  watery,  and  sometimes  brownish  and  even  curdy  fluid  occurs 
daily  or  more  frequently.  Such  is  the  erotic  condition  of  these  patients 
that  the  sight  of  a  pretty  woman,  of  her  breast  or  her  ankle,  throws  them 
into  a  high  state  of  nervousness  and  sexual  erethism.  I  have  known 
several  instances  in  which  one  woman  only  exerted  this  morbid  influence 
upon  the  man.  Accidental  slight  contact,  the  glance  of  the  eye,  the 
sound  of  the  voice,  and  the  grasp  of  the  hand  served  to  so  excite  and 
exalt  them  sexually  that  an  orgasm,  with  or  without  partial  erection, 
would  result. 

These  cases  run  a  somewhat  peculiar  course.  In  some  the  symptoms 
and  conditions  continue  in  a  more  or  less  subdued  manner,  and,  though 
they  disturb  the  patients  considerably,  the  latter  arrive  at  a  state  of  mind 
by  which  they  bear  their  troubles  more  or  less  philosophically.  In  this 
class  of  cases  the  affection  runs  on  from  year  to  year  in  a  monotonous 
way.  Such  patients  are  neither  healthy  nor  very  sick.  But  cases  are 
sometimes  seen  in  which  the  chronic,  uneventful  course  of  the  afl"ection  is 
varied  by  the  development  of  more  or  less  severe  exacerbations.  In  this 
event  the  health  becomes  deteriorated,  the  patients  lose  their  appetite  and 
weight,  and  present  the  appearance  of  very  weak  and  sick  men.  Con- 
comitantly with  this  condition  the  nervous  system  becomes  much  dis- 
turbed and  the  patients  present  the  symptoms  of  neurasthenia.  A  nerv- 
ous apprehension  and  anxiety  are  very  frequent  concomitants.  Such  an 
exacerbation  may  last  one  month  or  many  months,  and  may  lead  to  per- 
manent invalidism. 

In  old  men  suff'ering  from  hypertrophy  of  the  prostate  a  low  grade  of 
seminal  vesiculitis  is  a  not  uncommon  concomitant.  In  many  of  these 
cases  the  vesicular  complication  passes  unnoticed,  for  the  reason  that  it 
may  give  rise  to  no  symptoms  at  all,  or,  if  present,  they  are  not  pro- 
nounced in  character.  Then,  again,  they  may  be  masked  by  the  dis- 
turbances produced  by  the  prostatic  aifection. 

Tuberculosis  of  the  seminal  vesicles  will  only  be  touched  upon  lightly 
here.  The  onset  of  the  aff'ection  is  attended  with  moderate  and  not  well- 
defined  symptoms,  which  are  frequently  referred  to  the  posterior  urethra 
and  the  prostate.  When  the  aff'ection  begins,  as  it  rarely  does,  primarily 
in  the  vesicles,  the  symptoms  may  be  for  some  time  so  mild  and  vague 
that  they  are  not  understood.  Beginning  in  the  prostate,  as  so  commonly 
occurs,  tuberculosis  either  goes  backward  to  the  vesicles  or  downward  to 
the  testicles.  With  the  involvement  of  the  posterior  urethra  the  symp- 
toms are  increased  frequency  of  micturition,  pain  with  the  act,  occasional 
hemorrhages,  and  a  purulent  discharge.  With  the  extension  backward 
to  the  seminal  vesicles  these  symptoms  become  more  pronounced.  The 
rectal  touch  then  shoAvs  that  the  prostate  is  swollen  and  hard,  with  well- 
defined  borders  and  an  irregular  nodulated  surface,  on  which  there  may 
be  spots  Avhich  feel  soft.  At  the  distal  end  of  the  prostate  the  seminal 
vesicles  also  are  swollen.  In  the  early  stages  of  the  process  that  portion 
only  which  merges  into  the  prostate  is  thickened,  hard,  and  perhaps 
nodular.  With  the  further  extension  of  the  disease  the  whole  organ 
becomes  enlarged,  hard,  uneven,  and  nodulated.     This  period  of  density 


224  OONOBRHCEA  AND  ITS  COMPLICATIONS. 

and  nodulation  of  the  vesicles  may  be  only  transitory,  and  there  is  left  a 
voluminous,  smooth,  and  perhaps  doughy  tumor.  Richet  compares  the 
sensation  conveyed  to  the  finger-tip  to  that  of  sebaceous  cysts  or  to  a 
pocket  injected  with  tallow.  This  sensation  is  due  to  the  softening  of 
tuberculous  matter.  Guelliot  emphasizes  the  point  that  induration  and 
nodulation  are  not,  as  we  have  been  taught,  absolutely  constant  in  tuber- 
culosis of  the  seminal  vesicles.  Out  of  fifty  cases  examined  by  him,  he 
only  observed  these  signs  eight  times. 

In  addition  to  the  symptoms  already  given  of  tuberculosis  of  the 
seminal  vesicles  (and  it  must  be  remembered  that  this  aifection  is  gener- 
ally a  concomitant  of  a  similar  process  in  the  prostate),  there  is  much 
sexual  erethism.  In  some  cases  the  genital  excitation  amounts  even  to 
torment.  Erections  are  strong  and  constant,  desire  for  coitus  is  con- 
tinuous and  imperative,  and  pollutions  are  frequent.  This  excitation  is 
the  outcome  of  the  hypergemic  condition  of  the  infective  process.  As 
degenerative  changes  take  place  in  the  tissues  the  condition  changes,  the 
desire  slowly  abates,  and  finally  the  genesic  function  is  wholly  lost.  This 
form  of  genital  tuberculosis  is  usually  concomitant  with  involvement  of 
other  vital  parts  which  in  the  end  leads  to  death.  Cases  are  on  record, 
however,  which  go  to  show  that  tuberculosis  of  the  seminal  vesicles  may 
undergo  degenerative  changes — caseation  and  absorption,  followed  by 
atrophy  and  fibroid  degeneration. 

There  is  an  important  point  in  the  clinical  history  of  chronic  seminal 
vesiculitis  concerning  which  our  knowledge  is  very  limited,  and  which 
requires  much  future  study  on  a  scientific  basis.  This  may  be  formulated 
in  these  questions :  Is  chronic  seminal  vesiculitis  the  starting-point  of 
tubercular  infection  ?  and  about  how  frequently  does  this  infectious  com- 
plication occur  ?  It  is  as  reasonable  to  suppose  that  a  chronically  inflamed 
seminal  vesicle  may  become  tuberculous  as  it  is  that  an  epididymis  simi- 
larly affected  may  be,  and  Ave  know  that  such  is  sometimes  the  case.  But 
as  regards  the  seminal  vesicles  we  have  little  knowledge  of  a  scientific 
nature.^ 

Diagnosis. — The  diagnosis  of  seminal  vesiculitis,  in  whatever  form  it 
may  exist,  is  to  be  arrived  at  mainly  through  palpation  of  the  parts  by 
the  finger  inserted  into  the  rectum.  It  has  already  been  shown  how  little 
light  the  subjective  symptoms  throw  upon  the  nature  of  the  trouble.  It 
is  not,  as  a  rule,  as  easy  as  it  is  claimed  to  be  by  some  to  make  out  clearly 
the  outlines  and  dimensions  of  the  seminal  vesicles.  In  the  examination 
some  authors  state  that  the  patient  should  bend  the  body  forward  as  far 
as  he  can,  his  feet  being  about  a  foot  apart.  It  is  always  well  that  the 
bladder  should  be  full,  for  in  that  condition  the  vesicles  are  more  readily 

^  In  an  interesting  essay  Dr.  E.  Fuller  ("  Persistent  Urethral  Discharges  dependent 
on  Subacute  or  Chronic  Seminal  Vesiculitis,"  Journal  Cutaneous  and  Ge)iito-iirina.ri/  Dis- 
eases, June  and  July,  1894)  reports  22  cases  of  chronic  seminal  vesiculitis,  in  7  of  which 
he  thinks  that  there  was  tubercular  involvement.  This  subject  is  so  important  that  we 
must  insist  on  strong  proof  before  accepting  statements  regarding  it.  There  is  no  abso- 
lutely clear  history  in  Dr.  Fuller's  cases  of  a  coexistent  tubercular  affection  elsewhere  in 
any  of  his  patients,  except  in  three  cases,  and  in  them  it  is  vague,  and  the  diagnosis  is 
mainly  based  on  the  patient's  poor  condition,  the  failure  of  stripping  of  the  vesicles  to 
cure  the  trouble,  and  the  improvement  under  good  hygiene  and  nutritive  treatment.  On 
so  important  and  yet  so  obscure  a  subject  we  should  be  slow  to  make  dogmatic  statements 
regai-ding  tubercular  complication,  knowing,  as  we  do.  that  seminal  vesiculitis  is  not 
infrequently  a  concomitant  of  a  state  of  ill-health  which  may  even  be  alarming. 


INFLAMMATION  OF  THE  SEMINAL   VESICLES.  225 

detected.  Then  the  finger  (which  should  be  a  long  one)  is  introduced 
into  the  rectum,  and  then,  having  defined  the  outline  of  the  prostate,  the 
vesicles  are  sought  for  above  and  to  the  outside  of  this  body. 

This  examination  can  also  be  made  with  the  patient  on  his  back  in 
the  lithotomy  position,  in  which  event  the  bladder,  being  full,  tends  to 
sag  down  in  the  pelvis.  It  is  easy  to  conceive  that  in  some  patients  in 
the  bending-forward-and-standing  position  the  bladder  may  tilt  forward 
toward  the  abdominal  Avail,  and  then  the  vesicles  will  be  more  inacces- 
sible. 

At  the  prostate  the  two  vesicles  approach  to  within  a  finger's  breadth 
of  one  another,  and  on  the  inner  side  of  each  is  the  vas  deferens,  which 
at  this  part  frequently  becomes  much  ampullated.  I  myself  think  that 
very  often  this  ampullation  of  the  vas  deferens,  which  may  be  increased  in 
size  by  the  gonorrhoeal  or  chronic  hypergemic  process,  is  mistaken  for 
enlargement  of  the  seminal  vesicles.  It  certainly  is  next  to  impossible  to 
say  from  rectal  examination  in  life  that  the  vas  deferens  is  not  swollen 
and  the  vesicle  is.  These  parts  are  in  such  intimate  juxtaposition  that  it 
is  nearly  impossible  to  distinguish  between  the  two.  It  is  important,  also, 
to  have  a  good  knowledge  of  the  structure  and  physical  characters  of 
the  vesicles  in  their  normal  state.  To  this  end  study  on  healthy  men  is 
necessary.  The  seminal  vesicles  in  health  have  a  firm,  somewhat  resistant 
structure,  which,  while  not  presenting  a  brawny  feel  to  the  touch,  gives 
the  sensation  of  having  tolerably  thick  walls.  Therefore  the  surgeon 
must  not  enter  upon  the  examination  with  the  idea  that  he  is  to  feel  two 
oblong,  rather  soft,  and  readily-compressible  little  bladders. 

If  diseased,  the  seminal  vesicles  will,  in  the  acute  stage,  feel  much 
swollen  in  all  directions,  tender,  perhaps  hot,  and  may  present  a  doughy 
sensation,  like  that  of  the  over-filled  leech.  In  the  stage  of  abscess  the 
swelling  will  be  great,  the  pain  intense,  and  the  symptoms  severe  and 
pointing  to  intrapelvic  trouble. 

In  the  chronic  forms  a  large  flabby  tumor  may  be  felt.  If  both  ves- 
icles are  involved,  the  base  of  the  bladder  beyond  the  prostate  is  the  seat 
of  the  tumor,  which  is  usually  of  goodly  size,  often  very  large.  Abdom- 
inal pressure,  exerted  deep  down  and  toward  the  pelvis,  may  often  afford 
much  aid  in  these  examinations.  Some  authors  lay  stress  upon  the  pres- 
ence of  a  sound  in  the  bladder,  pushing  it  base  downward  toward  the  rec- 
tum, as  being  of  great  help  to  the  finger  in  the  rectum.  Perhaps  in  some 
cases  this  procedure  may  be  admissible  or  practicable,  but  it  should  never 
be  resorted  to  without  due  thought  concerning  the  nature  of  the  case  and 
the  state  of  the  deep  urethra  and  prostate.  In  all  acute  cases  the  intro- 
duction of  the  sound  as  an  accessory  aid  to  diagnosis  is  strictly  interdicted. 
In  chronic  cases  the  surgeon  must  always  remember  that  the  posterior 
urethra  may  be  the  seat  of  a  low  grade  of  inflammation,  and  that  the 
prostate  may  also  be  at  least  hypersemic.  This  same  caution  applies  very 
strongly  to  the  cases  of  old  men  who  are  suffering  from  enlargement  of 
the  prostate  and  also  from  a  chronic  inflammatory  condition  of  the  seminal 
vesicles — a  complication  which  is  sometimes  met  with. 

Examination  and  manipulation  of  the  seminal  vesicles  by  means  of  the 
finger-tip  cause  a  flow  of  pus,  with  perhaps  blood,  into  the  urethra  when 
the  inflammation  is  recent  and  active.  In  the  subacute  cases  the  discharge 
is  muco-purulent  and  mucoid,   containing  masses  of  inspissated  semen, 

16 


226  GONORBHCEA  AND  ITS  COMPLICATIONS. 

masses  of  mucus,  sympexia,  and  sometimes  very  minute  calcareous  con- 
cretions. 

Pathology. — In  the  acute  gonorrhoea!  stage  it  is  probable  that  the 
lesion  of  the  mucous  membrane  is  similar  to  that  of  gonorrhoea  of  the 
urethra.  This  is  a  field  worthy  of  careful  study.  As  yet  the  observa- 
tions have  been  macroscopical  rather  than  microscopical.  In  the  main, 
the  morbid  process  consists  of  swelling  of  the  mucous  membrane  .and 
small-cell  thickening  in  the  submucous  connective  tissue.  The  vesicles 
then  may  be  much  dilated,  or,  again,  they  may,  by  contraction  of  the 
newly-formed  tissue,  become  much  shrivelled.  Within  the  vesicles  a 
brownish  mucus,  muco-pus,  spermatozoa  alive  or  dead,  sympexia,  and 
calcareous  concretions  may  be  found.  Gouley  states  that  of  sixty  dissec- 
tions of  the  seminal  vesicles  made  in  cases  of  prostatic  enlargement,  in 
three-fourths  of  them  the  vesicles  were  shrivelled  and  hard. 

Cancer  of  the  seminal  vesicles  is  very  rare,  and  usually  secondary  to 
involvement  of  the  prostate,  testicles,  bladder,  a'hd,  very  rarely  indeed,  of 
the  rectum.  Gu^lliot  could  only  report  one  case  in  which  it  was  probable 
that  the  malignant  process  began  primarily  in  the  vesicles.  Out  of  13 
cases  of  secondary  cancer  of  these  structures,  he  found  it  consecutive  to 
cancer  of  the  testicles  in  1  case,  to  cancer  of  the  rectum  in  1  case,  to  can- 
cer of  the  bladder  in  3  cases,  and  to  cancer  of  the  prostate  in  8  cases, 
Gouley  alludes  to  one  case,  but  gives  no  particulars.  Zahn,  according  to 
Kocher,^  has  reported  a  case  which  he  believes  to  have  been  one  of  pri- 
mary sarcoma  of  one  seminal  vesicle.  The  patient  was  seventy-six  years 
old,  and  his  urine  was  passed  by  drops.  At  the  autopsy  infiltrations  of 
sarcoma,  which  were  regarded  as  secondary,  were  found  in  the  heart,  mes- 
entery, and  small  intestine.  The  prostate  was  healthy,  but  both  seminal 
vesicles  were  enlarged  and  infiltrated  with  round  and  spindle-shaped  sar- 
coma-cells. 

Prognosis. — In  the  acute  form  of  this  trouble  resolution  usually  takes 
place.  In  the  chronic  forms  amelioration  and  cure  may  be  obtained.  In 
some  cases,  however,  the  morbid  process  goes  on  to  the  formation  of  large 
tumors  which  require  operative  measures.  Tubercular  infiltration  of  the 
seminal  vesicles  may  perhaps  undergo  resolution  or  lead  to  cicatrization 
or  caseation,  but  in  most  cases  it  is  continuous  with  or  concomitant  to  a 
similar  aflFection  of  other  organs,  and  in  the  end  death  results.  In  malig- 
nant new-growths  a  lethal  outcome  is  inevitable. 

Treatment. — -When  recognized  in  the  acute  stage,  seminal  vesiculitis  is 
to  be  treated  on  the  general  principles  which  govern  the  management  of 
all  phlegmasise  of  the  genital  and  urinary  organs.  Hughes  of  Dublin 
recommends  the  application  of  three  or  four  leeches  to  the  anterior  wall 
of  the  rectum  (previously  cleansed  and  disinfected)  near  the  vesicles. 
This  procedure  will  always  be  found  to  be  difiicult  and  disagreeable,  so 
that  the  best  plan  is  to  apply  a  large  number,  of  leeches  upon  the  peri- 
neum and  the  murgin  of  the  anus.  Injections  of  cold  water  may  be  used, 
and  the  rectum  may  be  packed  with  ice  if  the  procedure  is  pleasant  to  the 
patient.  Opium  in  suppositories,  diluents,  and  saline  cathartics  may  be 
administered  as  necessity  requires. 

Should  an  abscess  form,  it  may  be  reached  by  means  of  a  long  incis- 
ion, as  suggested  by  Mr.  Lloyd,  in  the  perineum  just  anterior  (about 

^  Die  Krankheiten  der  Mannlichen  Geschlechtsorgane,  Stuttgart,  1887,  pp.  638  et  seq. 


INFLAMMATION  OF  THE  SEMINAL    VESICLES.  227 

three-quarters  of  an  inch)  to  the  anus,  great  care  being  taken  that  the 
membranous  urethra,  the  prostate,  and  the  rectum  are  not  cut.  In  this 
operation  much  aid  will  be  given  by  means  of  the  finger  in  the  rectum. 
The  incision  may  be  made  in  the  median  line  laterally,  or,  if  both  vesi- 
cles are  the  seat  of  acute  suppuration,  it  may  be  crescentic.  Then  the 
dissection  between  the  base  of  the  bladder  and  the  rectum  must  be  cau- 
tiously made.  The  resulting  cavity  should  be  treated  on  general  surgical 
principles.  When  the  abscess  is  not  large,  but  is  well  defined,  Gouley 
recommends  that  the  "parts  should  be  brought  to  view  by  means  of  a 
Sims  speculum  in  the  rectum,  and  a  slightly-curved  aspirating  needle,  not 
less  than  two  millimetres  in  calibre,  should  be  thrust  into  the  abscess  and 
the  cavity  quickly  emptied,  and  then  well  irrigated  with  a  warm  subli- 
mate solution  (1 :  5000).  A  single  aspiration  may  sufiice,  but  in  case  the 
cavity  refills  the  aspiration  and  irrigation  should  be  repeated." 

In  more  acute  and  extensive  abscesses  Gouley  recommends  free  incis- 
ion through  the  rectal  wall,  followed  by  careful  antiseptic  packing.  If 
these  operative  procedures  through  the  rectal  wall  are  adopted,  it  is  im- 
portant to  remember  that  the  after-treatment  must  be  conscientiously 
carried  out,  bearing  in  mind  the  great  danger  of  sepsis  and  the  possibility 
of  the  formation  of  fistulae. 

In  the  treatment  of  chronic  seminal  vesiculitis,  in  which  we  may  find 
distended  pouchy  vesicles,  much  stress  has  recently  been  laid  by  Dr.  E. 
Fuller  ^  upon  what  he  terms  stripping  or  milking  the  vesicles.  This  pro- 
cedure is  accomplished  by  the  finger-tip  gently  but  firmly  pressing  or 
kneading  as  much  of  the  organ  as  is  within  reach  from  above  downward, 
so  as  to  express  the  contents  through  the  ejaculatory  duct  into  the  pros- 
tatic urethra.  Fuller  causes  the  patient  to  bend  his  body  at  right  angles 
to  his  lower  extremities,  and  in  this  position  he  introduces  the  finger,  all 
the  while  making  counter-pressure  on  the  abdomen,  the  bladder  being,  if 
possible,  well  filled.  Should  there  be  resistance  of  the  perineal  muscles, 
it  is  recommended  that  the  surgeon  should  rest  his  foot  on  a  chair,  then, 
with  the  knee  well  braced  against  the  elbow,  such  firm  and  continuous 
pressure  may  be  exerted  as  will  enable  the  surgeon's  finger  to  reach  the 
vesicle,  the  resistance  of  the  muscles  having  been  overcome.  By  this 
manoeuvre  Fuller  thinks  that  he  has  succeeded  in  some  difficult  cases. 
As  has  already  been  said,  it  is  no  easy  matter  in  many  cases  to  reach  the 
vesicles  and  clearly  define  their  size  and  shape,  even  when  every  favoring 
condition  is  present.  Then,  again,  at  the  best,  only  the  lower  half  of  the 
vesicle  is  really  accessible  to  the  stripping  process.  Further  than  this,  it 
must  be  very  clearly  remembered,  as  has  already  been  pointed  out,  that 
the  seminal  vesicles  are  made  up  of  blind-ended  tubes  or  diverticula,  and 
that  they  have  not  the  structure  and  arrangement  of  racemose  glands, 
firm  pressure  on  which  will  cause  the  contents  to  exude  into  the  excretory 
duct.  An  inspection  of  Fig.  30  will  clearly  show  that  it  is  a  physical 
impossibility  to  cause  the  contents  of  the  third  tube — or,  as  we  call  it, 
the  handle  of  the  jack-knife — to  exude  into  the  urethra,  for  the  reason 
that  it  is  a  blind  sac  or  pouch,  its  non-patulous  part  ending  downward 
near  the  prostate.  This  portion  of  the  vesicle  is  fully  as  large  as  the 
other  two-thirds  are,  and  the  contents  of  this  large  part  cannot  in  any 
way  be  extruded  into  the  urethra.     For  anatomical  reasons  it  will  be 

^  "  Seminal  Vesiculitis,"  Journ.  Cut.  and  Gen.-urin.  Diseases,  Sept.,  1S93. 


228  GONORRHCEA  AND  ITS  COMPLICATIONS. 

clearly  seen  that  the  utmost  that  can  be  accomplished  in  stripping  or 
milking  a  vesicle  is  to  act  upon  about  one-quarter  of  its  whole  structure. 
I  have  no  doubt  that  the  ampullation  of  the  vas  deferens,  which  is  so 
common  near  the  prostate,  has  often  been  mistaken  for  enlargement  of 
the  seminal  vesicles.  In  theory,  stripping  the  vesicles  seems  to  be  a 
rational  treatment,  in  that  it  seeks  to  rid  these  organs  of  retained  chronic 
inflammatory  matter  and  to  restore  the  tone  in  muscular  and  mucous  tis- 
sues which  have  become  relaxed  and  flabby.  Undoubtedly,  in  some  cases 
benefit  may  result  from  the  proceeding,  but  as  yet  the  cases  in  'which  it 
has  been  employed  are  so  small  in  number  and  so  wanting  in  conspicu- 
ously brilliant  and  uniform  results  that  it  must  for  the  time  be  considered 
simply  as  a  therapeutical  suggestion,  and  it  is  for  the  future  to  determine 
the  extent  of  its  worth.  Certainly  the  muscular  movements  of  urination, 
defecation,  and  emission  must  and  do  produce  much  efl"ect  upon  the  condi- 
tion of  the  seminal  vesicles,  and  in  all  probability  the  normal  state  of 
these  sacculated  appendages  is  largely  dependent  upon  these  normal 
^' strippings"  and  "milkings." 

The  treatment  of  the  cases  of  chronic  seminal  vesiculitis  in  which 
there  is  neurasthenia,  debility,  and  often  great  mental  depression  belongs 
largely  to  the  domain  of  general  medicine.  Such  cases  require  good 
hygiene — if  possible  an  entire  change  of  scene,  rest,  and  pleasant  sur- 
roundings. Tonics  combined  with  nux  vomica  and  ergot  produce  much 
benefit.  Iron,  quinine,  and  coca  are  also  indispensable  in  some  cases. 
The  urethra,  bladder,  prostate,  and  seminal  vesicles  should  be  very  care- 
fully examined  by  instruments  and  by  inspection  of  the  urine.  If  there 
is,  as  so  frequently  happens,  a  coexistent  posterior  urethritis,  this  should 
be  properly  treated.  I  have  seen  cases  of  cure  in  which  the  foregoing 
measures  have  been  carried  out.  Then,  again,  only  amelioration  of  the 
symptoms  may  be  produced.  In  some  cases  the  health  seems  to  be  re- 
stored for  a  short  or  long  period,  and  then  a  relapse  occurs  and  the  whole 
treatment  has  to  be  repeated. 

In  the  treatment  of  large  hydroceles  of  the  seminal  muscles  one  or 
more  tappings  above  the  pubis  may  eff"ect  a  cure.  In  cases  of  abscess- 
formation  the  cyst,  which  is  usually  of  large  size,  must  be  reached  through 
an  abdominal  incision,  well  sterilized,  packed  Avith  gauze,  and  allowed  to 
heal  from  the  bottom. 


CHAPTER    XXIL 

EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS  (SWELLED  TESTICLE). 

The  most  frequent  complication  of  gonorrhoea  is  an  inflammation  of 
the  epididymis  which  may  be  sharply  limited  to  that  appendage  or  it  may 
also  involve  the  testicle.  The  former  is  called  "epididymitis,"  and  the 
latter  "epididymo-orchitis,"  and  both  are  known  under  the  title  "swelled 
testicle."     In  some  cases  of  swelled  testicle  there  is  a  concomitant  inflam- 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  229 

mation  of  the  vas  deferens  in  more  or  less  of  its  extent,  and  to  this  phleg- 
masia the  terms  "  deferentitis "  and  "  funiculitis  "  have  been  applied. 
This  complication  is  also  called,  less  correctly,  "  inflammation  of  the  sper- 
matic cord"  when  that  portion  near  or  in  immediate  continuity  with  the 
epididymis  is  involved.  Acute  inflammation  of  the  tunica  vaginalis,  with 
a  greater  or  less  amount  of  efl"usion,  also  occurs  in  cases  of  swelled  testicle, 
particularly  when  the  morbid  process  is  centred  in  the  epididymis. 

In  former  years  swelling  of  the  testicle  in  the  course  of  acute  and 
chronic  gonorrhoea,  and  as  a  result  of  instrumentation  in  the  urethra,  was 
explained  by  such  vague  and  unsatisfactory  terms  as  sympathy,  reflex 
action,  and  metastasis.  In  the  light  of  our  present  knowledge  of  the 
gonorrhoeal  process  these  hypotheses  have  no  scientific  worth  whatever. 
The  testicular  inflammation  results  undoubtedly  from  the  extension  of  the 
gonorrhoeal  process  into  the  utriculus  masculinus,  and  from  there  into  the 
ejaculatory  duct,  the  vas  deferens,  and  testis.  Though  the  anatomical 
and  clinical  facts  thus  far  in  our  possession  do  not  clearly  show  that  the 
inflammation  creeps  step  by  step  along  the  mucous  membrane  of  the  whole 
length  of  the  vas  deferens,  there  can  be  no  doubt  that  such  a  pathological 
condition  does  take  place.  Reasoning  by  analogy  in  the  light  of  the 
undisputed  fact  that  the  gonorrhoeal  process  begins  at  the  fossa  navicu- 
laris,  and  passes  backward  by  direct  continuity  of  tissue,  and  not  by 
jumps,  to  the  bladder,  it  is  fair  to  assume  that  this  process  further  spreads 
along  the  whole  length  of  the  vas  until  it  reaches,  and  in  most  cases  local- 
izes itself  in,  the  testis.  Why  the  whole  length  of  the  vas  deferens  is 
not  rendered  swollen,  inflamed,  and  painful  in  each  case,  together  with 
the  testis,  we  cannot  say.  That  the  inflammation  may  be  arrested  along 
the  canal  at  various  parts  there  can  be  no  doubt. 

In  the  majority  of  cases  of  epididymitis,  as  we  have  seen,  the  gonor- 
rhoeal process  first  invades  and  localizes  itself  in  the  posterior  urethra, 
from  which  it  spreads  to  the  testis.  Jadassohn  ^  and  Neisser  ^  both  claim 
that  the  epididymis  may  be  attacked,  while  the  posterior  urethra  yet 
remains  intact.  Neisser  says  "  that  patients  may  sufi'er  from  epididy- 
mitis without  there  being  any  possibility  of  finding  gonococci  or  even  an 
inflammation  in  the  posterior  urethra,  even  if  examinations  are  frequently 
repeated.  I  do  not  know  how  the  gonococci  get  there,  but  the  fact  is 
certain."  Jadassohn  says :  "The  bacteria  which  have  reached  the  pos- 
terior urethra  may  have  been  carried  away  by  the  stream  of  urine,  whilst 
those  already  in  the  ejaculatory  duct  are  safe  in  this  respect ;  or  by  the 
inflammation  of  the  epididymis  the  catarrhal  process  in  the  posterior 
urethra  may  have  been  brought  to  an  end  for  a  time  or  finally,  as  also 
happens  in  the  anterior  urethra."  I  have  seen  and  carefully  examined 
a  case  of  epididymitis  in  which  I  could  not  at  any  time,  even  remote, 
discover  any  evidence  whatever  of  involvement  of  the  posterior  urethra. 
So  it  may  be  that  in  some  cases,  as  the  infective  process  travels  along  the 
vas  deferens  toward  the  testis,  it  wholly  ceases  in  the  posterior  urethra. 
We  certainly  see  cases  of  men  who  after  gonorrhoeal  epididymitis  have  no 
longer  any  urethral  discharge,  and  never  thereafter  any  relapse  of  their 
gonorrhoea. 

^  Op.  Ci7.,  pp.  188  and  189. 

^  "  Zur  Bedeutung  der  Gonorrhoisclien  Prostatitis,"  Verhandl.  der  Deut.  Dermat. 
Oesellschaft,  Wien  und  Leipzig,  1894,  pp.  325  et  seq. 


230  GONOBBHGEA   AND  ITS  COMPLICATIONS. 

There  is  very  frequently  in  cases  of  epididymitis  and  epididymo-orchitis 
a  swollen  and  painjpul  condition  of  the  vas  deferens  as  it  leaves  the  epi- 
didymis and  ascends.  This  swelling  of  the  vas  may  extend  an  inch  and 
even  more  up  the  tube.  It  is  usually  lost  sight  of  by  reason  of  the 
greater  prominence  and  painfulness  of  the  testicular  phlegmasia.  Bergh 
of  Copenhagen,^  an  acute  and  accurate  observer,  in  two  series  of  cases  of 
gonorrhoeal  epididymitis,  numbering  in  all  348,  found  coexistent  localized 
involvement  of  the  vas  deferens  in  182  cases.  This  same  complication 
was  studied  by  Hassing,^  who  found  the  proportion  still  higher. 

Swelled  testicle,  therefore,  may  consist  only  of  inflammation  of  the 
epididymis,  but  this  is  usually  complicated  with  acute  inflammation  and 
more  or  less  copious  efi'usion  into  the  cavity  of  the  tunica  vaginalis.  This 
combination,  with  in  some  cases  some  involvement  of  the  vas  deferens, 
constitutes  the  majority  of  the  cases  of  swelled  testicle  from  gonorrhoea. 
The  less  common  combination  is  inflammation  of  the  epididymis  and  testis, 
in  which  case  the  tunica  vaginalis  is  very  apt  to  be  affected,  with  perhaps 
a  limited  invasion  of  the  vas  deferens. 

Until  within  the  last  few  years  the  statement  was  made  and  quite  gen- 
erally accepted  that  swelled  testicle  appeared  as  a  complication  in  the  third 
week  of  gonorrhoea,  chiefly  toward  its  end,  and  then  rather  less  frequently 
in  the  three  following  weeks.  Cases,  of  course,  were  observed  in  which 
the  complication  appeared  later.  This  statement,  that  the  testicle  became 
affected  chiefly  in  the  third  week,  was  based  on  the  erroneous  idea  that 
gonorrhoea,  as  a  rule,  travelled  back  leisurely,  and  if  it  reached  the  pos- 
terior urethra  at  all,  it  did  so  generally  in  the  third  week.  This  view  has 
been  shown  to  be  incorrect  (see  page  123),  since  in  most  cases  the  onward 
advance  of  the  gonorrhoeal  process  is  very  prompt,  and  it  is  the  rule  rather 
than  the  exception  that  the  posterior  urethra  should  be  attacked.  The 
date  of  the  onset  of  epididymitis  has  been  carefully  studied  by  Bergh  in 
926  cases,  as  will  be  seen  in  the  following  table : 

Appearance  of  Cronorrhoeal  Epididymitis. 


In  th 

e  1st  -^^ 

'eek  in 

70 

cases. 

In  the  4th  month 

in  19  cases. 

a 

2d 

229 

"       oth         " 

7     " 

H 

3d 

176 

"       6th 

15     " 

(C 

4th 

135 

"       7th         " 

1     " 

11 

5th 

79 

"       8th 

2     " 

a 

6th 

52 

"       9th 

5     " 

a 

7th 

39 

In  1  year  in 

3     " 

11 

8th 

23 

"  IJ  years  in 

2     " 

ti 

9th 

32 

"  2 

2    " 

u 

10th 

11 

"  3        " 

3     " 

a 

11th 

12 

926  cases. 

« 

12th 

9 

In  these  926  cases  the  testicular  complication  developed  in  the  first  three 
weeks  in  475  cases,  which  is  rather  more  than  one-half  of  the  whole  num- 
ber. Now,  when  it  is  remembered  that  gonorrhoea  usually  lingers  for  a 
day  or  two,  and  perhaps  longer,  in  the  prodromal  stage  at  the  fossa  navic- 
ularis,  it  will  be  seen  how  promptly  the  testicle  was  attacked  in  so  many 
cases  in  which  we  may  deduct  one,  two,  or,  exceptionally,  three  days.  •  All 

^  "Beitrag  zur  Kenntniss  der  Entstehung  der  Urethritischen  Epididymitis,"  Monats- 
hefte  fur  Prac.  Dermat,  1884,  pp.  161  et  seq. 
^  See  Bergh's  essay. 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  231 

these  figures  are  in  support  of  the  view  that  gonorrhoea  promptly  spreads 
backward  and  invades  the  posterior  urethra.  It  does  not  follow,  however, 
that  the  infective  process  will  pass  through  the  ejaculatory  ducts  and 
down  to  the  testes.  This  further  extension  may  perhaps  depend  on  the 
condition  of  the  openings  of  the  ejaculatory  ducts.  If  these  openings 
are  lax  and  patulous,  the  infection  may  readily  pass  into  them  and  onward. 
On  the  other  hand,  if  the  calibre  is  small  and  they  are  tightly  compressed, 
they  may  not  offer  a  favorable  condition  to  the  spread  of  the  inflamma- 
tion. It  is  difficult  otherwise,  then,  on  these  anatomical  grounds  to  ex- 
plain cases  in  which  in  every  attack  of  gonorrhoea  the  testis  is  aff"ected, 
and  why  in  some  cases  where  there  has  been  no  extraneous  source  of  irri- 
tation or  injury  of  the  parts  the  extension  of  the  phlegmasia  has  been  so 
prompt.  It  must  be  remembered  that  in  many  cases  the  spread  of  the 
disease  is  due  to  hard  work,  violent  exercise,  to  excesses,  alcoholic  and 
sexual,  and  to  the  intemperate  use  of  very  active  treatment,  perhaps  with 
a  view  of  aborting  the  disease. 

Summing  up  the  results  of  the  observations  of  Bergh,  which  are  fully 
in  accord  with  my  own,  and  which  further  have  the  support  of  the  statis- 
tics furnished  by  Unterberger,^  it  may  be  said  that  within  the  first  three 
weeks  of  gonorrhoea  the  testis  is  attacked  in  the  majority  of  cases  of 
swelled  testicle,  and  that  between  the  fourth  and  sixth  weeks,  inclusive,  it 
is  attacked  rather  less  frequently.  Thus  there  were  475  in  the  first  three 
weeks,  inclusive,  and  266  cases  between  the  fourth  and  sixth  weeks,  inclu- 
sive. These,  therefore,  are  the  periods  in  which  acute  gonorrhoeal  inva- 
sion of  the  testis  most  frequently  occurs.  When  epididymitis  develops 
after  this  period  of  six  weeks,  which  corresponds  to  the  period  of  decline 
of  the  gonorrhoea,  it  is  usually  the  result  of  some  extraneous  influence 
acting  on  the  disease  in  the  posterior  urethra. 

Double  epididymitis  sometimes  occurs,  in  which  case  usually  the  second 
testis  is  attacked  from  one  to  three  weeks  after  the  first  one.  In  some 
cases,  however,  the  second  testicle  is  not  involved  until  later — eight,  ten, 
or  even  twelve  weeks.  An  epididymis  or  testis  once  the  seat  of  gonor- 
rhoeal inflammation  is  thereafter  very  liable  to  be  affected  with  each  repeti- 
tion of  the  infection,  and  also  when  a  chronic  deep  urethral  inflammation 
undergoes  an  exacerbation  and  an  acute  condition  results.  Further  than 
this,  mechanical  injury,  over-exertion,  undue  pressure  on  the  testis,  may 
for  years  after  light  up  a  more  or  less  severe  recrudescence. 

Cases  have  been  reported  by  Castelnau,  Vidal,  and  others  in  which 
epididymitis  developed  from  three  to  ten  days  before  the  appearance  of 
the  urethral  discharge.  Bergh  speaks  of  two  cases  in  which  epididymitis 
appeared  in  four  and  six  hours  after  a  violent  coitus,  and  in  Avhich  the 
discharge  appeared  several  days  later.  These  cases  used  to  be  looked 
upon  as  curiosities,  and  the  pathological  conditions  underlying  them  Avere 
not  clearly  grasped.  Their  pathogenesis,  however,  is  not  difficult  of 
explanation.  In  all  such  cases  there  has  been  a  previous  antecedent 
gonorrhoea  which  has  left  a  latent  posterior  urethritis.  In  sexual  and 
alcoholic  excesses  this  latent  condition  becomes  an  acute  one,  and  for  some 
reason,  perhaps  anatomical,  the  phlegmasia  travels  through  the  ejacula- 
tory duct  into  the  testis  before  it  spreads  forward  and  invades  the  anterior 

^  "  Zur  Frage  iiber  den  Zeitpunkt  des  Auftretens  des  Epididymitiden,  etc.,"  Monatshefte 
fiir  Prak.  Dermal.,  1884,  vol.  iii.  pp.  97  et  seq. 


232  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

urethra.  As  we  have  seen  (see  page  168),  a  latent  posterior  urethritis 
may  undergo  exacerbation,  and  the  inflammatory  process  may  in  one  or 
several  days  spread  into  the  anterior  urethra.  There  is  nothing  inexplic- 
able or  wonderful,  therefore,  in  cases  in  which  the  testis  is  attacked  before 
the  urethral  discharge  appears. 

In  years  gone  by  there  was  much  discussion  as  to  which  testis,  the 
right  or  the  left,  was  more  frequently  the  seat  of  gonorrhoea!  inflamma- 
tion. It  was  claimed  that  the  condition  of  the  veins  on  the  left  side,  and 
the  fact  that  men  "  dressed  "  on  that  side,  tended  to  produce  inflammation 
in  that  testis.  Others,  again,  claimed  that  the  right  testis  was  more  fre- 
quently affected  than  the  left.  It  seems  strange  that  such  a  minor  point 
should  cause  so  much  discussion  and  give  rise  to  such  a  formidable  array 
of  statistics  as  it  did.  From  my  own  experience  I  am  inclined  to  agree 
with  Bergh,  who  has  gone  quite  carefully  over  the  subject,  and  who  says 
that  on  an  average  both  epididymes  are  attacked  in  about  the  same  pro- 
portion. 

There  is  great  discrepancy  in  the  statements  of  authors  as  to  the  fre- 
quency of  swelled  testicle  in  gonorrhoea.  The  truth  is,  that  no  general 
statement  can  be  nnade.  Hospital  statistics  always  show  a  large  percent- 
age, for  the  reason  that  in  very  many  cases  poorer  patients,  owing  to  the 
severity  of  the  aff'ection,  are  forced  to  enter  them.  In  dispensaries  and 
clinics  the  proportion  is  also  quite  large,  but  patients  who  frequent  them 
are  men  who  have  to  work  hard  and  cannot  spare  themselves,  Avho  are 
careless  in  their  habits,  perhaps  given  to  drink,  and  who  often  induce  the 
disease  by  the  intemperate  use  of  balsamics  and  injections. 

In  private  practice,  particularly  among  the  middle  and  upper  classes, 
swelled  testicle  cannot  be  said  to  be  common.  As  a  general  rule,  it  may 
be  said  to  depend  very  largely  on  the  method  of  treatment  followed. 
Active  interference  in  the  acute  stage,  aggressive  attempts  at  aborting  the 
disease,  the  too  early  use  of  balsamics  and  strong  injections,  are  the  under- 
lying causes  of  many  cases  of  swelled  testicle.  On  the  other  hand,  a 
mild  and  palliative  treatment  in  the  acute  stage  tends  to  make  the  per- 
centage of  these  cases  quite  small.  Bergh  is  disposed  to  think  that  in 
private  practice  in  each  100  cases  of  gonorrhoea  7  will  become  affected 
with  swelled  testicle.  In  my  judgment  and  experience  this  percentage  is 
far  too  high  :  I  think  even  3  per  cent,  a  high  figure. 

Symptoms. — Before  the  onset  of  the  affection  the  urethral  discharge 
usually,  but  not  always,  ceases,  and  patients  complain  of  varying  symp- 
toms. In  some  a  pain  in  the  groin,  at  the  external  ring,  and  along  the 
vas  deferens,  either  in  the  external  or  in  the  pelvic  segment,  is  complained 
of.  In  somewhat  rare  cases  pain  is  experienced  in  the  whole  length  of 
the  vas  deferens.  Some  patients  even  complain  of  a  pain  which  reaches 
to  the  kidney.  In  some  cases  the  pain  seems  to  be  at  first  in  the  deep 
urethra  or  in  the-  seminal  vesicles,  and  these  patients  sometimes  suffer  from 
pollutions  Avhich  may  be  painful  and  bloody.  The  most  common  history 
given  by  patients  is  that  they  felt  at  first  a  dull  pain  and  a  sensation  of 
weight  in  the  scrotum,  which  they  perhaps  attributed  to  cold  or  to  a 
strain  or  jarring  motion.  In  general,  there  are  no  premonitory  constitu- 
tional symptoms,  but  as  the  intensity  of  the  inflammation  increases  a  chill 
and  fever  of  various  degrees,  with  malaise,  waiit  of  appetite,  great  thirst, 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  233 

a  frequent  desire  to  urinate,  and  perhaps  constipation,  may  supervene. 
As  a  rule,  the  systemic  reaction  is  not  great,  but  in  very  severe  cases,  and 
particularly  those  in  which  the  vas  deferens  is  involved,  there  may  be 
well-marked  fever  with  all  its  concomitants — namely,  hot  skin,  coated 
tongue,  rapid  pulse,  together  with  nervousness  and  agitation.  In  some 
rare  cases  there  are  nausea  and  vomiting.  The  invasion  of  the  affection 
may  be  prompt  or  slow.  Many  patients  walk  and  attend  to  their  duties 
with  mild  and  bearable  discomfort  for  one  or  more  days  before  they  are 
forced  to  assume  the  recumbent  position.  In  other  cases,  particulai'ly 
those  in  which  one  or  more  exciting  causes  are  active,  the  affection  is  well 
under  way  and  the  patient  on  his  back  within  twenty-four  hours.  Early 
examination  of  a  case  shows  that  the  epididymis,  with  perhaps  the  vas,  is 
swollen  and  painful,  and  that  the  scrotum  over  it  is  somewhat  reddened. 
In  some  cases  the  pain  and  swelling  are  confined  to  the  globus  minor  or 
tail  of  the  epididymis,  which  becomes  of  the  size  of  a  hickory-nut,  and 
the  affection  may  thus  be  limited :  usually,  how^ever,  the  body  and  globus 
major  or  head  of  the  organ  are  promptly  involved.  Then  a  large  tumor 
is  found  seated  superiorly  and  posteriorly  to  the  testis,  and  the  furrow 
which  naturally  exists  between  that  organ  and  the  epididymis  may  be 
present  or  it  may  be  obliterated.  The  shape  of  the  tumor  varies  in  dif- 
ferent cases.  The  epididymis,  becoming  enlarged,  may  cover  the  testis 
like  a  cap,  or  it  may  grow  longitudinally  and  form  a  semilunar  tumor, 
which  rests  on  the  organ  like  a  crest  on  a  helmet,  the  head  of  the  append- 
age reaching  well  forward  and  the  tail  Avell  upward.  There  is  also  usually 
more  or  less  lateral  expansion  of  it,  sometimes  almost  enveloping  the 
testis.  Pressure  on  the  testis  in  such  a  case  usually  causes  no  pain,  but 
when  the  sw^ollen  epididymis  is  held  between  the  thumb  and  fore  finger  the 
patient  winces  or  cries  out.  While  at  rest  in  the  horizontal  position,  with 
the  scrotum  well  supported,  the  patient  may  be  tolerably  comfortable. 
Coincidently  with  this  inflammation,  the  scrotum  on  the  affected  side 
becomes  of  a  deep,  even  purplish,  red,  very  much  swollen  from  oedema, 
and  adherent  to  the  testis.  Pain  is  at  this  time  severe,  sometimes  almost 
unendurable,  and  continuous,  with  paroxysms  at  night.  Slight  motion 
tends  to  increase  the  patient's  sufferings,  and  pressure  even  of  the  bed- 
clothes causes  agony.  Coincident  involvement  of  the  cord  is  attended 
with  a  still  greater  amount  of  pain,  which  extends  up  to  the  inguinal 
canal.  In  these  very  severe  cases  the  testicle  is  also,  as  a  rule,  the  seat 
of  inflammation.  When  the  epididymis  alone  is  inflamed,  the  swelling  is 
very  considerable,  but  when  it  and  the  testis  are  involved,  it  is  great,  so 
that  a  tumor  of  the  size  of  a  small  fist  is  formed.  The  testis  will  be 
found  to  be  very  painful  and  tender,  and  a  much  larger  area  of  the  scro- 
tum will  become  inflamed,  thickened,  and  of  a  deep  red.  While  at  first 
there  is  only  moderate  and  localized  adhesion  of  the  upper  portion  of 
the  organ  to  the  scrotal  wall,  when  epididymo-orchitis  is  present  there  is 
adhesion  of  a  large  surface  corresponding  to  the  size  of  the  swollen  testi- 
cle. In  proportion  as  the  testicular  inflammation  is  great,  the  tunica 
vaginalis  becomes  aff'ected  and  the  seat  of  serous  effusion,  by  which  the 
size  of  the  tumor  is  materially  increased.  With  this  concomitant  the 
acme  of  the  inflammation  may  be  said  to  be  reached.  The  patient  then 
wdll  complain  of  pains  in  the  perineum,  in  the  thighs,  the  groins,  and 
the  lumbar  regions.     In  some  cases  patients  complain  bitterly  of  deep 


234  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

pelvic  and  rectal  pains,  which  are  due  to  a  complicating  inflammation 
of  the  seminal  vesicles. 

In  the  acute  stage  particularly,  and  also  in  the  period  of  decline  of 
epididymo-orchitis,  examination  of  the  prostate,  and  sometimes  the  semi- 
nal vesicles,  by  means  of  rectal  touch  will  in  many  cases  reveal  swelling 
and  congestion  of  that  organ,  sometimes  in  its  totality,  and  again  on  the 
side  corresponding  to  the  testicular  inflammation.  Lucas  ^  in  285  cases 
examined  found  that  in  174  there  was  no  perceptible  change  in  the  pros- 
tate, and  that  in  the  balance  the  organ  was  more  or  less  swollen  and 
painful. 

In  its  full  height  swelled  testicle  consists  of  inflammation  of  the  epi- 
didymis, of  the  testis  proper,  of  the  tunica  vaginalis,  which  is  the  seat  of 
effusion,  and  of  exudative  oedema  of  the  subscrotal  connective  tissue  and 
of  the  scrotal  wall,  Avith  perhaps  inflammation  of  more  or  less  of  the  cord. 
At  this  time  it  is  difficult  to  detect  fluctuation  in  the  hydrocele  unless  the 
effusion  is  very  copious.  The  tissues  are  too  hypersemic  and  opaque  to 
admit  of  the  light  test  for  translucency.  This  hydrocele  is  due  to  inflam- 
mation of  the  tunica  vaginalis  testis,  and  is  called  vaginalitis.  This  com- 
plicating extension  of  the  gonorrhoeal  process,  although  a  very  frequent, 
is  not  a  constant,  symptom,  and  is  always  consecutive  to  the  inflammation 
of  the  epididymis.  There  is  commonly  an  effusion,  varying  in  quantity 
and  character,  within  the  tunica  vaginalis.  This  may  consist  only  of 
serum,  and  be  apparently  due  to  simple  obstruction  of  the  circulation,  or 
it  may  contain  fibrin  and  other  products  of  inflammation.  Sometimes 
bands  of  lymph  bind  the  two  opposed  surfaces  together,  as  in  pleurisy. 
The  subscrotal  cellular  tissue  also  participates  in  the  inflammatory  action, 
and  is  thickened  by  oedema  or  fibrinous  deposit.  As  a  rule,  well-marked 
swelled  testicle  reaches  its  acme  within  forty-eight  or  seventy-two  hours. 

Much  depends  in  these  cases  upon  the  vigor  and  efficiency  of  the  treat- 
ment, which  may  prevent  the  affection  from  reaching  the  point  of  full 
development,  and  which  will  usually  superinduce  the  stage  of  decline. 
Swelled  testicle  may  exist  in  a  severe  form  from  one  to  five  days  in  un- 
treated cases,  when  subsidence  of  the  inflammation  begins.  In  carefully- 
treated  cases  the  intensity  of  the  symptoms  need  not  last  longer  than 
twenty-four  or  thirty-six  hours.  The  first  symptom  of  improvement  is 
amelioration  of  the  pain,  and  soon  it  is  noticed  that  the  patient  can  move 
in  bed  with  more  freedom  than  before.  The  redness  and  oedema  of  the 
scrotum  become  less,  and  its  adhesion  gradually  passes  away,  and  the 
swelled  organ  becomes  smaller  and  can  be  more  freely  manipulated.  The 
swollen  epididymis  may  be  quite  clearly  made  out,  the  testis  can  be  dis- 
tinctly felt,  and  if  any  hydrocele  is  present  it  may  be  detected  by  palpa- 
tion or  perhaps  by  the  light  test.  At  this  time  the  general  health  of  the 
patient  will  improve ;  he  will  lose  his  anxious  look,  drink  less  of  fluids, 
and  ask  for  food.  As  a  rule,  the  course  of  swelled  testicle  in  bad  cases 
occupies  from  ten  to  fourteen  days,  during  which  time  the  patient  will 
have  been  confined  to  his  bed.  At  the  end  of  this  time,  though  he  may 
go  about,  he  is  far  from  well,  and  should  be  looked  after  Avith  the  most 
careful  attention.  Unless  removed  by  tapping,  the  hydrocele  remains  for 
a  long  period,  and  while  it  does  the  testis  remains  swollen  and  tender. 
When  there  is  no  hydrocele  the  testis  is  found  to  gradually  become  smaller 

1  These  de  Paris,  1894. 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  235 

and  softer,  and  soon  the  line  of  demarcation  between  it  and  the  epididymis 
can  be  made  out.  During  this  period  of  involution  the  epididymis  also 
grows  smaller,  but  much  more  slowly,  and  for  longer  or  shorter  periods  it 
is  found  to  be  enlarged  and  indurated.  Its  continuance  in  this  state  is 
governed  largely  by  the  duration  and  intensity  of  the  inflammation.  With 
the  oedema  of  the  part  there  is  cell-exudation,  and  the  future  of  the  case 
depends  on  the  extent  and  severity  of  this  morbid  condition  and  whether 
it  is  appropriately  treated.  So  rapid  and  complete  is  the  involution  of  the 
swelling  of  the  epididymis  in  some  cases  that  it  seems  scarcely  credible ; 
in  others  it  is  slow,  occupying  several  months ;  while  in  others  permanent 
enlargement  and  induration  are  left.  In  severe  cases — luckily,  not  com- 
mon— the  testis,  tunica  vaginalis,  epididymis,  and  vas  deferens  are  left  in 
a  state  of  induration  and  chronic  subacute  inflammation. 

During  an  acute  attack  of  swelled  testicle  the  suff"erings  of  the  patient, 
as  in  gonorrhoea,  are  sometimes  increased  by  the  occurrence  of  nocturnal 
emissions. 

As  a  rule,  the  first  attack  of  swelled  testicle  is  the  most  severe,  and  it 
renders  the  patient  very  liable  to  relapses.  The  afiection  is  usually  uni- 
lateral, though  rarely  both  testes  are  involved.  Exceptionally,  inflam- 
mation of  one  organ  is  followed  by  that  of  its  fellow,  and  this  condition  is 
called  see-saw  epididymitis,  the  epididymite  a  bascule  of  Ricord. 

Much  gradation  in  intensity  is  observed  in  swelled  testicle.  Some 
patients  simply  complain  of  a  little  uneasiness  and  heaviness  in  the 
scrotum,  and  the  surgeon  is  the  first  to  find  the  epididymis  more  or  less 
enlarged.  Other  patients  present  more  marked  subjective  symptoms, 
with  moderate  epididymitis  and  often  involvement  of  the  testicle,  yet  by 
means  of  medical  applications  and  with  the  support  of  a  suspensory  they 
are  able  to  go  about  with  moderate  freedom.  Resolution  of  the  inflam- 
mation also  varies  considerably  in  difi"erent  subjects.  In  some  cases  with 
very  little  care  the  testis  soon  returns  to  its  normal  state,  while  in  others 
it  is  sloAV,  in  spite  of  the  most  careful  treatment. 

In  a  normally-placed  testis  little  difficulty  is  experienced  in  determin- 
ing the  extent  and  localization  of  the  inflammation,  but  it  must  be  re- 
membered that  exceptionally  there  exist  malpositions  of  the  epididymis, 
when  confusion  may  occur.  The  most  common  form  of  malposition  is 
where  the  epididymis  is  placed  anterior  to  the  body  of  the  testis,  in  which 
the  features  observed  in  the  normal  testis  would  be  reversed.  Then  it  may 
be  seated  on  one  side,  either  external  or  internal,  in  which  event  the  diag- 
nosis need  not  be  difficult.  In  the  third  variety  the  epididymis  and  vas 
deferens  are  attached  superiorly,  the  long  axis  of  the  testis  being  in  the 
antero-posterior  direction.  In  a  fourth  variety  the  epididymis  and  vas 
deferens  form  a  loop  or  sling  from  before  backward  around  the  testis.  It 
is  always  important  to  make  a  correct  estimate  of  the  position  of  the 
parts,  particularly  if  puncture  of  the  tunica  vaginalis  is  decided  upon.  It 
is  a  good  rule  to  find  the  vas  deferens  high  up  in  the  scrotum,  and  if 
practicable  trace  it  downward  between  the  tips  of  the  thumb  and  fore 
finger. 

Sometimes,  even  when  the  epididymis  is  normally  placed,  its  weight 
and  bulk  are  so  much  inci'eased  by  inflammation  that  it  falls  downward 
and  forward  with  the  testis  above  it.  Examination  then  reveals  the  tail 
of  the  epididymis  anteriorly  and  the  head  posteriorly,  the  organ  hanging 


236  QONORRHCEA  AND  ITS  COMPLICATIONS. 

antero-posteriorly  in  the  scrotum.  Then,  again,  owing  to  the  heaviness 
of  the  epididymis,  it  sinks  down  to  the  bottom  of  the  scrotum,  and  the 
testis  then  lies  directly  on  top  of  it. 

Gonorrhoeal  inflammation,  when  it  attacks  an  undescended  or  mis- 
placed testis,  has  frequently  been  unrecognized.  Berkeley  Hill  speaks 
of  the  case  of  a  young  man  suifering  from  gonorrhoea,  obstinate  con- 
stipation, stercoraceous  vomiting,  fever,  and  great  abdominal  tenderness, 
particularly  in  the  left  iliac  region.  The  right  testis  was  found  in  the 
scrotum,  but  the  left  one  could  not  be  discovered.  After  death,  from 
peritonitis,  a  small  inflamed  testis  was  found  close  to  the  internal  ring. 
Undescended  testis  in  the  inguinal  canal  need  ofi'er  no  diagnostic  difiiculty. 
Ricord  mistook  a  perineal  swelling  for  abscess  of  Cowper's  gland,  but 
examination  of  the  scrotum  showed  absence  of  one  testis,  and  a  diagnosis 
of  misplaced  and  inflamed  testis  was  made.  An  interesting  case  of  testis 
in  perineo,  complicated  by  congenital  inguinal  hernia  and  acute  orchitis, 
is  reported  by  Dr.  J.  A.  Williams,^  who  gives  the  bibliography  up  to  the 
date  of  his  essay,  with  a  synthetical  table  of  the  cases.  Gosselin  reported 
the  rare  occurrence  of  gonorrhoea  attacking  the  epididymis  seated  in  the 
scrotum  while  the  testis  Avas  retained  in  the  inguinal  canal,  in  which  the 
first  diagnosis  was  epiplocele. 

It  very  often  occurs,  as  pointed  out  by  Le  Double,^  that  in  patients 
having  varicocele,  inguinal  hernia  and  ectopia  of  the  testis,  epididymitis 
develops  on  the  side  on  which  either  of  these  conditions  exists.  Of  14 
cases  of  hernia  observed  by  Le  Double,  the  epididymitis  appeared  on  the 
affected  side  in  12  cases.  In  8  out  of  9  epididymitis  developed  on  the 
side  on  which  the  vai'icocele  was  present.  In  these  cases  the  testicular 
trouble  often  aggravates  the  condition  of  the  varicocele,  while  the  latter 
may  tend  to  induce  atrophy  of  the  testis. 

Statistics  seem  to  shoAv  that  swelled  testicle  occurs  more  frequently  on 
the  left  than  on  the  right  side,  presumably,  according  to  some  authors, 
from  the  fact  that  men  usually  "dress"  on  this  side.  As  to  the  fre- 
quency with  which  different  tissues  of  the  testis  are  attacked,  the  statistics 
of  Sigmund  show  that  in  1342  cases  of  swelled  testicle  the  epididymis 
alone  was  involved  in  61 ;  the  epididymis  and  tunica  vaginalis  in  856  ; 
the  epididymis  and  cord  in  108  ;  and  these  three  parts  together  in  317. 

Gronorrhoeal  inflammation  of  the  vas  deferens  outside  of  the  inguinal 
canal,  without  involvement  of  the  corresponding  testis,  is  a  rather  rare 
complication.  In  the  three  cases  which  I  have  seen  there  w^as  a  fusiform 
or  cylindrical  swelling  of  the  size  of  one's  finger  or  of  a  sausage,  begin- 
ning at  the  external  ring  and  ending  near  the  epididymis.  The  overlying 
skin  was  hot,  red,  rather  oedematous,  and  not  freely  movable  over  the  in- 
flamed cord.  There  was  moderate  fever  in  two  cases,  and  the  pain  was 
severe  ;  in  the  third  case  the  febrile  symptoms  were  well  marked,  and  the 
patient  vomited  and  was  much  constipated.  These  symptoms,  in  addition 
to  which  the  patient  said  that  he  first  experienced  pain  after  prolonged 
coughing,  led  my  house-surgeon  to  think  the  case  was  one  of  hernia.  The 
existence  of  a  discharge  led  to  inquiries,  which  settled  the  diagnosis,  which 
was  further  confirmed  by  palpation. 

1  The  British  Med.  Journal,  July  21,  1883. 

^  Be  I' Epididymite  blennorrhagiqiie  dans  les  Cas  de  Hernie  inguiiude  de  Varicocele  on 
d' Anomalies  de  rAppareil  genital,  Paris,  1879. 


EPIDIDYMITIS  AXD  EPIDIDYMO-ORCHITIS.  237 

Gosselin  reported  a  case  in  "which  the  swelling  began  below  the  external 
ring  and  extended  to  the  level  of  the  head  of  the  epidid^^mis.  It  was  of 
the  size  of  a  hickory-nut,  hard  and  painful,  and  from  it  a  cord  of  the  size 
of  a  goosequill  stretched  to  the  tail  of  the  eiDididymis.  Above  the  tumor 
the  vessel  was  hard  and  cord-like. 

Localized  inflammation  of  the  vas  deferens  within  the  pelvis  sometimes 
occurs,  and  causes  much  deep-seated  pain  during  acute  gonorrhoea.  In 
some  cases  the  swelling  can  be  made  out  by  physical  examination.  In 
other  cases  the  swelling  is  inaccessible,  but  the  history  of  the  case  and  the 
symptoms  point  to  involvement  of  the  vas.  Sometimes  the  surgeon  sus- 
pects the  case  to  be  one  of  intra-pelvic  abscess.  In  very  exceptional  cases 
a  considerable  part  of  the  pelvic  portion  of  the  vas  may  be  involved. 
Mauriac^  reports  the  case  of  a  man  suffering  from  acute  gonorrhoea  in 
whom  the  vas  could  be  felt  as  a  hard,  painful  cord,  and,  owing  to  the 
extreme  leanness  of  the  patient,  it  could  be  followed  into  the  pelvis.  By 
the  finger-tip  in  the  rectum  the  seminal  vesicle  of  the  same  side  was 
found  to  be  swollen. 

Induration  of  the  epididymis  may  exist  without  impairment  of  the 
function  of  the  testis.  In  some  cases  so  copious  and  dense  is  the  prolif- 
eration of  cellular  tissue  that  constriction,  even  to  the  extent  of  oblitera- 
tion of  the  vasa  eiferentia,  is  produced,  rendering  the  testis  sterile.  This 
is  especially  to  be  feared  when  the  globus  minor  is  involved,  since  at  this 
point  the  tubes  unite  into  one,  whereas  at  the  globus  major  there  is  a  mul- 
titude of  minute  eiferent  vessels,  some  of  which  may  escape.  Unilateral 
induration  of  the  globus  minor  may  cause  obliteration  of  the  deferent  duct 
and  sterility  of  one  testis.  When  it  occurs  on  both  sides,  absolute  steril- 
ity may  be  produced,  but,  as  a  rule,  such  patients  have  their  usual  sexual 
desires,  and  their  erections  and  ejaculations  are  complete.  Their  semen, 
however,  is  entirely  wanting  in  spermatozoa.  Further,  the  size  and  con- 
sistency of  the  testes  remain  as  before,  and  atrophy  is  very  rarely  pro- 
duced. It  has  been  observed  that  in  favorable  cases  treatment  has  more 
or  less  perfectly  removed  the  induration,  and  that  the  spermatozoa  have 
again  been  found  in  the  semen. 

Atrophy  of  the  testes  has  been  known  to  occur  in  a  few  cases  follow- 
ing epididymo-orchitis,  and  hypertrophy  is  not  very  uncommon,  particu- 
larly in  subjects  who  have  had  repeated  attacks  of  the  affection.  I  have 
seen  two  well-marked  cases  of  atrophy  due  to  acute  urethritis,  and  Rona  ^ 
has  published  an  interesting  case  of  this  complication. 

Abscess  of  the  testis  is  a  not  frequent  complication  of  gonorrhoeal 
epididymo-orchitis,  the  focus  of  the  trouble  being  usually  in  the  epididy- 
mis. It  should  be  promptly  opened  and  the  wound  treated  antiseptically, 
otherwise  fistulse  and  fungous  growths  are  liable  to  form.  It  does  not,  of 
necessity,  follow  that  the  vas  deferens  will  be  occluded.  In  these  cases 
of  abscess  of  the  epididymis  or  testis  following  gonorrhoea  a  suspicion  of 
tuberculosis  is  warranted,  and  the  patient  should  be  well  looked  after  and 
placed  in  the  best  of  hygienic  conditions.  Cysts  in  the  epididymis  some- 
times follow  swelled  testis,  and  are  sometimes  the  seat  of  acute  pain,  and 
may  be  mistaken  for  circumscribed  abscesses. 

Abscess  of  the  body  of  the  testis  somewhat  rarely  occurs  during  gon- 

^  Annales  de  Dennat.  et  de  Syphilif/raj)hic,  No.  6,  1891,  pp.  407  et  seq. 
^  Monatshefte  fur  Prak.  Dermat.,  vol.  v.,  1886,  jip.  360  et  seq. 


238  GONORBBCEA   AND  ITS  COMPLICATIONS. 

orrhoeal  epididymo-orchitis.  An  incision  should  be  made  as  soon  as  fluc- 
tuation is  discovered.  In  some  cases  the  wound  heals  and  the  integrity 
of  the  organ  seemingly  remains.  In  other  cases  a  hernia  of  the  testis 
tissues  occurs,  and  protrudes  as  a  fungous  mass  from  the  opening  in  the 
scrotal  walls.  In  some  of  these  cases  the  morbid  process  may  be  of  a 
benign  character  and  the  mass  may  be  due  to  simple  hyperplasia.  In 
some  cases  tuberculosis  may  be  present.  Consequently,  all  such  cases 
should  be  carefully  examined  and  watched. 

Chronic  hydrocele  is  frequently  caused  by  swelled  testicle.  V^tault 
thinks  that  the  eifusion  is  due  to  congestion  of  the  vessels  of  the  tunica 
vaginalis,  caused  by  presence  of  the  indurated  tissue  in  the  head  of  the 
epididymis.  It  is  also  probable  that  the  acute  inflammation  during  gon- 
orrhoea leaves  a  tendency  in  the  vessels  of  the  testis  and  the  tunica  vag- 
inalis to  engorgement  and  consequent  effusion  of  serum. 

Gangrene  of  the  scrotum  is  a  somewhat  rare  complication  of  swelled 
testicle ;  and  of  it  I  have  seen  two  cases — one  in  a  diabetic  patient,  and 
the  second  in  a  man  suffering  from  Bright's  disease.  It  usually  begins, 
particularly  in  cases  which  have  been  poulticed,  at  a  dependent  portion 
of  the  sac  as  a  black  spot,  Avhich  spreads  and  destroys  more  or  less  of  the 
walls,  laying  bare  the  testis  or  testes,  which,  however,  are  not  invaded. 
After  the  cessation  of  the  gangrene  the  parts  usually  heal  and  cover  the 
organs  again,  unless  the  destruction  has  been  very  extensive. 

Gangrene  of  the  testicles  is  a  very  rare  complication  of  acute  gon- 
orrhoea. Bogdan  ^  reports  a  case  in  Avhich  both  testicles  were  destroyed 
by  gangrene.  Gangrene  of  the  scrotum  may  follow  gangrene  of  the 
testes. 

In  a  case  of  acute  gonorrhoea  Samter^  observed  the  development  of 
trismus,  for  which  no  other  etiological  cause  than  the  urethral  inflamma- 
tion could  be  ascertained. 

Neuralgia  is  a  not  uncommon  sequela  of  swelled  testicle.  It  may  exist 
as  a  slightly  painful  sensitiveness  of  the  organ  and  along  the  cord,  par- 
ticularly on  pressure  or  during  active  motion,  or  as  a  distinct  dull  pain 
subject  to  irregular  and  fugitive  paroxysms.  Usually,  in  these  cases  the 
epididymis  is  found  to  be  enlarged  and  very  sensitive.  It  is  commonly 
seen  in  weak,  sickly  subjects,  particularly  those  of  neuropathic  tendency, 
and  subjects  given  to  worry  and  fretting. 

Reflex  neuralgias,  first  fully  described  by  Mauriac,^  are  not  infrequent 
complications  and  sequelae  of  swelled  testicle.  The  pain  is  generally  uni- 
lateral and  confined  to  the  territory  supplied  by  the  lumbar  and  sacral 
nerves  of  the  affected  side,  but  may  cross  the  median  line  and  extend  in 
various  directions.  Spinal  pain,  seated  at  the  junction  of  the  lumbar  and 
sacral  plexuses,  is  sometimes  complained  of,  and  it  may  be  bilateral  and 
more  severe  on  the  unaffected  side.  Deep-seated  pain,  as  if  in  the  kid- 
neys, extending  from  the  ribs  to  the  sacrum,  pains  radiating  from  the 
lower  part  of  the  lumbar  portion  of  the  cord  and  radiating  upon  the 
abdomen  and  lower  extremity,  and  a  sense-  of  a  constriction  encircling  the 
body  under  the  level  of  the  umbilicus,  are  also  sometimes  experienced. 

^  Annates  de  Dei~m,.  et  de  Syph.,  1893,  pp.  1211  et  seq. 
2  Bed.  klin.  Wochenschrift,  1889,  No.  9. 

'^  Etude  sur  les  Nevralc/ies  reflexes  symptomatiques  deV  Orchi-epididymite  blennorrhagiqueSy 
Paris,  1870. 


EPIDIDYMITIS  AND  EPIDWYMO-OECHITIS.  239 

Pains  and  vague  unpleasant  sensations  are  felt  at  spots  along  the  inter- 
costal nerves  and  in  the  course  of  their  distribution. 

The  pains  aifecting  the  leg  are  not  uncommon,  and  they  may  be  seated 
in  the  anterior  crural  or  posteriorly  in  the  sciatic  nerve.  The  pains  in  the 
anterior  crural  nerve  involve  the  anterior  aspect  of  the  thigh  as  far  as  the 
knee,  rarely  below  that,  though  Mauriac  says  that  the  internal  saphenous 
nerves  may  be  the  seat  of  pain.  The  pains  in  the  sciatic  nerve  are 
referred  to  the  sciatic  notch,  from  which  they  may  extend  forward  to  the 
great  trochanter  or  downward  to  the  popliteal  space.  In  many  cases  they 
are  limited  to  the  buttocks  and  postero-external  portion  of  the  thigh.  The 
pains  may  be  of  a  neuralgic  character,  continuous  or  with  exacerbations, 
sometimes  of  a  fulminating  character,  and  remissions,  or  mav  exist  as 
more  or  less  extensive  hypersesthesia  of  all  those  parts  supplied  by  the 
lumbar  and  sacral  nerves  and  their  branches. 

The  intensity  of  these  pains  sometimes  amounts  to  agony,  and  they 
cause  insomnia,  nervous  excitement,  and  prostration  and  emaciation :  they 
may  last  several  days  or  several  months,  but  in  the  end  they  cease.  It  is 
frequently  observed  that  a  relapse  of  the  epididymo-orchitis  is  accompanied 
or  followed  by  some  neuralgic  manifestations.  Such  morbid  phenomena 
emphasize  the  necessity  of  careful  and  intelligent  treatment  of  the  testicular 
lesion. 

Patients  who  have  suffered  from  epididymitis,  particularly  those  in 
whom  relapses  have  been  frequent  and  whose  epididymes  are  thickened, 
are  prone  to  engorgement  and  gummatous  infiltration  of  these  parts  if 
they  subsequently  contract  syphilis.  The  same  tendency  is  observed  in 
cases  in  which  the  testis  proper  has  been  inflamed  during  gonorrhoea. 
Chronically  inflamed  and  indurated  epididymes  sometimes  become  the 
seat  of  caseous  degeneration,  and  in  sickly,  scrofulous,  and  tuberculous 
subjects  tuberculosis  may  attack  them. 

Orchitis  and  Epididymo-orchitis  occurring-  in  the  Course  of  Various 

Diseases, 

Inflammation  of  the  testicles,  alone  or  in  combination  with  epididymitis 
and  vaginalitis,  may  also  occur  as  a  complication  of  a  number  of  infective 
diseases. 

In  the  course  of  mumps  the  testicle  may  become  painful,  swollen,  and 
hard.  The  affection  called  mumps,  or  parotidean  orchitis,  may  be  limited 
to  the  gland  and  it  may  involve  the  epididymis  and  the  tunica  vaginalis. 
The  onset  of  this  inflammation  is  brusque  and  its  course  rapid,  so  that  in 
from  three  days  to  a  week  it  may  cease.  Involvement  of  the  second  tes- 
ticle sometimes  occurs.  In  this  form  of  orchitis  resolution  may  be  perfect, 
but  not  uncommonly  total  atrophy  occurs. 

Under   the  title   orchite   amygdalienne,   or  tonsillar  orchitis,   French  • 
authors^  have  described  an  acute  and  ephemeral  orchitis  in  men  suffering 
from  tonsillitis.     The  onset  of  this  affection  is  sudden,  its  course  rapid, 
and  resolution   may   take   place   within    a   few   days.      The   affection   is 
observed  in  adolescents,   and   is    usually  unilateral.      It  may  result  in 

^  Verneuil,  "Les  Epanchements  dans  la  Tunique  vaginale,  metastatique  de  I'Arriere 
bouche,"  Archives  gen.  de  Medecine,  1857,  and  Joal,  "  Orchite  et  Oviirite  aniygdalienne," 
ibid.,  1886,  vol.  xviii.  pp.  678  et  seq. 


240  GONOEEHCEA  AND  ITS  COMPLICATIONS. 

abscess  and  atrophy.     According  to  Monod  and  Terrillon,^  this  orchitis 
is  an  anomalous  form  of  mumps-orchitis. 

During  the  course  of  small-pox  the  testicle,  its  envelope,  and  its 
appendages  may  be  attacked  with  more  or  less  violent  inflammation. 
This  complication  may  occur  in  men  who  have  previously  suffered  from 
gonorrhoea  and  in  those  who  have  not.  According  to  B^raud,^  whose 
essay  is  admirable  in  every  respect,  the  affection  is  usually  unilateral,  of 
ephemeral  duration,  and  is  not  followed  by  any  serious  consequences  or 
permanent  lesion. 

It  is  the  consensus  of  opinion  of  authors  that  orchitis  is  not  a  common 
complication  of  small-pox.  In  432  cases  observed  by  Curschmann^  it 
was  present  4  times. 

This  complication  has  been  studied  in  an  exhaustive  manner,  micro- 
scopically, by  Chiari,'*  who  found  in  fifteen  cases  of  old  and  young  subjects 
parenchymatous  inflammation  studded  Avith  colonies  of  cocci. 

Orchitis  accompanied  by  epididymitis  and  vaginalitis  is  a  very  rare 
complication  of  scarlet  fever.  Two  cases  have  been  reported  as  occurring 
in  boys  six  and  eight  years  old.  In  one  case  observed  by  Henoch  ^  the 
tunica  vaginalis  was  distended  to  the  size  of  a  fist.  In  Horteloup's^  case 
the  organ  was  much  enlarged,  and  there  was  swelling  of  the  epididymis 
and  effusion  into  the  tunica  vaginalis.     Resolution  occurred  in  this  case. 

Orchitis  may  develop  during  the  course  of,  or  subsequent  to,  whooping 
cough.  In  a  boy  aged  fifteen  years,  otherwise  healthy,  just  recovering 
from  this  trouble,  acute  orchitis  suddenly  developed.  This  was  accom- 
panied by  such  alarming  symptoms  as  stupor,  delirium,  very  high  tempe- 
rature, and  very  rapid  pulse,  which  lasted  a  short  time  and  rapidly  disap- 
peared. The  testes  also  underwent  resolution.  This  case,  reported  by 
Pierse,''  seems  to  be  unique. 

There  have  been  so  many  cases  reported  in  w:hich  orchitis  developed 
during  malarial  fever,  and  for  which  no  other  pathogenic  cause  or  condi- 
tion can  be  assigned,  that  it  seems  reasonable  to  accept  the  latter  as  cause 
and  the  former  as  effect.  One  testis  or  both  may  be  attacked.  Magnani^ 
reports  two  cases  in  which  there  was  no  evidence  of  gonorrhoeal  origin, 
and  in  which  he  thinks  that  the  plasmodium  of  malaria  was  the  patho- 
genic agent. 

The  cases    reported  by  three    French  army  surgeons  —  Bertholon,® 
Schmidt,^"  and  Charvot  ^^ — stationed  in  Africa  are  very  significant,  since 
they  were  carefully  observed  for  long  periods.     In  these  cases  the  epidid- . 
ymis  was  suddenly  attacked,  together  with  the  testis,  and  sometimes  the 

^  Traite  des  Malad.  du  Testicule,  Paris,  1889,  p.  369. 

^  "Eecherches  sur  I'Orchite  et  I'Ovarite  varioleuse,"  Archives  cjen.  de  Medecine,  1859, 
vol.  xiii.  pp.  274  et  seq. 

^  Ziemssen's  Handb.  der  Spec.  Path,  und,  Therapie,  vol.  ii.,  2d  part,  1877. 

*  "Orchitis  variolosa,"  Zeitsch.fur  Heilkunde,  vol.  vii.-,  1886,  pp.  385  et  seq. 

^  Berlin  klin.  Wochenschr.,  1865,  No.  12. 

®  Diet,  enyclop.  des  Sciences  med.,  3d  Series,  vol.  xvi.  p.  578,  art.  "  Testicule  "  (case  of 
Augagneur  and  MoUiere). 

'  Lcmcet,  Aug.  3,  1889. 

^  "  Sull  I'Orchite  d'origine  pallustre,"  Gazz.  Med.  Itcd.  Lombard,  1887,  vol.  vii.  pp.  415 
et  seq. 

^  "  Orchites  paludeennes  primitives,"  Archiv.  de  Med.  et  de  Pharm.  milit.,  Oct.,  1886. 

^"  "  Orchite  paludeenne,"  ibid.,  March,  1887. 

^^  "  Orchite  paludeenne,"  Annates  des  Malad.  des  Org.  Gen.-urin.,  1887,  p.  733, 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  241 

tunica  vaginalis.  The  clinical  picture  was  that  of  acute  orchitis.  The 
tendency  of  the  disease  is  to  quite  prompt  resolution,  after  which,  in  some 
cases,  atrophy  may  occur  and  an  indurated  epididymis  may  be  left.  The 
pain  incident  to  this  inflammation  is  usually  severe,  sometimes  continuous, 
and,  again,  it  may  be  intermittent.  Quinine  has  an  excellent  effect  in 
aborting  and  causing  the  resolution  of  this  inflammatory  process. 

Mazel  ^  reports  tAvo  cases  in  which  the  epididymis  and  the  vas  deferens 
became  acutely  inflamed  in  malarious  subjects,  and  in  which  also  quinine 
produced  excellent  results.  Southern  surgeons  Avho  practise  in  malarious 
districts  of  this  country  from  time  to  time  meet  with  orchitis  as  a  result  of 
malarial  infection. 

There  is  abundant  evidence  to  prove  that  influenza,  or  la  grippe, 
may  be  the  exciting  cause  of  orchitis  in  subjects  who  have  never  suffered 
from  gonorrhoea  or  any  phlegmasia  of  the  urinary  tract.  This  infectious 
disease  also  has  been  known  to  cause  recrudescences  of  epididymitis  and 
orchitis  in  organs  previously  the  seat  of  gonorrhoeal  inflammation.  The 
physical  signs  generally  are  those  of  acute  gonorrhoeal  inflammation,  but 
as  a  rule  resolution  occurs  more  promptly.  Zampetti  ^  reports  three  cases 
of  orchitis,  in  one  of  which  there  was  a  testicular  abscess  caused  by  the 
grip.  Other  cases  with  satisfactory  histories  have  been  reported  by  Har- 
ris,^ Briscoe,*  and  Kelly .^  In  most  of  the  published  cases  the  physical 
signs  are  those  of  acute  gonorrhoeal  orchitis.  In  some  cases  the  phleg- 
masia seems  to  be  greatest  when  limited  to  the  testis  proper.  In  other 
cases  the  tunica  vaginalis  and  epididymis  are  involved.  Thus  Fiessinger^ 
reports  the  case  of  a  boy  nine  years  old  who  had  very  severe  vaginalitis, 
with  three  distinct  exacerbations  during  its  course,  and  the  inflammation 
in  the  last  outburst  invaded  the  epididymis.  Walker^  reports  a  still  more 
severe  case  in  a  man  twenty-four  years  old,  in  whom  a  suppurating  vagi- 
nalitis led  to  gangrene  of  the  testes. 

That  the  epididymis  alone  may  be  attacked  is  well  shown  in  a  case 
reported  by  Lamarque,^  in  which  double  epididymitis  attacked  a  man 
during  the  decline  of  an  attack  of  influenza.  In  this  case  there  were 
absolutely  no  gonorrhoeal  antecedents. 

In  some  cases  of  grip-orchitis  there  is  a  mild  muco-purulent  urethral 
discharge.  Lamarque  reports  such  a  case,  which  was  in  no  way  depend- 
ent upon  gonorrhoea. 

When  uncomplicated  these  testicular  affections  due  to  grip  run  an 
acute  course  and  quite  rapidly  go  on  to  complete  resolution. 

During  the  course  of  pneumonia  and  for  some  time  after  its  deferves- 
cence inflammation  of  the  testicle  or  epididymis  may  occur  as  a  result  of 
that  infective  process.  I  have  recently  had  in  my  hospital  service  the 
case  of  a  man  in  whom  a  destructive  abscess  of  the  testicle  occurred,  for 
which  no  other  origin  than  pneumonia  could  be  ascertained.  In  this  case 
there  was  no  antecedent  gonorrhoea  nor  testicular  affection.     Prioleau* 

^  "Fimiciilo-epididymite  palud^enne,"  Journ.  de  Med.  et  Chir.  pratiq.,  Feb.,  1889- 
^  Gazz.  degli  Oqndali  Milan,  1890,  vol.  xii.  p.  578. 

»  Lancet,  vol.  i.,  1892,  p.  22.  *  Ibid.,  p.  193.  ^  m^i^  p.  359. 

"  Gaz.  med.  de  Paris,  Feb.,  4,  1893. 
''  Correspond.  Blatt.  filr  Schiveiz  Aerzte,  Aug.  ],  1890. 

8  "Complications  g^nito-urinaires  de  la  Grippe,"  Annates  des  Mai.  des  Organ.  Gen.- 
win.,  Sept.,  1894. 

8  Le  Mercredi  medical,  1894,  No.  36,  p.  439. 

16 


242  GONOBRHCEA  AXD  ITS  COMPLICATIONS. 

reports  the  case  of  an  old  man  in  Tvliom  suppurating  orchitis  developed  in 
the  interval  of  tAvo  attacks  of  pneumonia.  In  my  case  and  in  that  of 
Prioleau  there  wei'e  concomitant  chills  and  fever.  In  the  pus  of  my  case 
pus-cocci  were  found,  and  in  the  pus  of  Prioleau's  case  diplococci  were 
discovered. 

Testicular  inflammation  ^  occurs  somewhat  rarely  during  the  course  of 
typhoid  fever,  Liebermeister  having  found  2  instances  in  200  cases.  Gren- 
erally,  it  is  toward  the  end  of  the  fever  that  the  epididymis  is  attacked, 
either  in  a  subacute  or  a  brusquely  acute  manner.  There  is  usually  a 
concomitant  rise  in  the  temperature  and  an  ephemeral  return  of  the  gen- 
eral symptoms.  In  some  cases  this  complication  appears  early  in  the  dis- 
ease, and  in  others  after  full  defervescence  and  cure. 

Usually  this  form  of  epididymitis  is  unilateral,  and  resolution  takes 
place  slowly,  leaving  no  trace  after  it.  Then,  again,  induration  has  been 
known  to  follow.  In  some  cases  the  testis  and  vas  deferens  are  attacked. 
Jaccoud^  reports  a  case  of  suppurative  orchitis  in  a  typhoid-fever  patient. 
Abscess  of  the  testicle,  however,  is  not  common.  Hanot  ^  reports  a  case 
in  which  abscess  began  in  the  epididymis  and  led  to  the  destruction  and 
extrusion  of  the  testicle.  In  another  case  reported  by  Hanot*  atrophy 
of  the  testis  occurred. 

Jaccoud  and  Kocher^  claim  that  they  have  found  the  typhoid  bacillus 
in  the  pus  of  typhoid  orchitis. 

Several  cases  have  been  reported  in  which  during  typhoid  fever  chronic 
urethritis  has  undergone  recrudescence,  and  epididymo-orchitis  has  resulted. 

It  is  claimed  by  some  that  inflammation  of  the  testicle  may  occur  during 
the  course  of.  acute  articular  rheumatism.  This  assertion  is  made  on  the 
basis  of  cases  reported  many  years  ago.  The  reader  desiring  further 
information  is  referred  to  the  essays  of  Stoll  ^  and  Bouisson,''  if  they  are 
accessible  to  him,  though  they  are  not  to  me.  The  essential  lesion  is 
said  to  be  an  acute  vaginalitis.  I  have  never  seen  such  a  case,  nor  has 
one  been  reported  within  this  generation. 

The  same  doubt  exists  as  to  the  etiological  relation  of  gout  to  testicu- 
lar inflammation.  Cases  have  been  reported  in  support  of  this  relation- 
ship, but  they  are  so  lacking  in  essential  detail  as  to  the  previous  history 
of  the  patient  and  to  the  pathogeny  of  the  aff'ection  itself  that  I  deem  it 
wise  not  to  quote  them.  Here,  then,  is  a  field  for  careful  and  discrimi- 
nating clinical  observation. 

During  the  course  of  pyaemia  and  of  grave  phlegmonous  inflammation 
in  bones  orchitis  may  supervene. 

Epididymo-orchitis  from  Operations  in  the  Urethra. 

The  introduction  of  bougies,  sounds,  and  catheters  for  various  condi- 
tions is  not  infrequently  followed  by  epididymitis  or  epididymo-orchitis. 

^  In  the  Revue  de  Medecine,  Paris,  Oct.  and  Nov.,  1883,  Ollivier  gives  the  resuhs  of 
the  study  of  twenty -seven  cases. 

^  Annales  des  Mai.  des  Org.  Gdn-urin.,  vol.  ix.,  1891,  p.  262. 

^  Sociele  anatomique,  1873.  *  Archiv.  gen.  de  Med.,  vol.  ii.,  1878. 

^  Op.  cit,  pp.  265  et  seq. 

"  Encydopedie  des  Sciences  med.,  Paris,  1837,  7th  division  ("M4d.  pratique,"  by  Stoll, 
p.  234,  quoted  from  Monod  and  Terrillon). 

^  Montpellier  medicale,  1860,  vol.  iv.,  p.  336,  quoted  as  above. 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  243 

In  the  course  of  gradual  dilatation  for  stricture  and  for  chronic  urethritis, 
as  a  result  of  catheterism  in  retention  of  urine  in  acute  gonorrhoea,  and 
in  the  retention  which  sometimes  follows  severe  operations,  chiefly  about 
the  rectum  and  abdomen,  and  also  elsewhere,  inflammation  of  the  testicle 
sometimes  occurs.  In  young  and  old  subjects,  upon  whom  lithotrity,^ 
litholopaxy,  and  lithotomy  have  been  performed,  the  testicle  may  become 
damaged.  This  accident  not  infrequently  occurs  when  a  catheter  or  other 
instrument  is  tied  in  the  bladder. 

In  cases  of  hypertrophy  of  the  prostate,  in  which  the  necessity  for  the 
introduction  of  the  catheter  is  more  or  less  urgent,  testicular  inflammation 
is  not  very  uncommon.  In  many  of  these  cases  the  testicular  complica- 
tion may  be  traced  to  the  use  of  a  too  large  catheter,  to  one  which  has  by 
age  become  rather  rough,  and  often  to  dirt  which  has  been  carried  on  the 
catheter  owing  to  the  patient's  carelessness. 

While,  in  general,  the  symptoms  of  this,  as  we  may  call  it,  traumatic 
epididymo-orchitis  resemble  those  of  gonorrhoea,  they  present  certain 
somewhat  distinctive  features.  As  a  rule,  the  testicular  inflammation 
comes  on  quite  promptly  after  the  receipt  of  the  injury.  Then,  again, 
the  onset  may  not  occur  for  several  days,  and  then  may  be  slow,  halting, 
and  intermittent.  In  the  cases  where  the  inflammation  is  slow  in  devel- 
opment its  course  is  usually  prolonged,  and  resolution  comes  on  rather 
tardily.  In  some  cases,  however,  the  invasion  is  rapid  and  brusque,  and 
in  these  particular  cases  we  not  unfrequently  observe  quite  prompt,  even 
markedly  rapid,  resolution. 

The  physical  signs  diff"er  in  various  cases  according  to  the  mode  of 
invasion.  In  the  slowly-developing  cases  the  patient  may  sufi'er  little 
pain,  and  may  discover,  sometimes  by  accident,  that  the  tail  or  head  of 
the  epididymis  is  somewhat  swollen,  hard,  and  perhaps  a  little  tender  on 
pressure.  The  swelling  may  then  increase  slowly,  limited  to  one  part  of, 
the  epididymis,  or  it  may  spread  and  involve  the  whole  of  it.  It  then 
feels  like  a  hard,  firm,  quite  bulky  crescent  seated  on  the  testis.  This 
condition  may  remain  indolent  for  a  varying  period,  and  it  may  quite  fully 
disappear,  or  it  may  lead  to  a  permanent  swelling  and  induration  of  the 
epididymis.     There  may  be  a  moderate  eff"usion  into  the  tunica  vaginalis. 

The  course  of  the  cases  in  which  the  onset  is  brusque  and  rapid  is,  in 
the  main,  quite  like  that  of  acute  gonorrhoea.  Abscess,  however,  is  more 
frequent  than  in  the  latter  condition. 

In  a  goodly  proportion  of  young  and  middle-aged  patients  this  post- 
instrumental  inflammation  is  limited  to  the  testicle,  with  sometimes  the 
involvement  of  the  tunica  vaginalis.  In  a  rather  larger  proportion  the 
epididymis  is  attacked.  In  elderly  and  very  old  men,  while  the  process 
may  be  limited  to  the  epididymis,  it  more  commonly  attacks  the  testis 
also.  In  these  cases  the  epididymo-orchitis  may  be  slow  in  development 
or  the  onset  may  be  quite  rapid.  When  the  testis  is  involved  there  is 
usually  much  pain. 

Abscess  of  the  epididymis,  of  the  tunica  vaginalis,  and  particularly 
of  the  parenchyma  of  the  testis,  is  a  not  uncommon  accident.  Abscess 
of  the  testis  in  old  men  may  lead  to  the  total  extrusion  of  the  gland  and 

^  According  to  Pilven  ("Orchite  consec.  au  Passage  des  Instruments,"  Thhe  de  Pari^, 
1884),  Guyon  observed  testicular  inflammation  in  13  out  of  188  cases  of  calculi  in  which 
exploratory  or  lithotrity  instruments  had  been  used. 


244  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

its  appendages.     This  sequela  may,  but  quite  rarely,  be  observed  in  young 
and  middle-aged  men. 

Orchitis  due  to  Muscular  Contraction. 

So  many  cases  have  been  reported  in  Avhich  epididymitis  and  orchitis, 
separately  or  combined,  have  developed  as  a  result  of  muscular  injury — 
orcTiite  par  effort — that  to-day  this  causative  factor  is  quite  generally 
admitted.  In  these  cases  the  pain  on  the  receipt  of  the  injury  may  be  at 
first  slight,  and  may  gradually  become  severe,  or  it  may  be  violent  and 
sickening  from  the  first. 

In  most  cases  the  left  testis  is  affected,  and  the  clinical  picture  resembles 
that  of  gonorrhoeal  inflammation  of  these  parts. 

There  is  considerable  difference  of  opinion  as  to  the  mechanism  of 
the  traumatism  in  these  cases,  in  which  patients  slipping  with  violence, 
lifting  heavy  Aveights,  or  by  any  means  rudely  shaken  become  attacked 
by  testicular  pain  and  inflammation. 

According  to  Velpeau  and  Roux,  violent  contraction  of  the  abdominal 
muscles,  particularly  of  the  fibres  of  the  rectus  abdominalis  muscle,  which 
are  present  in  arched  form  over  the  cord  at  the  external  abdominal  ring, 
injures  the  cord,  and  the  inflammation  then  descends  to  the  testis.  This 
theory,  for  obvious  reasons,  meets  with  much  opposition. 

Another  view  is  that  advocated  by  Tillaux,  who  claims  that  the  injury 
results  from  violent  contraction  of  the  cremaster  muscle,  which  jerks  the 
testis  against  the  pillars  of  the  external  rings  by  what  French  authors 
call  the  coup  de  fouet,  or  whip-snap,  action. 

The  most '  rational  explanation  of  this  action  is  that  of  Martin,^  who 
says :  "  The  spermatic  plexus  of  veins  is  peculiarly  under  the  influence 
of  intra-abdominal  pressure :  the  vessels  are  provided  with  but  few  and 
imperfect  valves,  are  feebly  supported  by  the  surrounding  tissues,  and 
hence  are  especially  subject  to  disease.  This  varicosity  of  these  veins  is 
one  of  the  most  common  surgical  affections,  and  the  effect  of  the  contrac- 
tion of  the  abdominal  parietes  and  the  diaphragm  upon  these  dilated 
vessels  is  so  marked  that  succussion  on  coughing  or  straining  in  any  way 
is  sufficiently  distinct  to  simulate  that  of  omental  hernia.  Given,  then, 
a  sudden  and  violent  increase  of  pressure  in  these  vessels,  it  is  perfectly 

possible  to  conceive  that  rupture  may  take  place Such  rupture 

would  naturally  take  place  in  the  cord,  in  the  epididymis,  or  even  in  the 
substance  of  the  testicle." 

In  addition  to  this  action,  I  think  that  spasmodic  contraction  of  the 
cremaster  and  of  the  fibres  of  the  rectus  muscle  may  also,  in  some  cases, 
play  an  accessory  part.  In  many  cases  of  this  form  of  epididymo-orchitis 
the  patients  have  previously  been  free  from  venereal  diseases,  gonorrhoea 
especially.  In  some  cases  patients  will  absolutely  deny  any  previous 
gonorrhoeal  infection.  There  can  be  no  doubt  that  a  latent  subacute 
inflammatory  condition  of  the  testis  or  cord  may  be  transformed  into  an 
acute  condition  by  means  of  muscular  traumatism.  Duplay  and  his 
^l^ve,  Delome,^  claim  that  the  underlying  causes  in  these  cases  are  latent 
urethritis,  cystitis,  and  prostatitis. 

^  "  Epididymitis  caused  by  Abdominal  Strain,"  Med.  News,  Nov.  29,  1890. 
^  "  De  I'Orchi-epididymite  prdtendue  par  effort,"  These  de  Paris,  1877. 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  245 

This  form  of  testicular  trouble  usually  goes  on  promptly  to  resolution, 
though  induration  of  the  epididymis  and  enlargement  of  the  testicle  may 
result.  Terrillon  ^  has  published  a  case  in  which  atrophy  of  the  testis 
occurred,  which  was  attended  with  such  severe  pains  that  castration  was 
resorted  to.  The  microscopic  examination  of  this  testis  showed  the  cha- 
racteristic lesions  of  traumatic  orchitis. 

Strangulation  of  the  Testis  and  Epididymis  from  Torsion  of  the 
Cord. — There  are  in  medical  literature  less  than  twenty -five  cases  recorded 
in  which  the  testicle,  seated  either  in  the  inguinal  canal  or  just  in  the 
scrotum,  became  acutely  swollen  and  painful  as  a  result  of  torsion  of  the 
spermatic  cord.  Of  these  cases  the  majority  were  those  of  boys  from 
thirteen  to  twenty-one  years  old,  while  in  the  great  minority  were  old  men 
and  young  children.  In  most  of  the  cases  there  is  a  history  or  evidence 
of  undescended  or  imperfectly  descended  testis  ;  consequently,  as  a  rule, 
the  swelling  is  found  in  the  inguinal  canal  or  just  within  the  upper  part 
of  the  scrotum.  The  objective  symptoms  are  localized  swelling,  oedema, 
and  redness.  The  subjective  symptoms  are  varied,  and  they  may  point 
to  strangulated  hernia,  traumatism,  or  inflammation  of  the  appendix  ver- 
miformis.  There  are  pain,  some  fever,  and  frequently  constipation  and 
vomiting,  which,  however,  is  not  stercoraceous.  As  distinguished  from 
hernia,  it  will  be  noted  that  the  constipation  is  not  so  persistent,  the  shock 
is  decidedly  less,  and  there  are  no  abdominal  symptoms.  The  tumor 
is  harder  than  that  of  hernia,  and  is  absolutely  without  impulse  and  is 
irreducible.  Though  the  position  and  quite  sharp  localization  of  the 
tumor,  together  with  its  history  and  concomitant  symptoms,  point  very 
convincingly  to  the  testis  (and  it  is  absent  from  the  scrotum  in  the  majority 
of  cases),  it  sometimes  happens  that  a  diagnosis  is  not  arrived  at  until  an 
exploratory  incision  has  been  made.  Then  the  testis  and  epididymis  are 
found  to  be  swollen,  of  a  deep-blue  or  even  black  color  from  hemorrhagic 
infarction,  and  sometimes  they  are  gangrenous.  When  the  tumor  is  below 
the  internal  ring  the  finger-tip  pressed  over  that  part  will  show  that  the 
case  is  not  one  of  hernia.  Hernia  may  be  found  as  a  complicating  condi- 
tion of  this  accident  to  the  testis. 

The  exciting  causes  of  torsion  of  the  cord  are,  in  the  main,  excessive 
labor  and  violent  and  sudden  strain.  In  some  of  the  reported  cases  no 
exciting  cause  whatever  could  be  ascertained,  and  in  some  instances  the 
condition  developed  while  the  patient  was  asleep. 

Usually  torsion  of  the  cord  leads  to  destruction  of  the  testicle.  Van 
der  Poel,^  however,  reports  an  interesting  case  in  which  this  accident 
occurred  at  various  intervals  of  time,  and  was  promptly  remedied  by 
taxis. 

The  twist  of  the  cord  may  be  partial  or  complete,  or  the  cord  may  be 
twisted  several  turns.  The  essential  and  underlying  cause  of  torsion  of 
the  cord  is  due  to  disturbance  in  the  development  of  the  vaginal  process 
of  the  peritoneum,  in  which  the  mesorchium  is  either  too  slender  or  too 
long,  and  hence  does  not  give  the  testis  the  necessary  amount  of  fixation. 
The  mesorchium  then  allows  greater  movement  than  normal,  and  the  testis 

^  "  De  rOrchite  par  Effort  sa  Termination  par  Atrophic  testiculaire,"  Annales  des  Mai. 
des  Org.  G^n.-urin.,  vol.  iii.,  1885,  p.  239. 

'^  Medical  Record,  June  15,  1895.  The  reader  is  referred  to  this  essay  for  a  r&um^  of 
the  published  cases. 


246  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

may,  as  a  result,  encounter  difficulty  in  entering  the  inguinal  canal  and 
impediment  in  traversing  it.  When  it  is  in  the  inguinal  canal  the  flat 
condition  of  the  testis  militates  against  its  replacement,  and  renders  this 
impossible  as  soon  as  inflammation  has  become  established. 

When  it  occurs  in  the  scrotal  sac,  torsion  of  the  cord  may  be  reducible. 
Hemorrhagic  infarction  of  the  testis  and  epididymitis  calls  for  prompt 
incision  and  extirpation. 

Neuralgia  of  the  testis  sometimes  follows  epididymo-orchitis  and  epi- 
didymitis. Usually  but  one  testis  is  the  seat  of  pain.  In  some  cases  the 
pain  is  in  the  testis  itself;  in  others  it  is  said  to  radiate  and  extend  to  the 
groin.  The  pain  may  be  mild  and  constant,  and  readily  made  Avorse  by 
exertion.  In  some  cases  the  pressure  of  the  clothes  causes  much  suff'er- 
ing.  Then,  in  other  cases,  the  pain  is  severe  and  paroxysmal,  "svith  inter- 
vals of  full  comfort. 

In  many  cases  neuralgia  of  the  testis  is  a  distinct  morbid  entity,  and 
in  these  cases  treatment  will  usually  give  relief.  But  testicular  pain  and 
pain  in  the  spermatic  cord  are  often  complained  of  by  neurasthenic  and 
neurotic  patients  and  cranks  in  whom  no  treatment  seems  to  do  any  good, 
and  in  whom  no  abnormality  of  the  parts  can  possibly  be  discovered. 
Such  patients,  by  reason  of  their  complaints  and  importunities,  act  as 
thorns  in  the  flesh  of  the  surgeon.  Happily,  there  are  not  many  of 
them. 

Neuralgia  of  the  testis  may  depend  on  chronic  inflammation  in  the 
posterior  urethra,  and  also  on  the  pressure  on  the  nerves  of  the  parts  by 
the  effused  tissue. 

It  must  be  remembered  that  neuralgia  of  the  testis  may  be  sympto- 
matic of  stone  in  the  bladder,  various  diseases  of  that  viscus,  and  kidney 
disease. 

Induration  of  the  epididymis  following  gonorrhoeal  inflammation  may 
be  limited  to  the  tail,  to  the  head,  or  may  involve  the  whole  appendage. 
In  some  cases  it  is  absorbed,  and  in  others  it  remains  permanently.  It 
sometimes  feels  like  a  little  mass  of  flrm  structure  of  rounded  or  ovoid 
shape  when  seated  at  either  head  or  tail.  In  general,  the  swelling  is  not 
very  large,  but  it  may  remain  for  a  long  period  localized  to  the  head,  and 
be  nearly  as  large  as  the  testis.  In  some  cases,  when  the  whole  epididy- 
mis is  chronically  indurated,  it  forms  a  half-moon-shaped  mass  whose  bulk 
is  greater  than  that  of  the  gland.  The  most  frequent  form  of  induration 
of  the  epididymis  is  that  in  which  the  part  is  about  as  thick  as  a  lead 
pencil  or  a  peanut.  It  is  hard  to  say  which  is  most  frequently  found — 
induration  of  the  head  or  the  tail  of  the  epididymis.  Hard  enlargement 
of  the  whole  appendage  is  less  common  than  the  localized  induration. 

The  surface  of  simple  gonorrhoeal  induration  of  the  epididymis  is 
usually  smooth  or  of  rounding  or  wavy  outline,  in  marked  contrast  to 
the  nodulated  and  angular  feel  of  tubercular  "epididymitis.  In  chronic 
syphilis  the  epididymis  is  sometimes  enlarged  in  whole  or  in  part,  and 
the  general  outline  of  the  swellins^  is  much  like  that  of  the  s:onorrhoeal 
affection. 

In  these  cases  the  diagnosis  depends  ver}^  largely  on  the  history  of  the 
cases  and  on  the  presence  of  concomitant  lesions  or  of  salient  stigmata. 

Causes  of  Epididymitis  and  Epididymo-orchitis. — Gonorrhoea  being  the 
predisposing  cause,  various  exciting  causes  are  often  the  starting-points 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  247 

of  the  trouble.  These  are  the  early  use  of  strong  injections,  particularly 
when  used  to  abort  the  disease,  and  the  premature  administration  of 
copaiba,  cubebs,  and  oil  of  santal ;  indulgence  in  alcoholic  stimulants ; 
and  sexual  excitement,  with  or  without  coitus,  since  men,  either  from  lust 
or  with  a  mistaken  idea  that  they  may  thus  rid  themselves  of  their  trouble, 
often  have  connection  while  suffering  from  gonorrhoea.  In  the  majority 
of  cases,  walking,  activity  in  business,  lifting  heavy  weights,  pulling  vio- 
lently, dancing,  riding,  particularly  on  horseback,  bicycling,  and  skating, 
are  the  immediate  causes.  Passage  of  sounds  and  catheters  toward  the 
decline  of  gonorrhoea  is  frequently  followed  by  epididymitis.  Conse- 
quently, such  instrumentation  should  not  be  adopted  in  the  declining 
stage  of  cronorrhoea,  or  when  stricture  of  the  urethra  is  followed  bv  a  mild 
and  ephemeral  epididymitis  or  epididymo-orchitis. 

Diagnosis. — Commonly,  no  difficulty  is  experienced  in  the  diagnosis 
of  swelled  testicle,  since  the  history  of  the  case  and  the  nature  of  the 
lesion  are  so  clear.  In  some  rare  cases  of  acute  hydrocele  doubt  might 
exist,  but  it  would  be  soon  dispelled  by  a  consideration  of  the  history  of 
the  case  and  an  examination  of  the  parts.  Swelled  testicle,  with  redness 
and  oedema  of  the  scrotum,  is  said  to  have  been  mistaken  for  erysipelas 
of  that  pouch.  Such  an  error  will  rarely  occur,  and  with  ordinary  care 
will  be  promptly  found  out.  Haematocele  of  the  tunica  vaginalis  may  at 
first  resemble  gonorrhoeal  swelled  testicle,  but  the  history  of  traumatism 
will  settle  the  question.  The  same  remarks  apply  to  orchitis  of  trau- 
matic origin. 

In  epididymo-orchitis,  or  epididymitis  accompanied  by  inflammation 
of  the  cord  as  far  as  the  external  ring,  a  mistaken  diagnosis  of  hernia 
may  be  made,  particularly  when  there  is  much  fever,  with  constipation 
and  vomiting,  as  sometimes  occurs.  The  error  need  not  be  of  long  dura- 
tion, since  in  the  scrotal  lesion  there  is  a  history  of  gonorrhoea,  while  in 
hernia  there  is  usually  a  history  of  a  fugitive  or  permanent  tumor  in  the 
groin,  and  perhaps  of  antecedent  inflammation  or  strangulation  of  the 
hernial  sac. 

Epididymitis  of  a  misplaced  or  undescended  testis  sometimes  is  difii- 
cult  of  recognition.  In  such  cases  the  history  of  an  urethral  discharge 
should  cause  suspicion,  when  the  examination  of  the  scrotum  will  show 
absence  of  one  testis.  It  must  be  remembered  that  the  testis  may  be 
retained  within  the  abdominal  cavity,  in  the  inguinal  canal,  and  that  it 
may  be  found  in  the  perineum. 

In  all  cases  it  is  of  importance  to  assure  one's  self  of  the  relation  of 
the  epididymis  to  the  testis,  since  puncture  of  the  tunica  vaginalis  is  so 
frequently  necessary.  It  is  important  to  ascertain  whether  inversion 
of  the  epididymis  is  present,  since  puncture  under  these  circumstances 
might  wound  or  destroy  the  vas  deferens.  In  swelled  testicle  the  seat  of 
inversion  the  tumor  is  long  antero-posteriorly,  with  the  epididymis  well, 
forward  and  the  testis  under  and  rather  behind  it. 

In  cases  of  inflammation  of  the  vas  deferens  it  is  well  to  seek  it  as  it 
leaves  the  tail  of  the  epididymis,  and  trace  it  until  it  will  be  found  to  be 
lost  in  the  swollen  meshes  of  the  cord,  since  it  may  not  be  possible  to 
examine  it  as  it  escapes  from  the  canal.  The  diagnosis  of  these  cases  is 
more  difficult  when  the  portion  of  the  cord  between  the  external  and  in- 
ternal rincrs  is  also  swollen. 


248  GONORRHCEA  AND  ITS  COMPLICATIONS. 

Prognosis. — The  prognosis  of  swelled  testicle  from  gonorrhoea  is,  in 
the  main,  good,  since  more  or  less  complete  resolution  generally  occurs. 
It  depends,  however,  largely  upon  the  promptness  and  efficiency  of  the 
treatment  and  on  the  nature  of  the  patient.  Careless  habits,  intolerance 
of  restraint,  and  poor  fibre  tend  to  make  the  prognosis  more  serious.  The 
occurrence  of  the  various  structural  complications  already  detailed,  and 
the  supervention  of  the  various  neuralgias,  of  course  make  the  condition 
more  serious.  The  fecundity  of  a  man  is  not  imperilled  by  induration  of 
one  epididymis  and  the  occlusion  of  its  vas  deferens,  but  the  total  occlu- 
sion of  both  of  these  ducts  renders  him  sterile.  Though  his  procreative 
power  is  lost,  his  ability  to  copulate  remains.  The  question  of  the  ster- 
ility of  a  man  often  becomes  an  important  matter  in  domestic  relations. 
It  must  not  be  stated  with  absolute  positiveness  that  when  no  spermatozoa 
are  found  in  the  semen  a  man  is  absolutely  sterile,  since  it  may  be  that 
there  is  present  a  temporary  stenosis  due  to  exudation,  and  for  the  reason 
that  under  treatment  resolution  of  the  infiltration  may  be  produced.  It 
is  only  in  cases  where  the  semen  examined  over  long  periods  is  found  to 
be  wanting  in  spermatozoa  that  the  existence  of  absolute  sterility  may  be 
asserted. 

The  prognosis  is  always  better  when  the  lesion  is  seated  in  the  head  of 
the  epididymis,  and  correspondingly  worse  when  in  the  tail,  since  in  that 
the  spermatic  vessels  have  converged  to  form  one — the  vas  deferens.  Since 
relapses  of  epididymitis  frequently  have  their  origin  in  chronic  subacute, 
deep-seated  urethral  inflammation,  their  occurrence  will  suggest  the  neces- 
sity of  the  removal  of  the  cause.  Apart  from  the  varying  conditions  of 
the  morbid  process  as  influencing  the  prognosis,  the  latter  largely  depends 
on  the  treatment  of  the  testicular  disorder  in  its  declining  and  chronic 
stages.  If  in  these  periods  active  conservative  treatment  is  followed,  full 
resolution  may  be  obtained  in  the  majority  of  cases. 

Treatment. — Absolute  rest  in  bed  is  the  first  indication  in  the  treat- 
ment of  the  severe  form  of  gonorrhoeal  epididymitis.  During  the  pre- 
monitory stage  the  sooner  the  patient  takes  to  his  bed  the  better  for  him. 
The  next  indication  is  to  place  the  swollen  organ  in  a  position  of  rest  and 
comfort ;  and  for  this  the  suspensory  bandage  is  generally  useless.  A 
number  of  excellent  procedures  are  at  our  command.  The  simplest  is  to 
form  an  immovable  platform  or  shelf  on  which  the  organ  may  rest.  This 
may  be  done  with  India-rubber  adhesive  plaster ;  and,  though  regarded 
as  dirty  and  objectionable  by  some,  it  by  a  little  trouble  can  be  made 
cleanly  and  serviceable.  A  sufficiently  long  strip  of  adhesive  plaster, 
three  to  five  inches  wide,  is  placed  across  the  thighs  of  the  recumbent 
patient  so  high  "up  that  its  superior  border  touches  his  perineum,  whose 
scrotum  for  the  moment  has  been  carefully  lifted  toward  the  body.  While 
sufficient  adhesive  surface  is  applied  to  the  thighs,  that  portion  of  the 
plaster  which  forms  the  bridge  between  them  may  be  covered  with  gutta- 
percha tissue,  which,  being  folded  under,  adheres  to  the  adhesive  plaster. 
We  have  thus  a  water-proof  platform  or  bridge  upon  which  the  scrotum 
may  be  placed.  The  objection  that  this  application  involves  the  immo- 
bility of  the  patient  has  no  weight,  since  he  is  better  ofi"  in  that  con- 
dition. 

The  next  method  of  fixing  the  testes  is  to  take  the  heel  of  a  good- 
sized  firm  stocking,  upon  one  end  of  which  two  pieces  of  tape,  seated 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  24& 

about  one  inch  apart,  are  securely  sewn,  while  on  the  other  end  two  simi- 
lar pieces  of  tape  are  sewn  about  three  inches  apart.  A  waistband  having 
been  put  in  place,  the  suspensory  is  applied  to  the  scrotum  with  the  two 
tapes,  which  are  nearer  together  underneath,  each  one  of  Avhich  should  be 
passed  outward  and  upward  over  the  thigh  and  pinned  on  the  waistband 
at  about  the  anterior  superior  spine  of  the  ilium.  The  remaining  or 
superior  tapes  are  brought  up  on  each  side  of  the  penis  and  fastened  to 
the  waistband  in  the  median  line. 

The  third  efficient  method  requires  a  soft  linen  or  silk  handkerchief, 
which  should  be  folded  diagonally  so  as  to  form  a  triangle,  in  the  centre 
of  the  base  of  which  two  pieces  of  tape  are  to  be  sewn.  Having  placed 
a  firm  waistband  around  the  body  just  above  the  iliac  crests,  the  scrotum 
is  elevated  and  the  centre  of  the  base  of  the  handkerchief  triangle  is 
placed  in  accord  with  the  raph^  of  the  scrotum.  The  tapes  are  carried 
around  the  thighs  on  either  side,  and  are  secured  to  the  waistband  near 
the  iliac  crests.  Having  thus  rendered  the  bandage  firm,  the  two  outer 
ends  of  the  handkerchief  are  brought  upward  along  the  folds  of  the  groin 
and  secured  to  the  waist-bandage,  while  the  apex  of  the  handkerchief 
triangle  is  brought  upward  in  the  median  line  and  also  secured  to  the 
band.  By  these  means  the  testes  may  be  kept  at  rest  and  any  form  of 
application  may  be  used. 

What  is  known  among  athletes  and  actors  as  the  jock-strap  is  also 
very  useful  in  cases  of  swelled  testicle  either  when  the  patient  is  abed  or 
on  foot. 

The  scrotum  may  also  be  supported  by  a  wad  of  oakum  or  absorbent 
cotton  placed  between  the  thighs. 

The  next  indication  is  to  administer  a  brisk  cathartic  in  the  form  of 
pills  or  a  powder  of  from  five  to  ten  grains  of  calomel  and  bicarbonate 
of  soda.  The  diet  must  be  mild  and  sparing,  preferably  of  milk  or  of 
toast  and  weak  tea.  In  the  acute  stage  anorexia  is  very  common,  and 
the  thirst  is  great,  for  which  Vichy,  Apollinaris,  Poland,  and  Stafford 
waters  are  very  good.  Little  internal  medication  is  necessary,  though  the 
mixture  of  bicarbonate  of  potassa  with  tincture  of  hyoscyamus,  spokeii 
of  in  the  treatment  of  the  acute  stage  of  gonorrhoea,  may  be  given.  In 
nausea  and  sickness  of  the  stomach  medicine  is  not  beneficial. 

For  the  relief  of  pain,  particularly  at  night,  some  preparation  of  opium 
may  be  used  in  the  form  of  pill,  suppository,  or  hypodermic  injection. 
The  resulting  constipation  should  be  attended  to,  if  necessary,  by  enemas. 
I  have  found  pulsatilla  a  very  uncertain  remedy  in  acute  and  painful 
swelled  testicle,  and  far  inferior  to  laudanum  in  small  and  repeated  doses. 
Considering  the  infectious  nature  of  the  gonorrhoeal  swelled  testis,  it  is 
very  difficult  to  understand  what  action  such  a  drug  can  possibly  exert. 
Many  cases  of  swelled  testis,  for  unaccountable  reasons,  improve,  and  in 
such  instances  I  have  no  doubt  pulsatilla  has  got  the  credit  of  the  amelio- 
ration of  symptoms.  Salicylate  of  soda  has  been  exploited  as  a  valu- 
able remedy  in  these  cases,  but  it  has  failed  utterly  in  my  hands  to  comfort 
the  patient  or  affect  the  phlegmasia  in  any  way.  Henderson,^  however, 
used  salicylate  of  soda  in  twenty-grain  doses,  given  three  times  a  day, 
very  successfully  in  three  cases  of  gonorrhoeal  epididymitis.  Other  authors 
claim  that  they  have  seen  beneficial  eifects  follow  its  use. 

1  Lancet,  Dec.  \Q,  1892. 


250  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

In  general,  a  strong  lead-and-opium  wash,  perhaps  combined  with 
muriate  of  ammonia,  and  applied  to  the  organ  properly  fixed  on  old 
linen  or  lint  or  absorbent  cotton  or  gauze,  is  a  most  efficient  and  reliable 
remedy.  At  the  onset  of  the  affection  ice,  guardedly  applied,  may  be 
tried.  Small  pieces  may  be  placed  in  a  bladder  or  in  the  India-rubber 
bag  made  for  the  purpose,  and  these  should  be  placed  on  the  testis,  upon 
which  several  layers  of  linen  or  lint  had  been  already  laid.  A  little 
experimentation  Avill  soon  determine  how  much  intervening  linen  is  neces- 
sary to  produce  benefit  and  avoid  pain.  In  some  cases  this  treatment, 
when  thus  used,  is  attended  with  amelioration  of  the  patient's  sufierings 
and  a  decrease  in  the  intensity  of  the  inflammation.  In  other  cases,  how- 
ever, it  cannot  be  borne.     Its  range  of  usefulness,  therefore,  is  not  great. 

While  some  patients  are  benefited  by  cold  applications,  others  require 
hot  ones,  the  best  of  which  are  poultices  of  slippery  elm  or  flaxseed,  with 
which  may  be  incorporated,  in  the  proportion  of  8  to  1,  fine  chewing 
tobacco,  or  of  16  to  1  of  hyoscyamus,  belladonna,  or  digitalis  leaves. 
Should  these  narcotics  produce  exhaustion,  sickness  of  the  stomach,  or 
other  pathological  efi"ects,  they  must  be  abandoned.  Dr.  Bumstead 
thought  well  of  the  following,  applied  on  lint  to  the  scrotum : 

^.  Ext.  belladonnse,  3ij  ; 

Glycerinae,  5ss ; 

Aquae,  Ij.— M. 
Also  this : 

1^.  Pulv.  opii,  Sij  ; 

Glycerinse,  §j . — M. 

When  these  prescriptions  are  used  the  scrotum  must  be  enveloped  in 
gutta-percha  tissue  or  oiled  silk,  and  held  in  place  by  a  suspensory  if  the 
patient  goes  about. 

The  following  ointments  are  often  of  service  when  spread  thickly  on 
lint : 

^.  Pulv.  opii,  3ij  ; 

Pulv.  camph.,  3ss ; 

Vaseline  or  glycerinse,  §j. — M. 

And 

^.  Pulv.  opii, 

Pulv.  amyli,  da.  ^j  ; 

Glyceringe,  q.  s. 

Make  paste  of  the  thickness  of  tar. 

Ichthyol  pure  or  in  ointment  form  (gij  to  ^j  cerate)  has  been  recom- 
mended, but  after  several  trials  I  have  abandoned  it. 

When  the  intensity  of  the  inflammation  is  on  the  wane,  due  to  the  use 
of  either  heat  or  cold,  a  more  radical  treatment  may  be  followed.  Every 
efi"ort  must  be  made  to  cure  the  inflammation  of  the  deep  urethra.  One 
of  the  most  beneficial  is  the  application  at  white  heat  of  Paqnelin's  cautery 
over  the  scrotum  corresponding  to  the  swelled  testicle.  The  parts  must 
first  be  shaved  and  thoroughly  washed.  The  tip  of  the  cautery  ma^y  then 
be  applied  rapidly  and  but  for  a  second  or  two  in  ten  or  twelve  spots  well 
separated  from  each  other.     The  scrotum  is  then  to  be  enveloped  in  ab- 


EPIDIDYMITIS  AND  EPIDIDYMO-OBGHITIS.  251 

sorbent  cotton  and  put  in  a  comfortable  bandage.  The  cautery  may  be 
used  every  two,  three,  or  four  days.  The  effect  will  usually  be  promptly 
seen  in  the  amelioration  of  the  symptoms  and  the  subsidence  of  the 
swelling. 

Very  much  benefit  and  comfort  can  be  obtained  by  the  withdrawal  of 
fluid  from  the  cavity  of  the  tunica  vaginalis  just  as  soon  as  it  can  be 
done.  This  should  not  be  forgotten.  A  hypodermic  syringe  may  be 
used. 

Another  method  of  treatment  which  has  been  employed,  like  the  fore- 
going, in  the  declining  stage  in  my  ward  at  Bellevue  Hospital  with  much 
benefit,  is  the  application  every  day  or  two  of  a  solution  of  nitrate  of 
silver  (60  or  120  grs.  to  the  ounce  of  water).  The  whole  of  the  affected 
side  is  painted  and  the  parts  treated  as  directed  after  the  cautery  treat- 
ment. 

In  my  experience  the  best  method  of  treatment  is  to  apply  heat  or  cold 
as  the  case  indicates,  then,  when  the  inflammation  is  on  the  decline,  to 
use  the  cautery  or  the  nitrate  of  silver  or  perhaps  iodoform  ointment. 
When  the  patient  is  able  to  get  around  (and  this  treatment  requires  seven 
to  twelve  days)  he  may  apply  the  opium  ointment  or  paste,  with  as  much 
compression  of  the  testes  as  he  can  stand  with  comfort.  Internally  or  by 
suppository  opium  may  be  used  if  necessary. 

For  the  benefit  of  those  who  like  to  try  various  methods  of  treatment 
I  describe  in  a  few  words  those  which  are  to-day  most  advocated,  and  I 
omit  all  old-time  methods  which  have  proved  valueless  : 

Trzcinski,  a  Russian  surgeon,  uses  nitrate  of  silver  in  the  form  of  oint- 
ment (1  part  to  10  of  cerate  or  vaseline),  together  with  a  cotton  compress, 
and  claims  that  much  benefit  and  amelioration  of  symptoms  result. 

Iodoform  ointment  (^ij  to  vaseline  5j)  is  sometimes  very  efficacious  in 
the  subsiding  acute  or  declining  stages. 

Diday  and  Lardier  recommend  the  application  of  carbolic  acid  in  alco- 
hol (1  :  10)  as  being  of  much  benefit.  This  treatment  is,  however,  so 
painful  that,  although  it  produces  resolution  of  the  swelling,  it  is  not  to 
be  endorsed. 

Thidry  and  Fosse  ^  advocate  very  hot  vaporization  or  pulverization  of 
carbolic  acid  and  water  (1  :  50),  applied  for  twenty  minutes  two  or  three 
times  a  day.  They  consider  this  treatment  analgesic,  antiseptic,  and 
resolutive.     It  is  said  to  give  rise  to  no  local  or  general  accident. 

Applications  of  solutions  of  carbolic  acid  in  water  (^ij  to  oviij)  on 
gauze,  cotton,  or  lint  are  sometimes  very  soothing  in  the  acute  stage. 

Ughetto  ^  proposes  a  very  radical  treatment.  He  injects  directly  into 
the  inflamed  epididymis,  by  means  of  the  hypodermic  needle,  a  few  drops 
of  a  2  to  5  per  cent,  solution  of  carbolic  acid  in  water,  or  a  few  drops  of 
bichloride  of  mercury  in  water  (1  :  1000),  or  a  similar  quantity  of  equal 
parts  of  tincture  of  iodine  and  glycerin.  A  cure  is  said  to  have  followed 
in  seventeen  days. 

Dr.  Samuel  Alexander  ^  has  recently  quite  warmly  advocated  a  method 
of  treatment  first  used  by  Dr.  W.  Boeck.  This  consists  in  injecting  into  the 
posterior  urethra  watery  solutions  of  nitrate  of  silver,  1  to  3,  and  even  8, 
grs.  to  the  ounce.     Local  and  general  treatment  is  also  used. 

1  Gazette  med.  cle  Paris,  Nos.  44  and  45,  1891.  ^  11  Morgarini,  Nov.,  1892,  p.  653. 

'  Journal  of  Cutaneous  and  Genito-uvinary  Diseases,  vol.  ix.,  1891,  pp.  455  et  seq. 


252  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

In  France  the  method  of  Ducastel '  is  now  somewhat  the  vogue.  This 
is  the  so-called  treatment  by  stypage,  or  local  anaesthesia  induced  by  refrig- 
eration due  to  the  evaporation  of  methyl-chloride.  The  technique  is  as 
follows  :  A  mass  of  absorbent  cotton  is  sprayed  with  the  methyl-chloride, 
and  then  applied  over  the  affected  testicle  for  twenty  or  thirty  seconds 
once  or  twice  a  day.  A  skilled  person  may  use  this  treatment  directly  to 
the  part.  The  point  to  be  observed  is  not  to  touch  the  unaffected  parts 
with  the  chemical.  Care  must  be  exercised  in  order  that  dermatitis  be 
not  produced.  The  scrotum  may  be  enveloped  in  cotton  after  the  applica- 
tions. Ducastel  and  De  le  Valle  ^  report  that  immediate  relief  and  prompt 
resolution  are  produced,  and  that  the  duration  of  the  treatment  is  seven 
days,  and  the  sojourn  of  the  patients  in  the  hospital  is  eleven  or  twelve 
days.  Practically  the  same  method  of  treatment  was  tried  for  a  short 
time  at  Charity  Hospital  in  1869.  The  refrigerating  agent  used  was  sul- 
phuric ether  applied  continuously  on  lint,  the  scrotum  being  supported  by 
oakum.  The  idea,  I  think,  originated  with  Dr.  Assadorian,^  at  that  time 
one  of  the  house-surgeons. 

The  latest  novelty  in  the  treatment  of  epididymo-orchitis  is  the  method 
of  Balzer,^  who  uses  an  ointment  of  guiacol  in  the  proportion  of  3  or  5 
parts  to  30  parts  of  vaseline.  A  watery  solution  of  like  strength  may  also 
be  employed,  either  by  compress  or  by  spray.  This  agent  is  said  to  exert 
a  very  sedative  action  on  the  parts  by  easing  the  pain  and  rendering  the 
patient  comfortable. 

Strapping  the  testicle  is  never  appropriate  in  the  acute  stage,  though 
it  may  be  beneficial  in  some  cases  of  chronic  swelled  testicle.  It  is  much 
less  commonly,  employed  now  than  formerly,  owing  to  the  fact  that  it  is 
difficult  of  application,  is  not  cleanly,  loosens  quickly,  and  often  gives  rise 
to  fissures  and  inflammation  of  the  skin.  The  scrotum  must  be  smoothly 
shaved  before  the  plaster  is  applied.  Mercurial,  belladonna,  or  the  plain 
rubber  adhesive  plaster  may  be  used  in  strips  of  three-quarters  of  an  inch 
in  width.  A  better  method  of  pressure  to  the  enlarged  testis  is  that 
recommended  by  Corbett,  the  object  of  which  is  to  envelop  the  organ 
after  the  manner  that  a  football  is  covered  with  leather.  For  this  pur- 
pose oval  India-rubber  bulbs  of  various  sizes,  such  as  are  found  in  the 
spray  apparatuses,  may  be  used.  The  upper  part  is  cut  off  and  forms  the 
neck,  around  the  free  margin  pf  which  may  be  sewn  lead  wire  divided  into 
two  or  three  segments,  by  which  means  suppleness  is  retained  and  injurious 
pressure  of  the  cord  is  prevented.  The  bulb  is  then  cut  lengthwise,  and 
into  the  holes  pierced  on  each  side  of  the  cut  surfaces  silk  cord  may  be 
adjusted  like  laces  in  a  corset.  As  the  testis  grows  smaller,  more  and 
more  of  the  bulb  may  be  cut  away,  and  thus  the  holes  become  placed 
farther  back  and  further  pressure  is  made.  It  is  well  to  first  envelop  the 
testis  in  a  layer  of  absorbent  cotton,  and,  if  indicated,  ointments  may  be 
spread  on  it. 

Another  method  is  the  following,  recommended  by  Escalier,  which  is  a 
modification  of  the  suspensory  of  Langlebert :  The  testis  is  grasped,  and 

^  "  Traitement  de  rOrcliite  par  le  Stypage  au  Chlorure  de  Methyle,"  Annales  de 
Derm,  et  de  Syph.,  1890,  pp.  429-430. 

^  "  Etude  comparee  de  la  Refris;eration  et  de  la  Compression  dans  le  Traitement  des 
Orchites,"  Thhe  de  Paris,  1890. 

*  Am.  Journ.  Derm,  and  Syph.,  vol.  i.,  1870,  p.  216. 

*  Therapeutique  des  Maladies  veneriennes,  Paris,  1894,  pp.  69-70. 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  253 

around  its  upper  portion  a  ring  of  adhesive  plaster  is  fixed,  and  covered 
over  with  a  piece  of  silk  handkerchief,  over  Avhich  is  a  thick  layer  of 
absorbent  cotton,  and  over  that  again  a  layer  of  gutta-percha  tissue.  Then 
over  the  whole  strips  of  adhesive  plaster  are  passed  in  a  circular  manner, 
so  that  the  ends  may  be  drawn  more  or  less  tightly  before  being  fixed. 
About  every  twenty-four  hours  it  is  necessary  to  tighten  the  adhesive 
strips.  Removal  of  fluid  from  the  tunica  vaginalis  is  especially  necessary 
in  all  cases  before  compression  is  applied. 

In  those  extremely  severe  cases  in  which  the  testis  is  also  inflamed, 
together  with  serous  effusion  in  the  tunica  vaginalis,  prompt  puncture  of 
this  sac  is  urgently  called  for,  and  is  commonly  folloAved  by  marked  relief 
of  the  pain  and  tension  in  the  organ.  It  is  well  to  employ  a  small 
straight  bistoury,  and  to  make  a  number  of  minute  punctures  well  down 
into  the  cavity  of  the  tunica  vaginalis,  over  its  median  and  most  rounded 
portion,  taking  care  that  the  tunica  albuginea  is  not  wounded.  When 
practicable,  in  these  cases  withdrawal  of  the  fluid  by  the  hypodermic 
syringe  may  be  done.  The  older  surgeons,  particularly  French  and  Eng- 
lish, advocated  incisions  fully  six-tenths  of  an  inch  into  the  parenchyma 
of  the  testis.  Such  procedures  were  frequently  followed  by  hernia  of  the 
testis-substance  and  atrophy  of  the  organ,  and  should  not  be  resorted  to. 

In  cases  of  swelled  testicle  in  which  the  engorgement  is  very  great  a 
number  of  leeches,  according  to  the  powers  of  resistance  of  the  patient, 
may  be  applied  to  the  groin  as  far  down  as  the  scrotum,  but  not  on  it. 
Relief  is  rarely  afforded  unless  at  least  six  to  ten  or  twelve  leeches  are 
used. 

The  treatment  of  neuralgia  of  the  testis  following  gonorrhoea,  or  indeed 
any  morbid  process,  should  be  directed  primarily  to  the  affected  part. 
Blisters  with  cantharidal  collodion  may  produce  much  benefit.  Paquelin's 
cautery  and  the  various  stimulating  applications  already  detailed  may  be 
used.  Opium  and  belladonna  ointment  may  also  be  of  service,  according 
to  the  symptoms.  If  any  thickening  of  the  epididymis  or  cord  can  be  made 
out,  it  should  receive  energetic  treatment  on  the  lines  followed  in  treating 
induration  of  the  epididymis.  In  every  case  the  condition  of  the  deep 
urethra  should  be  ascertained,  and  if  any  inflammation  be  found,  it  should 
be  treated.  Any  general  morbid  condition  should  be  carefully  considered, 
and  proper  medication  and  hygiene  should  be  instituted.  It  is  well  to 
remember  that,  owing  to  fear,  after  recovery  from  gonorrhoea  some  patients 
remain  bravely  continent,  and  as  a  reward  sometimes  they  have  boring, 
aching,  and  dragging  pains  of  varying  severity  in  the  cord  and  testes, 
which  may  be  mistaken  for  neuralgia  of  the  testes,  and  which  may  be 
relieved  by  physiological  processes. 

Induration  of  the  epididymis  and  enlargement  of  the  testis,  which 
sometimes  follow  gonorrhoea  or  other  morbid  processes,  require  some  of 
the  foregoing  methods  of  treatment.  Stimulation  and  compression  are 
especially  indicated.  Strapping  the  testes  and  the  use  of  the  other  com- 
pressing agents  should  be  employed.  In  some  cases  benefit  follows  the 
continuous  use  of  iodine  or  iodide-of-lead  ointment.  In  some  cases  of 
chronic  induration  of  the  testis  and  epididymis,  not  due  to  syphilis,  mer- 
curial ointment  with  compression  will  produce  resolution.  Then,  again, 
I  have  seen  great  benefit  folloAv  the  combined  use  of  mercurial  ointment 
and  the  mixed  treatment,  though  the  induration  was  wholly  due  to  gonor- 


254  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

rhoea,  and  not  even  remotely  to  syphilis.  In  obstinate  cases  it  is  always 
well  to  try  this  combination  treatment. 

The  local  treatment  of  the  miscellaneous  forms  of  orchitis  due  to  in- 
fectious processes  and  to  traumatism  should  be  based  on  the  lines  already 
laid  down.  Such  surgical  relief  as  may  be  rendered  necessary  by  abscess- 
formation  should  be  applied  on  general  principles. 

The  testicular  inflammation  due  to  malaria  demands  quinine,  and  the 
other  infectious  forms  of  epididymo-orchitis  and  epididymitis  should  be 
treated  symptomatically  on  general  principles.  One  golden  rule  should 
always  guide  the  surgeon  in  the  treatment  of  these  testicular  afi"ections, 
and  that  is  not  to  cease  treatment  until  all  the  products  of  inflammation 
have  been  removed  by  absorption. 


CHAPTER    XXIII. 

aONORRHCEAL  OPHTHALMIA  AND  SERO-VASCULAR  CON- 
JUNCTIVITIS. 

Gonorrhceal  Ophthalmia. 

GoNOERHCEAL,  OPHTHALMIA  is  happily  a  rare  accident  rather  than 
complication  of  gonorrhoea.  According  to  statistics,  it  occurs  59  times  in 
37,034  cases  of  eye  diseases,  but  probably  in  far  greater  frequency  in  the 
course  of  gonorrhoea.  It  is  a  violent  and  often  destructive  inflammation, 
and  more  intense  than  purulent  conjunctivitis.  It  is  developed  in  the 
eyes  of  young  infants  during  delivery  by  gonorrhceal  pus  in  its  mother's 
vao^ina.  The  usual  mode  of  infection  is  the  transference  of  the  pus  from 
the  genitals  to  the  eyes  by  means  of  the  fingers.  In  some  cases  the  pus 
of  the  infected  eye  is  carried  to  the  other  by  the  fingers  during  sleep  or 
by  accident  during  the  day.  Towels  and  linen  are  also  said  to  be  the 
vehicles  of  infection. 

The  virulent  form  of  ophthalmia  has  been  shown  (see  p.  86)  to  be 
caused  by  pus-containing  gonococci.  The  less  virulent  form  is  said  to  be 
due  to  pus  not  containing  gonococci,  but  other  pyogenic  microbes.  In  the 
majority  of  cases  of  the  milder  affection  the  symptom-complex  is  much 
less  severe  than  in  gonorrhceal  ophthalmia,  but  in  some  cases  the  severity 
is  seemingly  just  as  great.  All  forms  of  chronic  urethral  and  vaginal  pus 
should  be  regarded  as  dangerous.  The  pus  of  balanitis  and  of  abscesses, 
though  said  to  be  innocuous  to  the  eyes,  should  never  be  carelessly  brought 
in  contact  Avith  them,  such  is  the  danger  of  infection  from  every  form  of 
purulent  secretion. 

This  form  of  ophthalmia  is  said  to  be  more  common  in  men  than  in 
women,  for  the  reason,  probably,  that  gonorrhoea  is  so  much  more  fre- 
quent in  the  former  than  in  the  latter.  It  may  occur  in  the  acute  stage 
of  gonorrhoea,  but  it  is  generally  seen  during  the  declining  stage.  It 
may  be  confined  to  one  eye  or  may  later  on  attack  the  other  one. 

Symptoms. — The  first  symptoms,  which  usually  begin  in  a  few  hours 
or  as  late  as  thirty  hours  after  contagion,  are  hyperaemia  of  the  con- 


OONORRHCEAL   OPHTHALMIA,  ETC.  255 

junctiva,  an  itching  sensation  at  the  margin  of  the  lids,  as  if  caused  by 
a  foreign  body,  soon  followed  by  increased  lachrymation,  a  gumming  of 
the  cilit^  together,  and  collection  of  little  masses  of  mucus  at  the  inner 
canthus.  The  watery  secretion  soon  becomes  mucoid  and  very  shortly 
purulent.  A  conjunctivitis,  mild  at  first  and  limited  to  the  lids,  but  later 
on  of  a  severe  type,  involving  the  ocular  mucous  membrane,  which  is  ele- 
vated above  the  sclerotic  coat,  is  then  seen.  All  of  the  conjunctival  sur- 
face is  then  of  a  very  deep-red  color,  much  swollen,  producing  eversion 
of  the  lids,  and  roughened  from  distention  of  the  papillae.  The  intense 
chemosis  of  the  conjunctiva  bulbi  is  well  shown  in  Figs.  86  and  87,  in 

Fig.  86. 


V\^\  A 

\  \  ■'■"" 

Gonorrhceal  ophthalmia,  showing  well-  Gonorrhoeal  ophthalmia,  showing  com- 

marked  ehemosis.  mencing  opacity  of  the  cornea. 

which  the  red,  swollen,  and  infiltrated  membrane  surrounds  the  cornea 
like  a  pad.  At  this  time  the  secretion  is  purulent  and  profuse,  and  much 
redness  and  oedema  of  the  integument  of  the  lids  is  present,  as  seen  in 
Fig.  88.  The  following  account  of  gonorrhoeal  ophthalmia  by  my  late 
colleague,  Dr.  Bumstead,  who  to  his  many  attainments  added  that  of  an 
accomplished  ophthalmologist,  is  inimitably  graphic  :  "  An  attack  of  gon- 
orrhoeal ophthalmia  is  so  rapid  in  its  progress  that  the  early  symptoms  just 
now  described  may  have  passed  away  before  the  first  visit  of  the  surgeon, 
who  is  often  called  to  see  his  patient  only  after  the  full  development  of  the 
disease.  He  probably  finds  him  sitting  up,  his  head  bent  forward,  his  chin 
resting  on  his  breast,  and  his  handkerchief  applied  to  his  cheek  to  absorb 
the  discharge,  which  irritates  the  surface  upon  which  it  flows.     The  eye- 


256 


GONOBBJKEA  AND  ITS  COMPLICATIONS. 


Fig.  88. 


lids  are  swollen,  especially  the  upper,  which  slightly  overlaps  the  lower, 
and  is  of  a  reddish  or  even  dusky  hue.  The  patient  states  that  he  is 
unable  to  open  the  eye.  His  inability  to  do  so  is  caused  less  by  an  in- 
tolerance of  light  than  by  the  mechanical  obstruction  which  the  swelling 
of  the  lids  occasions,  and  by  the  pain  which  is  excited  by  any  friction  of 
the  inflamed  surfaces  upon  each  other. 

"  The  surgeon  now  moistens  the  edges  of  the  lids  with  a  rag  dipped  in 

warm  water  in  order  to  facilitate  their 
separation,  and  proceeds  with  his  ex- 
amination. In  his  attempt  to  open 
the  eye  he  is  careful  not  to  make 
pressure  upon  the  globe,  in  order  to 
avoid  giving  unnecessary  pain,  and 
also  lest  the  cornea,  if  already  ul- 
cerated, may  be  ruptured  and  the 
contents  of  the  globe  escape.  With 
one  finger  just  below  the  eye  he 
slides  the  integument  downward  over 
the  malar  bone,  and  thus  everts  the 
lower  lid,  the  upper  lid  being  ele- 
vated by  a  similar  manoeuvre  with 
the  other  finger  of  the  same  hand 
applied  below  the  edge  of  the  orbit ; 
or,  again,  he  may  expose  the  globe 
by  seizing  the  lashes  and  margin 
of  the  upper  lid  with  the  thumb 
and  finger,  and  drawing  the  lid 
forward  and  upward.  All  this  may  be  accomplished  with  the  left  hand, 
the  right  being  free  to  wipe  away  the  discharge  or  to  make  application  to 
the  eye. 

"  As  soon  as  the  lids  are  separated  a  quantity  of  thick  yellowish  pus 
wells  up  between  them  and  partially  obstructs  the  view  :  the  swollen  palpe- 
bral conjunctiva,  compressed  by  the  spasmodic  action  of  the  orbicularis 
muscle,  may  also  project  in  folds.  The  collection  of  matter  is  now  re- 
moved with  a  soft  moist  sponge  or  rag,  and  the  surface  of  the  ocular  con- 
junctiva exposed.  This  membrane  is  found  to  be  of  a  uniform  red  color, 
with  the  vessels  undistinguishable  from  each  other,  and  elevated  above 
the  sclerotica  by  an  ejffusion  of  serum  and  fibrin  in  the  cellular  tissue 
beneath  it.  This  swelling  of  the  conjunctiva  is  seen  to  terminate  at  the 
margin  of  a  central  depression  occupying  the  position  of  the  cornea  and 
filled  with  a  collection  of  the  less  fluid  constituents  of  the  puriform  dis- 
charge, which  may  at  first  be  mistaken  for  the  debris  of  a  disorganized 
€ornea.  On  removing  this  matter,  however,  the  latter  structure  may  still 
be  found  clear  and  transparent  at  the  bottom  of  the  depression,  where  it 
is  overlapped  by  the  swollen  conjunctiva.  In  less  fortunate  cases  it  may 
have  become  hazy  from  infiltration  of  pus  between  its  layers,  or  ulceration 
may  have  commenced.  If  an  ulcer  is  not  evident  on  first  inspection,  it 
may  be  discovered  at  the  margin  of  the  cornea  by  gently  pushing  to  one 
side  the  overlapping  fold  of  the  conjunctiva.  Meanwhile,  the  secretion 
of  pus  is  constantly  going  on,  and  it  requires  repeated  removal.  It  is 
astonishing  to  observe  how  large  a  quantity  of  this  fluid  can  be  secreted 


OonorrhcBal  ophthalmia,  with  great  cedema  of 
of  the  tegumentary  parts. 


QONOBBHCEAL   OPHTHALMIA,  ETC.  257 

by  so  limited  a  surface.  It  has  been  estimated  at  more  than  three  ounces 
per  day  in  some  cases." 

The  amount  of  pain  occasioned  by  this  disease  varies  in  different  cases. 
During  the  development  and  acme  of  the  inflammation  it  is  generally  severe. 
It  is  described  by  the  patient  as  a  sensation  of  burning  heat  and  tension 
in  the  eyeball,  radiating  to  the  brow  and  the  temple.  The  system  at  large 
sympathizes  with  the  local  disease.  For  a  time  there  may  be  general 
febrile  excitement,  but  symptoms  of  depression  soon  appear ;  the  pulse 
becomes  rapid  and  irritable,  the  skin  cold  and  clammy,  and  the  patient 
anxious  and  nervous.  This  depression  of  the  vital  powers  is  not  invari- 
ably met  with,  but  is  the  most  frequent  condition  of  the  patient  after  the 
disease  has  continued  for  a  few  days  ;  and  it  may  appear  even  at  an  earlier 
pei"iod  when  the  health  has  been  previously  impaired  from  any  cause. 
Notwithstanding  the  severity  of  the  symptoms,  resolution  is  still  possible. 
Under  proper  care  and  treatment  the  inflammatory  action  may  abate  and 
the  tissues  recover  their  normal  condition,  leaving  the  eye  as  sound  as 
before  the  attack.  So  fortunate  a  result  is  more  to  be  hoped  for  than  con- 
fidently anticipated. 

Prognosis. — The  prognosis  is  always  grave,  especially  so  when  both. 
eyes  are  attacked.  If  treatment  is  instituted  at  an  early  period,  the 
chances  of  the  patient  are  best.  If  ulceration  of  the  cornea  has  taken 
place,  they  are  bad.  It  generally  begins  at  the  corneal  margin,  either 
superficially  or  deeply,  and  may  creep  around  or  may  advance  toward  the 
centre.  Sometimes  the  whole  cornea  is  extruded  and  the  contents  of  the 
eye  escape.  An  eye  has  been  known  to  be  thus  destroyed  within  twenty- 
four  hours,  and  even  in  a  single  night.  The  escape  of  the  contents  of  the 
globe  often  gives  the  patient  hope  that  he  is  recovering,  whereas  his  sight 
is  gone. 

According  to  the  extent  and  situation  of  the  ulceration  the  eye  is  more 
or  less  permanently  injured.  When  superficial  and  marginal,  the  result- 
ing opacity  of  the  cornea  may  not  interfere  with  the  sight,  which  may  be 
impaired  if  the  leucoma  is  central.  Perforation  of  the  anterior  chamber 
and  prolapse  of  the  iris,  when  partial,  may  also  be  remedied  by  art ;  but 
when  the  Avhole  or  the  larger  part  of  the  cornea  has  sloughed  away,  and 
the  prolapsed  iris  has  become  covered  with  a  dense  layer  of  fibrin,  form- 
ing an  extensive  staphyloma,  the  case  is  hopeless. 

Trachoma  or  exuberant  granulations  of  the  palpebral  and  bulbar  con- 
junctiva often  follow  gonorrhoeal  ophthalmia,  and  are  sometimes  of  much 
annoyance  to  the  patient  and  resistant  to  treatment.  Frequently  a  tend- 
ency to  hyperaemia  of  the  external  ocular  tissues  from  slight  irritation  is 
observed  over  long  periods. 

Diagnosis. — So  much  do  severe  cases  of  purulent  ophthalmia  resemble 
those  of  the  gonorrhoeal  form  that  a  sharp  diagnosis  is  often  impossible, 
owing  to  the  meagreness  of  the  history.  Any  intense  form  of  ophthalmia, 
whatever  may  be  its  origin,  must  be  looked  upon  in  as  serious  a  light  as 
that  due  to  gonorrhoea.  In  all  cases  the  pus  should  be  examined  micro- 
scopically at  once,  and  if  the  gonococcus  is  found  it  is  absolutely  certain 
that  the  case  is  of  gonorrhoeal  origin,  and  therefore  a  very  grave  one.  In 
general,  when  less  virulent  micro-organisms  are  found,  the  diagnosis  is  not 
bad.  The  earlier  a  case  of  gonorrhoeal  ophthalmia  is  seen  and  that  a 
proper  treatment  is  commenced,  the  better  is  the  prognosis.  In  infants 
17 


258  GONORRHOEA  AND  ITS  COMPLICATIONS. 

the  prognosis  largely  depends  on  the  care  which  the  case  receives.  In 
early  adult  life  there  is  such  resistance  of  the  tissues  that  with  care  the 
inflammation  may  be  controlled.  Toward  middle  age  and  in  elderly  sub- 
jects the  tissue-resistance  is  not  as  great,  and  the  prognosis  then  is  more 
serious. 

Treatment. — The  first  indication  in  treatment  is  to  procure  a  skilled, 
kind,  and  trusty  female  nurse — and  preferably  two,  one  for  the  day,  the 
other  for  the  night — who  should  be  in  constant  attendance.  She  should, 
at  the  outset,  be  thoroughly  impressed  with  the  gravity  of  the  case,  in- 
structed as  to  her  duties,  and  shown  the  technique  of  opening  the  eye  and 
removing  the  pus.  She  must  be  warned  of  the  intense  contagiousness  of 
the  secretions,  must  be  directed  to  keep  her  hands  and  nails  in  a  thor- 
oughly aseptic  condition,  and  she  should  provide  herself  with  a  pair  of  pro- 
tective concave  spectacles  having  a  diameter  of  two  inches.  In  case  one  eye 
only  of  the  patient  is  affected,  the  other  may  be  covered  by  Buller's  shield. 
This  consists  of  two  pieces  of  India-rubber  adhesive  plaster,  one  four 
and  the  other  four  and  a  half  inches  square,  between  which,  in  a  hole  in 
the  centre,  a  deep  watch-glass  is  fastened.  The  watch-glass  is  placed  over 
the  eye,  which  can  then  be  inspected,  while  the  margins  are  fastened  to 
the  nose,  forehead,  and  cheek.  It  is  well  to  leave  a  little  space  for  venti- 
lation on  the  lower  outer  angle.  Or  the  sound  eye  may  be  covered  with 
cotton  wool  strapped  down  with  adhesive  plaster,  over  which  a  solution  of 
gutta-percha  is  painted.     In  young  subjects  it  is  well  to  secure  the  hands. 

If  seen  before  inflammation  has  fully  developed,  four  to  six  leeches 
may  be  applied  at  the  external  can  thus  or  to  the  mucous  membrane  of 
the  corresponding  nostril,  or  if  not  at  hand  cups  may  be  used  on  the 
temples.  The  character  of  the  inflammation  being  manifest,  a  careful, 
continuous,  and  energetic  treatment  must  be  followed.  Constant  appli- 
cation of  cold  is  then  absolutely  required.  This  is  accomplished  by  means 
of  small  pieces  of  linen  of  a  single  thickness,  which,  when  thoroughly 
chilled  upon  a  piece  of  ice,  should  be  laid  over  the  eye,  and  replaced  by 
another  every  two  or  three  minutes  in  very  intense  cases.  These  pieces 
of  linen  should  be  burned  immediately  after  use.  The  further  treatment 
of  the  case  should  be  as  follows,  after  the  manner  proposed  by  my  friend. 
Dr.  J.  A.  Andrews,  which  has  been  productive  of  excellent  results  at 
Charity  Hospital :  When  the  inflammation  is  fully  established  the  indi- 
cations are  to  wash  away  the  pus  in  the  most  perfect  manner  as  soon  as 
possible,  and  to  render  the  conjunctival  surface  as  nearly  as  possible 
aseptic.  For  this  purpose  a  saturated  solution  of  boracic  acid  is  neces- 
sary. A  bichloride  solution,  1 :  10,000  or  20,000,  may  also  be  used. 
This  may  be  used  by  means  of  Andrews'  irrigator  No.  2,  made  by  Ford 
of  New  York,  or  by  means  of  a  piece  of  fine  rubber  tubing  attached  to 
a  fountain  syringe,  and  allowed  to  flow  with  the  utmost  gentleness. 
These  irrigations  must  be  repeated  as  often  as  necessary.  Then,  from 
the  beginning  of  the  disease,  a  2  per  cent,  solution  of  nitrate  of  silver 
should  be  dropped,  rather  than  brushed,  into  the  eye,  since  it  is  then 
distributed  by  the  movement  of  the  eyelids.  The  more  vascular  and 
swollen  the  conjunctiva,  the  more  frequent  should  be  these  instillations, 
which  may  be  made  from  three  to  four  times  daily,  according  to  indica- 
tions. Instillations  of  a  four-grains-to-the-ounce-of-water  solution  of  atro- 
pine may  be  used  also  at  intervals  during  the  severity  of  the  attack.     As 


GONOBRHCEAL   OPHTHALMIA,  ETC.  259 

improvement  takes  place,  the  use  of  the  solution  of  nitrate  of  silver  should 
be  more  infrequent  until  it  is  finally  dropped. 

If  chemosis  has  taken  place,  the  ocular  conjunctiva  and  subjacent 
connective  tissue  should  be  divided  by  means  of  blunt  scissors,  and  in 
case  the  eversion  of  the  lids  is  not  complete,  the  outer  commissure  should 
be  freely  divided,  together  with  the  canthal  ligament,  for  the  inflamed 
surfaces  must  be  in  such  a  condition  that  they  can  be  thoroughly  treated. 
Excessive  oedema  of  the  lids  interfering  with  the  opening  of  the  eye  may 
be  relieved  by  minute  punctures  of  the  skin.  After  the  subsidence  of 
the  acute  symptoms  the  nitrate-of-silver  solution,  which  toward  the  end 
has  been  used  much  less  frequently  than  at  first,  may  be  replaced  by  a 
solution  of  sulphate  of  zinc,  as  follows  : 

^.  Zinci  sulphatis,  gr.  ij  ; 

Glyceringe,  gij  ; 

Vin.  opii,  3J  ; 

Aquae,  3v. — M. 

This  may  be  instilled  into  the  eye  by  means  of  a  glass-and-rubber  drop- 
ping-tube. 

Should  ulcer  of  the  cornea  occur,  the  pupil  should  at  once  be  dilated 
with  atropine  solution  and  vigorous  but  prudent  measures  adopted. 

The  granular  condition  of  the  conjunctiva  should  be  treated  by  the 
application  of  a  piece  of  sulphate  of  copper  to  the  surface  every  second 
or  third  day. 

Patients  suffering  from  gonorrhoeal  ophthalmia  should  occupy  a  large, 
well-ventilated  room,  which  should  be  moderately,  not  wholly,  darkened, 
and  they  should  be  placed  exclusively  in  the  care  of  the  surgeon  and  the 
nurse  or  nurses.  At  the  onset  of  the  disease  a  brisk  aperient,  even  a 
cathartic,  may  be  given,  which  should  be  repeated  as  necessary,  care 
being  taken  that  the  patient's  strength  is  not  impaired  by  it.  A  mild 
diet,  gruels  and  light  broths,  may  be  taken.  Should  evidences  of  mal- 
nutrition and  debility  appear,  with  weak  and  irritable  pulse,  more  nutri- 
tious food  of  the  most  digestible  character  must  be  given,  together  with 
tonics,  and  perhaps  ale,  porter,  milk  punch,  etc.  It  must  be  remembered 
that  the  vitality  of  the  corneal  tissue  is  very  low,  and  that  its  destruction 
may  be  hastened  by  an  impoverished  state  of  the  system. 

Convalescence  is  much  hastened  by  change  of  air,  particularly  in  the 
mountains.  It  is  sometimes  astonishing  to  observe  how  rapidly  the  nutri- 
tion of  the  patient  increases,  and  how  quickl}?-  the  trachoma  and  conjunc- 
tival congestion  disappear,  under  the  influence  of  country  air. 

Sero-vascular  Conjunctivitis. 

This  is  a  rare  form  of  purulent  conjunctivitis  of  which  little  has  been 
written.  This  form  of  ophthalmia  is  really  a  complication  of  gonorrhoea, 
and  not  one  of  its  accidents.  Though  the  pathogenesis  of  this  affection 
has  not  been  studied,  much  less  made  out,  I  think,  reasoning  by  analogy, 
that  it  will  later  on  be  settled  that  it  is  an  infectious  process  due  to  septic 
absorption,  like  gonorrhoeal  rheumatism,  etc.  It  certainly  is  not  due  to 
pus-contamination. 


260  GONORBHCEA  AND  ITS  COMPLICATIONS. 

This  form  of  conjunctivitis  is  called  by  Fournier  "  blennorrhagic 
sero- vascular  conjunctivitis."  Fragne,^  an  ^l^ve  of  Fournier,  employs  the 
title  "blennorrhagic  sero-vascular  conjunctivitis  without  inoculation" 
as   being  more  expressive. 

This  affection  begins  in  a  painless  and  insidious  manner,  but  its  ob- 
jective symptoms  are  well  marked.  The  patient  at  first  feels  a  slight 
heat  in  the  eye  and  a  sensation  as  if  some  particle  had  lodged  on  it. 
Then  the  conjunctiva  bulbi  becomes  rather  swollen  and  hypersemic. 
This  is  followed  by  hypergemia  of  the  conjunctiva  of  the  lids.  The  secre- 
tion is  at  first  serous  and  moderately  copious,  but  in  a  few  days  it  becomes 
slightly  purulent.  In  the  acme  of  the  inflammation  Ave  find  the  whole 
conjunctiva  rather  swollen,  with  perhaps  some  oedema  of  the  eyelids. 
The  mucous  membrane  is  of  a  quite  deep-red  color  and  of  velvety  appear- 
ance. The  oedema  is  not  usually  very  extensive.  The  affection  runs  an 
indolent  course,  and  usually  does  not  cause  much  pain  or  annoyance. 
One  or  both  eyes  may  be  affected.  After  cure  a  relapse  is  not  uncom- 
mon. I  have  seen  several  cases  in  which  patients  were  thus  affected  with 
each  attack  of  gonorrhoea. 

The  prognosis  is  almost  invariably  good. 

Treatment. — The  eye  should  be  irrigated  with  saturated  boracic-acid 
water,  and  a  few  drops  of  a  2  per  cent,  solution  of  nitrate  of  silver  may 
be  dropped  in  the  eye  once  or  twice  a  day.     Ice-cloths  may  be  necessary. 


CHAPTER  XXIV. 

GONORRHCEAL  RHEUMATISM. 

The  term  "gonorrhoeal  rheumatism"  is  applied  to  a  complex  inflam- 
mation, chiefly  of  the  joints,  fasciae,  bursse,  and  tendinous  sheaths,  and 
also  of  the  eye  and  fibrous  tissues,  which  follows  in  the  course  of  urethral 
gonorrhoea  and  gonorrhoeal  vulvitis,  vaginitis,  and  conjunctivitis.  It 
sometimes  complicates  urethral  suppuration  caused  by  instrumentation, 
even  as  simple  as  the  passage  of  a  sound.  This  form  of  rheumatism  does 
not  complicate  balanitis  or  simple  inflammations  of  the  external  genitals 
of  the  male  or  female. 

Gonorrhoeal  rheumatism  attacks  men  more  frequently  than  women^ 
and  is  seen  in  infants  and  in  the  young  and  the  old.  It  has  no  etiological 
relation  to  a  pre-existent  rheumatic  condition  or  diathesis,  for  the  reason 
that  we  see  many  truly  rheumatic  subjects  who  may  suffer  from  gonor- 
rhoea without  becoming  affected  with  its  rheumatism.  This  affection  may 
follow  each  attack  of  gonorrhoea,  but  such  a  course  is  far  from  being  the 
invariable  rule,  since  many  men  have  thus  suffered  once  after  gonorrhoea, 
and  never  again  after  subsequent  infections. 

Gonorrhoeal  rheumatism  is  a  rare  affection  if  compared  with  the  fre- 

1  Thhe  de  Paris,  1888. 


GONORRHCEAL  RHEUMATISM.  261 

quency  of  gonorrhoea,  and  occurs  in  about  10  per  cent,  of  all  cases  of 
that  disease. 

It  would  be  an  utter  waste  of  time  to  detail  the  old  views  and  discuss 
the  various  contentions  as  to  the  origin  and  nature  of  gonorrhoeal  rheu- 
matism. To-day,  in  the  light  of  our  knowledge  of  the  pathological  action 
of  the  gonococcus,  the  subject  is  quite  clear.  It  is  therefore  worth  while 
to  present  the  experience  which  led  up  to  this  condition  of  enlightenment. 
As  early  as  1883  it  was  claimed  by  Petrone  ^  that  he  had  found  the  gono- 
coccus in  the  fluid  of  gonorrhoeal  arthritis.  This  statement  was  further 
strengthened  by  the  observations  of  Kammerer,^  Horteloup,^  Bergmann,* 
Hartley,^  and  many  others,  who  claimed  that  they  also  found  the  gono- 
coccus in  the  joint  effusions  of  gonorrhoeal  rheumatism.  Owing  to  the 
fact  that  these  various  observers  had  only  used  the  microscope  in  their 
studies,  there  was  a  doubt  in  the  minds  of  many  whether  they  had  really 
discovered  the  gonococcus  or  some  other  diplococcus  resembling  it.  As  a 
result  of  various  studies,  the  following  hypotheses  as  to  the  origin  and 
nature  of  gonorrhoeal  rheumatism  were  entertained  :  First,  that  it  was  the 
direct  result  of  gonococcus  invasion  of  the  joints  and  various  fibrous  tis- 
sues ;  second,  that  it  was  the  result  of  a  mixed  infection,  in  which  the 
gonococcus  and  pyogenic  microbes  were  the  morbific  agents ;  third,  that 
the  process  began  by  the  invasion  of  the  gonococcus,  which  prepared  the 
way  for  pyogenic  microbes ;  and,  fourth,  that  it  was  a  phlegmasia  pro- 
duced by  toxines  carried  from  the  urethra  by  means  of  the  circulation  to 
the  parts  affected.  These  observations  have  since  been  confirmed  by  sev- 
eral observers. 

Deutschmann  ^  found  gonococcus  in  the  interior  of  the  pus-cells  of  two 
cases  of  the  joint  effusion  of  gonorrhoeal  rheumatism,  and  later  on  Hock  ^ 
was  able  to  obtain  pure  cultures  from  a  similar  fluid. 

The  latest  and  most  important  contribution  to  the  subject  is  made  by 
Finger,^  Ghon,  and  Schalgenhaufer.  Finger  found  in  the  case  of  an  in- 
fant suffering  from  purulent  ophthalmia  the  gonococcus  alone  in  peri- 
chondritis of  the  ribs,  and  the  gonococcus  and  streptococcus  in  the  in- 
flamed knee-joint,  also  affected  with  periarticular  suppuration.  In  the 
temporo-maxillary  articulation  the  streptococcus  alone  was  found.  This 
observation  of  Finger,  made  with  so  much  care  and  detail  Avith  the  aid  of 
the  microscope  and  culture-tests,  supported  by  many  observations  and  facts 
presented  by  others,  is  all-important  in  settling  the  doubt  as  to  the  caus- 
ative relation  of  the  gonococcus  to  gonorrhoeal  rheumatism. 

'  Rivinta  Clin,  cli  Bologna,  1883,  3d  series,  vol.  iii.  pp.  94  et  seq.,  and  Centralblt.  fiir 
Chirurgie,  1883,  No.  37,  p.  586. 

^  Centralblatt  fur  Chirurgie,  1884,  No.  11,  pp.  49  et  seq. 

*  Gazette  des  Hopitaux,  1885,  p.  1004.  *  St.  Petersburg  med.  Zeitsch.,  1885,  No.  35. 
5  Neiv  York  Med.  Journal,  April  2,  1887. 

Guyon  and  Janet  have  reported  four  cases  of  gonorrhoeal  rhenmatism  in  the,  joint 
eflfiisions  of  which  they  were  unable  to  find  the  gonococcus  or  any  other  microbe.  Too 
much  stress  need  not  be  laid  on  these  negative  observations,  for  the  reasons — first,  that 
the  particular  specimens  of  fluid  withdrawn  might  not  have  contained  the  microbes 
which  were  present  elsewhere ;  and,  second,  that  the  micro-organism  itself  might  have 
been  killed  bv  the  inflammatory  products  which  it  had  caused  {Annales  des  Mai.  des  Org. 
Gin.-urin.,  1889,  pp.  462  et  seq.). 

*  Graefe's  Archiv,  vol  xxxvi.,  1890,  pp.  109  et  seq. 
'  Wiener  klin.  Wochenschrift,  1893,  No.  41,  p.  73. 

®  Archiv  fiir  Derm,  und  Syphilis,  1894,  vol.  xxviii..  Heft  1,  pp.  2  et  seq.,  and  Heft  2, 
pp.  277  et  seq. 


262  GONORBHCEA  AND  ITS  C03IPLICATI0NS. 

Hewes '  has  recently  claimed  that  he  found  and  cultivated  the  gono- 
coccus  taken  from  the  joint  fluid  and  blood  of  two  cases  of  patients  suf- 
fering from  gonorrhoeal  rheumatism. 

Dr.  W.  H.  Welch  ^  has  reported  the  case  of  a  woman  suffering  from 
gonorrhoea  complicated  by  pyaemia  and  endocarditis,  from  whom  during 
life  he  extracted  some  blood.  This  was  mixed  with  agar,  and  as  a  result 
cultures  were  obtained  which  showed  the  gonococcus.  This  observation,, 
coming  from  so  eminent  an  observer,  certainly  carries  conviction  with  it, 
and  clearly  demonstrates  that  the  gonococcus  is  carried  into  the  blood- 
current,  which  may  deposit  it  throughout  the  body.  Welch  also  found 
the  gonococcus  in  the  purulent  secretion  of  gonorrhoeal  inflammation  of  a 
tendinous  sheath. 

In  the  light  of  our  present  knowledge,  therefore,  we  are  warranted  in 
stating  that  the  essential  inflammation  in  gonorrhoeal  rheumatism  is 
caused  by  the  gonococcus  and  its  toxines,  and  that  the  morbid  process 
may  be  further  complicated  and  aggravated  by  the  concurrent  or  subse- 
quent action  of  pyogenic  microbes.  Whether  the  cases  presenting  ordi- 
nary serous  eff"usion  are  due  to  the  gonococcus  alone  or  its  toxic  products, 
and  whether  the  cases  of  articular  and  fibrous-tissue  abscesses  are  due  to 
the  action  of  the  gonococcus,  aided  by  that  of  pus-microbes,  we  cannot 
to-day  state  with  scientific  precision.  The  results  of  observation  seem, 
however,  to  show  that  when  the  joint  effusion  is  serous  or  sero-fibrinous 
the  gonococcus  is  found  in  it,  and  that  when  it  is  sero-purulent  or  puru- 
lent pyogenic  microbes  are  found.  There  seems  to  be  sufiicient  evidence 
at  hand  to  warrant  the  statement  that  in  many  cases  the  pyogenic  mi- 
crobes dominate  in  the  phlegmasia,  and  thus  the  gonococci  perish  in  whole 
or  in  part. 

It  is  very  difiicult  to  state  definitely  the  date  of  the  onset  of  gonor- 
rhoeal rheumatism.  While  the  complication  may  and  does  occur  in  acute 
urethritis  in  a  goodly  number  of  cases,  as  I  have  myself  seen,  its  onset 
then  is  in  the  second  or  third  week  at  the  earliest.  Cases  have  been 
reported  in  which  this  form  of  rheumatism  is  said  to  have  begun  on  the 
sixth  day  of  acute  gonorrhoea,  but  is  very  probable  that  there  Avas  an 
error  in  the  observations.  Thouo;h  we  have  not  absolute  knowledge  on 
the  subject,  it  is  probable  that  absorption  of  septic  material  does  not  take 
place  until  the  infection  has  reached  the  posterior  urethra.  It  is  usually 
in  the  older  and  more  chronic  cases  of  gonorrhoea  that  its  rheumatism 
appears  ;  consequently  we  more  frequently  see  it  develop  in  one,  two, 
three,  and  four  months  after  the  beginning  of  the  infection,  and  even 
later. 

From  old  and  recent  medical  literature  Finger^  has  tabulated  375  cases 
in  which  the  site  of  the  disease  is  stated.  They  are  as  follows :  Gonor- 
rhoeal rheumatism  occurred^ 

1  Boston  Med.  and  Surg.  Journal,  No.  22,  1894. 

2  Med.  Record,  June  15,  1895,  p.  756.  ^  q^  ^h_^  pp_  296  et  seq. 

*  Bornemann's  statistics  (Studier  over  den  Gonorrhoiske  Rheumatismus,  Copenhagen, 
1887)  are  also  interesting.  They  are  based  on  the  study  of  278  cases.  In  these  cases  the 
knee  was  affected  240  times;  the  foot,  151 ;  the  shoulder,  68;  the  metacarpo-phalangeal 
joints,  51;  the  hip,  46;  the  elbow,  45;  and  the  jaw,  12.  It  was  noted  that  there  was 
not  uniformly  an  excess  of  synovial  fluid,  since  in  the  240  cases  in  which  the  knee  was 
attacked  it  was  only  found  183  times.  Affections  of  the  tendons  and  burspe  occurred  in 
41  patients  ;  4  suffered  from  periostitis ;  and  in  3  the  muscles  were  attacked.  Out  of  the 
whole  number  of  cases  (278),  endocarditis  occurred  in  2  cases  and  sciatica  in  5. 


GONOBBHOEAL  BHEUMATISM. 


263 


In  the  knee-joint 136  times. 

"  tibio-tarsal  joint  ...  59  " 

"  wrist-joint 43  " 

"  finger-joint 35  " 

"  elbow-joint 25  " 

"  shoulder-joint  ....  24  " 

"  hip-joint    ......  18  " 

"  maxillary  joint    ...  14  " 


In  the  metatarsus 

"  sacro-iliac  synchondrosis 

"  sterno-clavicular  joint 

"  chondro-costal  joint    . 

"  intervertebral  joint    . 

"  peroneo-tibial  joint    . 

"  crico-arytenoid  joint  . 


7  times. 
4  " 
4  " 
2  " 
2  " 
1  time. 
_J. ''__ 

375  times. 


In  about  60  per  cent,  of  cases  several  joints  are  involved,  and  then 
the  affection  is  termed  polyarticular,  and  in  40  per  cent,  only  one  joint  is 
involved,  the  affection  then  being  called  monoarticular. 

Besides  the  joints  other  structures  are  frequently  involved  in  gonor- 
rhoeal  rheumatism,  either  in  combination  with  the  joint  lesions  or  as 
special  inflammations.  The  bursse  are  quite  frequently  attacked.  The 
bursa  in  front  of  the  tendo  Achillis  and  the  one  beneath  the  os  calcis  are 
most  frequently  involved,  while  those  of  the  wrist,  ankle,  the  patella,  the 
tuber  ischii,  the  bicipital,  and  of  the  psoas  muscle  are  less  commonly 
attacked.  The  tendinous  sheaths  may  be  affected  in  gonorrhoeal  rheu- 
matism, either  alone  or  in  combination  with  joint  lesions.  The  sheaths 
most  commonly  the  seat  of  the  inflammation  are  the  extensors  of  the 
hands  and  fingers,  the  dorsal  flexors  of  the  toes  and  the  flexor  pollicis,  the 
sheaths  of  the  biceps  brachii,  and  of  the  tendo  Achillis.  The  external 
fibrous  structures  and  ligamentous  tissues  of  joints,  particularly  the  large 
ones  of  the  knee  and  the  elbow,  are  not  unfrequently  involved  by  this 
form  of  rheumatism,  which  is  called  periarticular  gonorrhoeal  rheumatism. 
This  may  also  be  said  of  smaller  joints,  such  as  of  the  hands,  feet,  and 
toes.  In  these  cases  there  is  no  intra-articular  phlegmasia.  The  plantar 
and  palmar  fascia  are  quite  rarely  the  seat  of  gonorrhoeal  inflammation. 

The  essential  lesion  of  the  joints  is  an  inflammation  of  their  synovial 
membrane,  which  may  result  in  serous  synovitis,  sero-flbrinous  synovitis, 
sero-purulent  synovitis,  which  are  the  more  common  forms,  and  purulent 
synovitis,  which  is  quite  rare.  Gonorrhoeal  rheumatism  is  essentially  an 
hydrarthrosis,  and  in  very  many  instances  the  disease  is  confined  to  the 
synovial  membrane  of  the  joint  during  the  whole  course  of  the  affection. 

In  some  cases  the  discharge  ceases  when  the  rheumatism  begins,  in 
others  it  is  increased  before  its  onset,  and  in  still  other  cases  there  is  no 
alteration  in  its  course. 

Acute  inflammation  of  one  joint,  particularly  of  the  knee,  and  called 
gonitis,  is  the  most  common  form  of  gonorrhoeal  rheumatism.  This  form 
is  called  acute  monoarticular  gonorrhoeal  rheumatism.  In  this  affection 
there  may  be  no  premonitory  symptoms  whatever,  and  the  patient's  first 
complaint  will  be  that  his  joint  is  rather  painful  and  that  he  limps  slightly. 
In  other  cases  there  is  a  slight  chill  and  fugitive  pains  over  the  body,  with 
malaise  and  mild  fever.  These  symptoms  usher  in  the  hydrarthrosis. 
In  more  severe  cases  these  symptoms  are  much  accentuated.  I  have  seen 
cases  in  which  there  was  mild  delirium,  with  a  condition  resembling 
typhoid  fever  in  its  third  week.  Again,  I  have  seen  cases — but  rarely, 
however — in  which  the  patient  was  stupid,  dull,  heavy,  and  very  feverish 
(temp.  102°  to  105°  Fahr.),  and  presented  the  appearance  of  profound 
septic  intoxication.  The  symptoms  may,  therefore,  be  very  mild,  quite 
severe,  and  exceptionally  very  severe  and  even  grave  in  character.  The 
acme  of  the  constitutional  symptoms  is  generally  reached  Avithin  a  week. 


264  OONORBHCEA  AND  ITS  COMPLICATIONS. 

and  from  that  time  onward  they  range  in  about  the  same  degree  of 
mildness  or  severity.  Sweating,  so  common  and  so  copious  in  ordinary 
rheumatism,  is  not  observed  to  any  marked  extent  in  the  form  under 
consideration. 

In  general  terms,  it  may  be  stated  that  the  symptoms  are  rather  mild 
in  cases  of  serous  effusion,  rather  more  severe  when  the  effusion  is  sero- 
fibrinous, and  most  severe  when  it  is  sero-purulent  or  purulent. 

The  pain  in  the  joint  is  at  first  slight,  but  it  speedily  increases  in 
intensity,  particularly  if  the  patient  continues  to  go  about.  The  evidences 
of  serous  effusion  into  the  joint  are  soon  seen.  If  the  knee-joint  is 
affected,  the  patella  is  soon  elevated  above  the  level  of  the  femur,  and 
two  fluctuating  cushions  may  be  seen  on  each  side  of  its  upper  portion 
and  over  the  lower  extremity  of  the  femur,  and  two  similar  ones  on  each 
side  of  its  lower  portion  over  the  head  of  the  tibia.  The  patella  floats  in 
the  fluctuating  cushion,  and  if  pressed  downward  it  rebounds  with  a  dis- 
tinct click.  With  the  onset  of  the  effusion  heat,  redness,  and  swelling 
a,re  observed  in  the  investing  integument.  In  many  acute  cases  there  is 
no  perceptible  thickening  in  the  fibrous  structures  around  the  joint.  In 
the  chronic  form  this  extra-articular  condition  may  be  observed.  In  the 
acme  of  the  affection  the  joint  is  much  enlarged  and  distended,  the  skin 
is  red  and  tense,  and  there  is  pain  which  may  be  dull  and  continuous  or 
throbbing  and  stabbing.  In  many  cases  the  pain  is  worse  at  night.  As 
the  phlegmasia  in  the  joint  increases  the  limb  becomes  more  and  more 
immobile. 

This  monoarticular  form  of  gonorrhoeal  rheumatism  may  constitute  the 
whole  affection,  but  in  some  cases  other  joints  become  involved.  When 
the  disease  thus  spreads,  there  is  no  abatement  of  the  morbid  process  in 
the  joint  first  affected,  but  there  may  be  an  intensification  of  the  general 
symptoms.  Under  favorable  circumstances  the  acute  dropsy  of  the  joint, 
in  the  monoarticular  form,  subsides  in  from  four  to  six  Aveeks,  but  if  the 
morbid  process  is  more  severe  and  the  exudates  are  sero-fibrinous,  sero- 
purulent,  or  purulent,  then  the  duration  is  much  longer — we  may  say 
indefinite.  ~ 

Monoarticular  gonorrhoeal  rheumatism,  also  called  gonocele,  may 
begin  in  a  slow  and  subacute  manner,  and  may  then  develop  into  a 
chronic  affection.  In  this  event  the  patient  experiences  very  little  pain, 
and  only  some  inconvenience  in  walking  and  moving  the  joint.  Sooner 
or  later  he  discovers  that  the  joint  is  enlarged  and  the  seat  of  serous 
effusion.  There  is  no  extra-articular  inflammation  and  no  general  sys- 
temic reaction.  In  this  condition  the  joint  may  remain  for  many  months. 
In  some  cases  visible  improvement  may  be  noted,  which  is  usually  followed 
"by  an  exacerbation  of  a  low  grade.  In  this  way  the  case  may  hitch  and 
halt  until  inflammatory  changes  in  the  synovial  membrane  and  articular 
surface,  and  even  the  bones,  are  developed  and  arthritis  deformans 
results. 

The  less  common  form  of  gonorrhoeal  rheumatism  is  that  in  which,  as 
a  general  rule,  two  or  three,  and  exceptionally  many,  joints  are  involved, 
and  it  is  called  polyarticular  acute  gonorrhoeal  rheumatism.  The  symp- 
tom-complex of  this  form  resembles  that  of  the  monoarticular  form.  The 
course  of  this  joint  affection,  however,  is  different.  Sometimes  during  the 
course  of  the  inflammation  in  the  first  joint  a  second  one  is  attacked,  but 


GONOBRHCEAL  RHEUMATISM.  265 

there  is  usually  no  marked  amelioration  in  the  condition  of  the  first. 
With  each  joint  involvement  the  symptoms  may  undergo  an  exacerbation, 
which  is  soon  followed  by  a  remission ;  and  thus  the  case  progresses  until 
several  or  many  joints  are  involved.  Usually  the  number  of  joints  in- 
volved is  not  as  great  as  in  articular  rheumatism.  I  have,  however,  seen 
a  case  in  which  every  joint  of  the  body,  even  the  temporo-maxillarv  artic- 
ulation, was  thus  involved,  and  as  a  result  became  ankylosed. 

In  this  form  also  there  is  usually  not  the  painful  thickening  of  the 
fibrous  tissues  around  the  joint  which  is  such  a  marked  feature  of  articular 
rheumatism.  The  disproportion  between  the  general  symptoms  and  the 
joint  lesions  is  so  marked  in  gonorrhoeal  rheumatism,  and  in  such  con- 
trast with  what  occurs  in  acute  articular  rheumatism,  in  which  the  symp- 
toms are  severe  and  striking,  that  the  nature  of  the  complaint  is  readily 
determined. 

The  course  of  this  form  of  rheumatism  depends  largely  on  the  nature 
of  the  effusion  and  of  the  exudates.  If  the  lesion  is  simply  a  serous 
efiusion,  the  afi"ection  may  last  two,  three,  or  many  months.  If  it  is  sero- 
fibrinous, it  may  last  longer ;  and  if  sero-purulent  or  purulent,  the  course 
may  be  indefinite. 

Chronic  dropsy  of  the  joint,  more  or  less  disorganization,  and  even 
ankylosis,  may  result.  In  very  chronic  cases  atrophy  of  the  muscles  con- 
nected with  the  diseased  joints  may  occur. 

As  complications  of  the  polyarticular  form  of  gonorrhoeal  rheumatism 
we  sometimes  see  sclerotitis,  iritis,  aquo-capsulitis,  bursitis,  and  inflamma- 
tion of  tendinous  sheaths. 

There  are  certain  minor  forms  of  gonorrhoeal  rheumatism  which  may 
or  may  not  present  conspicuous  objective  and  subjective  symptoms. 
These  are  inflammations  of  tendinous  sheaths,  of  bursse,  of  fascige,  and  of 
the  extra-articular  structures.  The  tendinous  sheaths  may  be  aff'ected 
alone  or  synchronously  with  the  joints.  Those  most  commonly  attacked, 
are,  as  before  stated,  the  extensors  of  the  hands  and  fingers,  the  dorsal 
flexors  of  the  toes  and  the  flexor  pollicis,  the  sheaths  of  the  biceps  brachii, 
and  the  tendo  Achillis.  The  visible  signs  of  this  affection  are  redness 
and  swelling  along  the  course  of  the  tendon.  This  elongated  phlegmasia 
is  more  or  less  painful,  and  causes  more  or  less  functional  impairment  of 
the  part  aff'ected.  So  commonly  is  this  condition  due  to  gonorrhoea,  and 
so  strikingly  in  contrast  with  the  phlegmasic  non-painful  tendinitis  due  to 
syphilis,  that  its  nature  will  be  readily  perceived.  Tuberculous  inflam- 
mation of  these  structures  may  be  attended  with  an  acuteness  of  symptoms, 
objective  and  subjective,  which  may  suggest  gonorrhoea  as  their  origin. 
This  point  should  always  be  borne  in  mind. 

Inflammation  of  bursae  due  to  gonorrhoea  shows  itself,  at  first,  as  a 
localized  red  and  rather  painful  swelling  of  the  part.  If  the  affection 
becomes  chronic,  the  redness  in  a  measure  disappears  and  the  part  be- 
comes less  painful.  The  bursse  of  the  tendo  Achillis,  of  the  os  calcis,  wrist, 
ankle,  patella,  and  tuberosity  of  the  ischium,  are  the  ones  most  commonly 
attacked.     This  affection  may  be  acute,  subacute,  and  chronic  in  course. 

It  is  not  uncommon  to  find  concomitant  inflammation  of  tendinous 
sheaths  and  of  bursse  in  the  course  of  polyarticular  acute  gonorrhoeal 
rheumatism. 

Inflammation  of  the  investing  structures  of  joints,  and  sometimes  of 


266  GONORRHCEA  AND  ITS  COMPLICATIONS. 

the  ends  of  large  and  expansive  tendons,  is  a  rather  infrequent  form  of 
gonorrhoeal  rheumatism,  and  is  termed  arthralgia.  This  condition  may 
exist  alone  or  in  conjunction  with  a  more  extended  development  of  the 
disease.  It  may  attack  the  outer  surface  of  one  or  more  large  joints  in 
whole  or  in  part.  There  may  or  may  not  be  redness  and  swelling,  but 
there  commonly  is  pain  of  an  acute,  aching,  persistent  character.  The 
area  of  pain  may  be  limited  to  an  inch  or  more  of  tissue,  and  it  may  be 
extensive.  There  is  usually  an  absence  of  general  symptoms.  This  affec- 
tion may  last  several  weeks,  and  even  months,  but  it  generally  yields  to 
vigorous  counter-irritation. 

I  have  many  times  observed  in  cases  of  chronic  posterior  urethritis, 
particularly  during  or  near  an  exacerbation,  patients  complain  of  rheu- 
matic pains  in  the  large  and  small  joints,  in  the  fasciae,  and  in  diffuse 
form  in  the  muscles.  Sometimes  these  attacks  of  pain  are  not  severe,  and 
cease  in  a  short  time ;  in  other  cases  the  pain  is  severe  and  persistent. 
In  all  the  cases  there  is  little  if  any  systemic  reaction.  I  am  led  to 
suspect  that  many  cases  of  mild  and  anomalous  rheumatism  are  in  reality 
caused  by  urethral  suppuration. 

The  fasciae  involved  in  gonorrhoeal  rheumatism  are  the  palmar  and 
the  plantar,  but  cases  thus  affected  are  very  rare :  I  have  seen  one  or  two 
of  each.  During  the  course  of  polyarticular  gonorrhoeal  rheumatism  the 
fibrous  sheaths  of  muscles  and  their  fasciae  are  sometimes  attacked.  In 
old  and  broken-down  subjects,  the  victims  of  very  chronic  and  sometimes 
never-ending  gonorrhoeal  rheumatism,  after  one,  several,  or  many  of  their 
joints  have  become  ankylosed,  the  disease  goes  on  and  on,  attacking  the 
fibrous  structures  of  muscles  and  bringing  about  their  atrophy.  In  such 
cases  also  we  may  find  persistent  arthritis  of  the  bones  of  the  hands  and 
feet,  which  results  in  permanent  disfigurement  and  sometimes  great  de- 
formity. 

In  some  cases  of  chronic  gonorrhoeal  rheumatism  sciatica,  mild  or 
severe,  may  occur,  as  pointed  out  by  Fournier,^  and  in  these  cases  peri- 
ostitis may  sometimes  be  observed. 

Martel  ^  describes  as  a  rare  complication  of  gonorrhoeal  rheumatism  a 
phlebitis  of  the  saphenous,  femoral,  and  iliac  veins,  which  may  undergo  res- 
olution or  lead  to  their  obliteration. 

The  eye  and  heart  complications  of  gonorrhoeal  rheumatism  are  de- 
scribed elsewhere. 

Diagnosis. — In  many  cases  the  existence  of  a  gonorrhoea  or  the  history 
of  a  comparatively  recent  attack  will  suggest  the  nature  of  the  case  under 
observation.  In  the  main,  the  absence  of  sweating  and  the  comparatively 
mild  systemic  reaction  (in  the  majority  of  cases)  will  suggest  gonorrhoea 
as  the  cause  of  the  rheumatism.  Then  the  predilection  of  the  disease 
to  attack  the  larger  joints,  particularly  of  the  knee,  ankle,  wrist,  and 
shoulder,  and  to  only  invade  one,  two,  or  three  joints,  is  indicative  of  gon- 
orrhoea as  its  cause.  Hydrarthosis  is  common  in  gonorrhoeal  rheumatism, 
and  is  infrequent  and  slight  in  the  ordinai-y  form  of  the  disease.  The 
absence  of  a  history  of  rheumatism  is  also  significant  of  urethral  suppura- 

^  "  De  la  Sciatique  blennorrhagique,"  Bull,  et  Memoir es  de  la  Societe  med.  des  Hop.  de 
Paris,  1869,  vol.  v.  pp.  34  et  seq. 

^  "  De  la  Phldbite  dans  le  Cours  du  Ehumatisme  blennorrhagique,"  27iese  de  Paris, 
1887. 


GONORRHCEAL  RHEUMATISM.  267 

tion  as  a  cause.  The  coincident  involvement  of  tendinous  sheaths,  fascise, 
and  bursse,  with  perhaps  the  iris  and  conjunctiva,  is  a  strong  point  against 
the  case  being  one  of  ordinary  inflammatory  rheumatism. 

In  any  case  of  doubt  careful  examination  of  the  urine  should  be  made, 
and  if  threads  largely  composed  of  pus-cells  are  found,  the  investigation 
should  be  pushed  in  the  direction  of  gonorrhoeal  rheumatism.  In  all  cases 
of  obscure  localized  chronic  rheumatism  of  the  extra-articular  structures, 
fascige,  tendinous  sheaths,  and  bursse,  a  suspicion  of  urethral  suppuration 
should  be  entertained  and  followed  up. 

Prognosis. — In  all  cases  of  involvement  of  the  larger  joints  by  inflam- 
matory eftusion  the  patient  is  a  lucky  man  if  he  is  well  on  his  feet  in  six 
weeks  or  two  months.  When  several  joints  are  involved  the  illness  will 
be  still  further  protracted,  and  when  the  morbid  process  gives  rise  to  sero- 
fibrinous or  sero-purulent  efi"usion  the  course  of  the  case  may  be  protracted 
for  several  or  many  months.  In  the  more  localized  forms  of  gonorrhoeal 
rheumatism  Avithout  much  systemic  reaction,  involving  the  extra-articular 
structures,  the  tendinous  sheaths,  fasciae,  and  bursse,  one,  two,  or  three, 
and  even  more,  months  may  elapse  before  the  patient  is  well  and  free  from 
pain.  In  many  cases  the  cure  is  largely  dependent  on  the  efiiciency  and 
vigor  of  the  treatment  adopted. 

Treatment. — The  golden  rule  in  the  treatment  of  all  cases  of  gonor- 
rhoeal rheumatism  is  to  cure  the  inflammation  in  the  urethra,  since  that  is 
the  source  and  origin  of  the  disease.  If  the  suppuration  is  subacute  or 
chronic,  it  must  be  treated  accordingly,  conforming  to  the  directi(ms  already 
given.  Antiblennorrhagics  have  no  perceptible  effect  in  these  cases.  In 
general,  very  mild  nitrate-of-silver  irrigations,  thrown  into  the  posterior 
urethra,  are  suitable  for  subacute  cases  of  urethral  inflammation,  and  more 
concentrated  solutions  by  instillation  in  chronic  cases.  It  is  wonderful  to 
see  the  marked  eff"ect  amelioration  of  the  urethral  inflammation  has  upon 
the  course  of  its  resulting  rheumatism. 

When  joints  are  involved,  the  patient  must  at  once  be  placed  on  his 
back  and  the  part  put  at  rest.  When  there  is  much  heat,  redness,  and 
swelling  of  the  joint,  cooling  applications,  such  as  ice-bags,  solution  of 
muriate  of  ammonia,  and  lead-and-opium  wash,  may  be  used.  In  plethoric 
subjects  temporary  ease  may  be  obtained  by  the  use  of  leeches.  In  some 
cases  a  flaxseed  poultice  in  which  laudanum  has  been  mixed  gives  com- 
fort. In  every  case  the  patient  should  receive  (unless  contraindicated) 
enough  opium  or  morphine  to  make  him  comfortable.  This  agent  rarely 
fails  to  give  relief,  but  we  may  use  antipyrine  or  phenacetin.  Salol,  sali- 
cylate of  sodium,  muriate  of  ammonia,  nitrate  of  potash,  oil  of  wintergreen, 
colchicum,  iodide  of  potassium,  and  quinine  may  be  used  in  appropriate 
doses.  If  these  agents  have  any  therapeutic  eff'ect  on  this  boxed-up  infec- 
tive process  in  the  joint,  it  is  well;  but,  to  say  the  least,  they  often  do. 
exert  a  moral  eff'ect  upon  the  patient,  who  feels  that  he  is  taking  medicine, 
and  therefore  doing  all  he  can  do  in  that  direction. 

With  the  decline  of  the  acuteness  of  the  joint  inflammation  much  val- 
uable aid  can  be  given  to  the  case  by  very  active  blistering  of  the  joint. 
This  may  be  done  by  the  application  of  cantharidal  collodion  or  a  fly 
blister  spread  on  sheep-skin.  The  fully-developed  blister  must  be  kept 
"open"  by  means  of  savin  or  tartar-emetic  ointment.  If  healing  of  the 
skin  takes  place,  the  blister  must  be  applied  again  in  the  same  vigorous 


268  GOXORBHCEA  AXD  ITS  COMPLICATIONS. 

maDner.  A  little  opium  is  a  great  help  in  keeping  the  patient's  courage 
up  while  he  is  undergoing  this  persistent  blistering  process.  "When  blisters 
fail  to  cause  the  hydrarthrosis  to  subside,  it  may  be  necessary  to  draw  off 
the  contained  fluid  and  to  irrigate  the  joint  with  sublimate  solution, 
2  :  5000,  or  carbolic  acid  and  water,  1 :  50.  Reaccumulation  of  the  fluid 
demands  a  repetition  of  the  process. 

In  all  of  the  phlegmasiae  produced  by  gonorrhoea!  rheumatism  the 
general  scheme  of  treatment  just  outlined  should  be  followed.  Over 
limited  patches  and  areas  of  a  subacute  or  chronic  nature  strong  tincture 
of  iodine  or  pure  ichthyol  may  be  applied.  In  chronic  cases,  particularly 
those  in  which  the  joint-cavity  is  not  involved,  I  have  seen  good  results 
follow  the  liberal  internal  use  of  iodide  of  potassium.  Indeed,  in  several 
cases  in  which  there  was  absolutely  no  history  of  syphilis  I  have  seen 
marked  benefit  follow  the  use  of  the  mixed  treatment  in  combination 
with  stroncr  mercurial  inunctions  and  of  mercurial  fumigations.  In  two 
cases  of  gonorrhoeal  rheumatism  of  the  bursje  in  front  of  the  tendo  Achil- 
lis  I  produced  a  prompt  cure  by  the  injection  of  fifteen  drops  of  a  5  per 
cent,  watery  solution  of  carbolic  acid.  This  treatment  may  be  used  in 
all  limited  bursal  and  fascial  inflammations  due  to  gonorrhoea. 

Paquelin's  cautery,  applied  to  limited  spots,  sometimes  tends  to  pro- 
mote resolution.  In  chronic  cases  mild  (never  severe)  massage  is  some- 
times surprisingly  beneficial.  In  all  chronic  cases,  where  practicable, 
pressure  to  the  extent  of  tolerance  should  be  applied  to  the  parts  by 
means  of  elastic  bandages.  India-rubber  adhesive  plaster,  or  plaster-of- 
Paris  splints.  When  suppuration  and  destruction  or  ankylosis  of  joints 
occurs,  the  cases  are  to  be  treated  on  general  surgical  principles. 

Since  in  many  cases  of  chronic  gonorrhoeal  rheumatism  there  is  a 
synchronous  general  cachexia,  tonics  should  be  given,  change  of  air 
ordered,  and  general  restorative  means  adopted. 


CHAPTER    XXV. 

PERITONITIS  IX  THE  MALE  DUE  TO  GOXORRHCEA. 

IxFLAMMATiON  of  the  peritoneum  of  greater  or  less  severity  may 
result  from  the  extension  of  the  gonorrhoeal  process  from  some  part  of 
the  seminal  apparatus  to  that  portion  of  the  membrane  in  close  contiguity 
with  it. 

Gonorrhoeal  peritonitis  may  be  developed  by  acute  inflammation  of 
the  seminal  vesicles.  The  infectious  process  then  begins  in  the  recto- 
vesical cul-de-sac,  where  it  may  localize  itself,  or  it  may  spread  indef- 
initely from  that  morbid  centre. 

Gonorrhoeal  inflammation  of  the  vas  deferens  or  of  a  limited  segment 
thereof  may  be  the  cause  of  peritonitis,  owing  to  the  fact  that  these  ana- 
tomical structures  are  for  a  considerable  distance  in  direct  contact  with 
each  other. 


PERITONITIS  IN  THE  MALE  DUE  TO   GONORRHCEA.  269 

ZeissP  claims  that  inflammations  of  the  lumbar  ganglia  (which  are 
situated  immediately  behind  the  peritoneum),  due  to  the  extension  of  the 
gonorrhoeal  process,  may  also  be  the  cause  of  peritonitis  from  contiguity. 

We  have  already  seen  that  during  the  course  of  gonorrhoea  a  limited 
portion  of  the  vas  deferens  might  become  swollen  and  painful  and  cause 
fear  of  peritoneal  involvement.  In  these  cases,  however,  the  deep  pelvic 
or  iliac  pain  usually  ceases  when  the  epididymis  becomes  swollen,  as  it 
usually  does.  In  the  majority  of  reported  cases  epididymitis  and  peri- 
tonitis had  existed  at  the  same  time.  Consequently,  the  testicular  in- 
flammation may  often  be  an  important  diagnostic  guide. 

Patients  attacked  by  gonorrhoeal  peritonitis  commonly  complain  of 
colic  at  first,  and  soon  direct  attention  to  the  tenderness  in  one  of  the 
iliac  fossae  or  of  the  groin.  With  the  extension  of  the  process  the  Avhole 
hypogastrium  may  become  swollen  and  tender,  and  from  that  the  whole 
abdominal  cavity  may  be  attacked.  The  symptoms  are  rapid  and  small 
pulse,  increased  respiration,  and  high  fever.  The  pain  is  intense,  par- 
ticularly on  pressure,  and  causes  the  patient  to  have  a  sallow,  drawn,  and 
anxious  facies.  There  may  be  obstinate  constipation,  and  exceptionally 
diarrhoea.  In  many  cases  vomiting,  particularly  of  bile,  has  been  ob- 
served. There  is  usually  much  distention  of  the  abdomen.  In  this  Avay 
the  disease  may  run  on  and  end  in  recovery,  but  a  survey  of  the  literature 
shows  that  in  many  instances  death  has  ensued. 

In  many  cases  rectal  exploration  reveals  marked,  even  intense,  ten- 
derness or  pain  in  the  prostate  and  seminal  vesicles. 

Horowitz^  reports  a  case  in  which  there  was  inflammation  of  the  left 
epididymis,  prostatitis,  inflammation  of  the  seminal  vesicles,  and  swelling 
of  a  considerable  portion  of  the  left  spermatic  cord,  which  was  complicated 
by  peritonitis.     In  this  case  recovery  took  place. 

According  to  Zeissl,  Wendelin  observed  a  case  in  which  there  was  much 
swelling  of  the  vas  deferens,  together  with  peritonitis,  Avhich  ran  such  a 
severe  course  that  perforation  of  the  bladder  and  rectum  occurred,  and 
death  followed. 

Faucon  ^  relates  a  case  of  epididymitis  in  which  there  were  severe  gen- 
eral symptoms,  together  with  a  swelling  at  the  internal  abdominal  ring 
which  extended  to  the  spine  of  the  ilium.  It  Avas  regarded  as  a  sub- 
peritoneal phlegmon,  and  was  incised,  but  no  pus  was  let  out.  Recovery 
took  place. 

Peter*  reports  a  fatal  case,  with  the  post-mortem  findings,  which  is 
interesting.  The  patient  was  a  boy  sixteen  years  old  who  had  gonorrhoea 
and  epididymitis.  He  was  attacked  by  the  usual  symptoms  of  acute  peri- 
tonitis, which  eventuated  in  death.  At  the  autopsy  diaphragmatic  pleurisy, 
general  peritonitis,  and  engorgement  of  the  liver  and  spleen,  were  found. 
The  urethra  was  red  in  its  anterior  part,  pale  in  the  posterior.  The  right 
seminal  vesicle  was  healthy,  but  the  left  was  swollen  and  contained  pus. 
The  surrounding  cellular  tissue  was  red  and  swollen,  and  the  peritoneum 

^  "Peritonite  causae  chez  I'Homme  par  Ur^thrite  blennorrhagique,"  Annales  des  Mai. 
des  Org.  Oen.-urin.,  1893,  vol.  xi.  pp.  481  et  seq. 

^  "  Ueber  Gonorrhoische  Peritonitis  beim  Manne,"  Wiener  med.  Wochenschrlft,  1892, 
Nos.  2  and  3. 

^  "  De  la  Peritonite  et  dii  Phlegmon  sous-peritoneal  d'origine  blennorrhagique,"  Arch, 
gen.  de  Med.,  1877.  vol.  ii.  pp.  385  and  545. 

*  L'  Union  medicale,  1856,  xso.  141,  p.  562. 


270  GONORRHCEA  AND  ITS  COMPLICATIONS. 

in  conticfuity  with  it  was  strongly  hyperamic.  The  left  vas  deferens  was 
swollen,  and  in  intimate  contact  with  the  peritoneum  which  surrounded  it. 

It  is  evident  that  in  this  case  the  infection  of  the  peritoneum  took 
place  through  the  seminal  vesicle  and  vas  deferens. 

Treatment. — The  patient  must  be  put  to  bed  as  soon  as  the  prodromal 
pains  are  felt.  If  he  is  of  vigorous  build,  leeches  may  be  applied  over 
the  painful  part.  Then  hot  poultices  must  be  kept  continuously  over  the 
abdomen.  Opium  should  be  given  internally,  and  all  symptoms  treated 
according  to  their  indications. 


CHAPTER    XXYI. 

CARDIAC  AFFECTIONS  AND  PYEMIA. 

Cardiac  Affections. 

So  many  well-attested  cases  have  been  reported,  particularly  within  the 
past  ten  years,  in  which  cardiac  lesions  of  varying  degrees  of  severity  have 
developed  during  the  course  of  acute  and  chronic  gonorrhoea  that  there  is 
now  no  longer  any  doubt  of  their  origin  in  this  virulent  infectious  process. 
Cardiac  complications  of  gonorrhoea,  however,  are  very  rare,  since  in  all 
less  than  fifty  cases  have  been  reported.  The  male  sex  seems  to  be  the 
one  most  liable  to  heart  complications  during  gonorrhoea,  for  there  are 
only  two  instances  on  record  in  which  they  occurred  in  women.  In  the 
majority  of  cases  cardiac  lesions  are  associated  Avith  or  follow  gonorrhceal 
rheumatism  as  complications  of  gonorrhoea. 

The  fibrous  and  serous  structures  of  the  heart  are  the  parts  primarily 
attacked,  the  endocardium  most  frequently,  and  the  pericardium  in  a 
smaller  percentage  of  cases. 

The  essays  of  Marty  ^  and  Gluzinski^  show  very  clearly  that  there  are 
some  cases  in  which  the  symptoms  are  comparatively  mild,  and  in  which 
recovery,  though  in  most  cases  with  impaired  heart,  may  occur.  In  such 
cases  the  patients  complain  of  a  "  stitch  "  in  the  left  chest  and  palpitation 
of  the  heart,  whose  action  is  accelerated  and  increased.  Sometimes  a 
slight  pericardial  crepitant  rale  may  be  heard.  In  the  mild  endocardial 
form  we  find  palpitations,  the  prolongation  of  the  first  sound,  with  rough- 
ness and  frequency  of  the  pulse.  There  may  be  prsecardial  dulness  and 
distress,  and  hruit  de  souffle  at  the  base  with  the  first  sound.  Soft  blow- 
ing murmurs  are  sometimes  heard  at  the  apex.  It  is  thought  that  the 
aortic  valves  are  more  commonly  attacked  than  the  mitral. 

In  some  of  these  milder  forms  of  cases  the  cardiac  complication  maybe 
ushered  in  by  rigors,  fever,  and  intense  headache,  which  are  soon  followed 
by  dyspnoea,  palpitations,  and  the  symptoms  given  above.     MacDonnell^ 

1  "  De  I'Endocardite  blennorrhagique,"  Arch.  gen.  de  Med.,  vol.  ii.,  1876,  pp.  66  et  seq. 

2  Epitomized  from  the  Eussian  in  British  Med.  Journal,  May  11,  1889,  p.  1084. 

^  "  Cardiac  Complications  in  Gonorrhceal  Eheumatism,"  Am.  Journ.  Med.  Sciences,  Jan., 
1891,  pp.  1  et  seq. 


CARDIAC  AFFECTIONS  AND  PYEMIA.  271 

reports  an  interesting  case  of  peri-  and  endocarditis  in  which  pleurisy  with 
efiusion  was  a  further  complication.  Recovery,  however,  took  place,  but 
the  patient  was  left  with  a  persistent  mitral  murmur. 

The  possibility  of  the  onset  of  cardiac  trouble  in  patients  suffering 
from  o-onorrhoea  should  be  kept  in  mind  by  the  surgeon,  and  if  found  the 
patient  should  at  once  be  put  to  bed  and  properly  cared  for.  Gluzinski 
verv  pertinently  remarks  that  in  these  mild  cases  the  patient  may  still 
keep  on  his  feet  despite  the  cardiac  lesion,  and  that  he  is  thereby  much 
exposed  to  heart  failure. 

There  are  about  ten  cases  on  record  in  which  malignant  endocarditis 
and  pvoemia  developed  as  a  result  of  gonorrhoeal  infection.  In  these 
cases  the  onset  was  sudden  and  severe,  and  attended  with  chills,  high 
fever,  and  evidence  of  profound  sickness. 

The  details  of  two  cases  will  give  a  tolerably  clear  idea  of  the  very 
grave  form  of  heart  troubles  following  gonorrhoea : 

In  Weichselbaum's  ^  the  patient  had  acute  enlargement  of  the  spleen, 
gonorrhoea  (with  gonococci-containing  pus)  of  three  weeks'  duration, 
and  endocarditis,  from  which  he  died.  At  the  autopsy  the  aortic  valves 
were  found  to  be  eroded  and  covered  with  a  grayish  and  reddish-white 
mass  of  vegetations.  There  was  loss  of  substance  in  the  mitral  valve 
and  perforation  through  the  wall  of  the  aorta  to  the  tricuspid  valve. 
The  streptococcus  pyogenes  was  found  in  the  vegetations,  and  was  culti- 
vated artificially. 

Ely's  ^  case  was  that  of  a  man  of  twenty-eight  Avho  had  a  urethral  dis- 
charge, and  entered  the  hospital  in  a  stupid  condition.  His  temperature 
was  105.8°  Fahr.,  and  pulse  130.  He  became  very  restless,  vomited, 
and  passed  urine  and  faeces  involuntarily.  He  was  attacked  with  partial 
hemiplegia,  failed  rapidly,  and  died.  At  the  autopsy  the  brain,  liver,  - 
and  lungs  were  found  to  be  congested,  the  spleen  large  and  soft  and  the 
seat  of  infarctions,  and  the  kidneys  large  and  studded  with  embolic  foci. 
The  aortic  valves  were  normal,  but  the  mitral  valves  had  recent  vegeta- 
tions along  the  margins.  Microscopical  examination  of  the  mitral  valve 
showed  recent  infiltration  of  the  substance  of  the  valve  with  small  round- 
cells  and  fibrin,  together  wdth  erosions  of  the  surface,  which  w^ere  covered 
with  fibrin  and  teeming  with  micro-organisms,  the  principal  of  which 
were  the  staphylococcus  pyogenes  aureus  and  the  streptococcus  pyogenes. 
The  pus  from  the  urethra  showed  diplococci  which  resembled  gonococci, 
and  a  large  number  of  other  micrococci. 

Schedler^  has  reported  a  case  of  malignant  endocarditis  following 
gonorrhoea,  in  which  joint-complications  first  developed,  and  later  on 
were  followed  by  the  heart  affection  and  death. 

Thus  we  see  that  a  very  grave,  even  deadly,  form  of  endocarditis  is 
a  very  rare  complication  of  gonorrhoea.  In  these  cases,  though  the 
heart  affection  is  a  very  prominent  feature,  the  essential  morbid  condition 
is  really  pysemia. 

This  grave  disorder  seems  to  be  caused  by  the  pyogenic  microbes 
staphylococcus  and  streptococcus.     Much  has  yet  to  be  learned  as  to  the 

^  "Zur  Aetiologie  der  Aciiten  Endocarditis,"  Centralbl.  filr  Bacteriol.  und  Parasitenk., 
vol.  ii.,  1887,  pp.  209  et  seq. 

^  Proceedings  of  the.  N.  Y.  Patholofj.  Society,  for  1888,  pp.  155  et  seq. 

^  "  Zur  Casuisiik  der  Herzaff'ectionen  nach  Tripper,"  Inaug.  Dissert.,  Berlin,  1880. 


272  GONORRHCEA   AND  ITS  COMPLICATIONS. 

pathology  of  these  cases  and  of  the  role  of  the  gonococcus  and  pyogenic 
microbes.  The  most  concise  statement  that  can  now  be  made  is  that  they 
are  the  result  of  mixed  infection. 

The  prognosis  in  all  these  cases  is  grave. 

The  treatment  must  be  based  on  the  indications  presented. 

Pyaemia. 

Besides  the  cases  of  endocarditis  and  pericarditis  which  have  their 
origin  in  urethral  suppuration,  there  are  a  number  of  cases  of  pyaemia, 
in  some  of  which  there  were  heart-complications,  on  record,  in  which  the 
infection  was  derived  from  pus-foci  near  the  urethra.  Thus,  Besan^on  ^ 
reports  two  cases,  in  one  of  which  the  suppuration  was  in  the  seminal  duct 
and  the  epididymis,  and  in  the  other  in  abscess  of  the  neck  of  the  bladder 
behind  old  strictures. 

Lancereaux  reports^  two  cases — one  in  which  the  infection  was  de- 
rived from  the  prostate,  and  in  the  other  from  the  testicle.  I  had  under 
my  care  a  man  who  died  from  pyaemia  following  acute  abscess  of  the 
prostate,  which  the  attending  physician  had  failed  to  incise.  There  are  a 
number  of  similar  cases  reported,  particularly  in  Continental  medical 
journals. 

Roswell  Park,  in  an  interesting  essay,^  reports  the  case  of  a  man  who, 
following  gonorrhoea,  had  suppuration  of  the  knee-joints  and  typhoidal 
symptoms,  with  high  fever,  which  resulted  in  death. 

Classen*  reports  a  similar  case  of  a  man  thirty-two  years  old  who, 
after  suffering  for  some  time  with  gonorrhoeal  rheumatism,  was  attacked 
by  severe  chills  followed  by  profuse  sweating,  great  thirst,  accelerated 
respiration,  anorexia,  together  with  a  temperature  of  104°  and  106°  Fahr. 
Death  occurred  at  the  end  of  a  month. 

Pyaemia  may  also  occur  as  a  result  of  gonorrhoea  in  the  female  sex. 

Hutchinson^  reports  in  a  clinical  lecture  the  case  of  a  young  woman 
who  presented  typhoidal  symptoms,  together  with  pleurisy  and  bronchitis. 
The  source  of  the  infection  was  found  in  a  profuse  purulent  vaginitis  of 
gonorrhoeal  origin.  This  woman  later  on  developed  abscesses,  but  finally 
recovered. 

According  to  Post,^  Delafield  has  seen  the  case  of  a  prostitute  who, 
while  suffering  from  gonorrhoeal  vaginitis  and  cystitis,  was  attacked  by 
rigors  and  febrile  movement,  which  rapidly  passed  into  a  typhoid  condi- 
tion, which  ended  in  death.  At  the  autopsy  acute  cystitis,  pyelitis,  and 
numerous  small  abscesses  in  both  kidneys  were  found.  A  somewhat 
similar  case  is  reported  by  Murchison.^ 

Bryant  ^  reports  the  case  of  a  man  suffering  from  urethral  stricture,  in 

^  "  Endocardite  ulcereuse  a  point  de  depart  genital  chez  I'Homme,"  L'  Union  Med., 
1886,  Nos.  ]  00  and  101. 

■■^  "Endocardite  a  point  depart  genital  chez  I'Homme,"  ibid.,  No.  100. 

^  "Pysemia  as  a  Sequel  of  Gonorrhoea,"  Journ.  Cuian.  and  Gen.-urin.  Diseases,  vol.  vi., 

i,  pp.  441  et  seq. 

^  "  Pysemia  as  a  Sequel  of  Gonorrhnea,"  Albany  Med.  Annals,  vol.  xi.,  March,  1890,  p. 


51. 


Philadelphia  Med.  and  Surg.  Reporter,  Feb.,  1876,  pp.  105  et  seq. 
®  "  Deaths  from  Gonorrhoea,"  Boston  Med.  and  Surg.  Journal,  May  5,  1887. 
'  Transaction'^  of  Clinical  Society  London,  vol.  ix.,  1879. 
"  New  York  Med.  Journal,  April  8,  1887,   pp.  372  et  seq. 


AFFECTIONS   OF  THE  SPINAL   CORD.  273 

which  five  abscesses  seated  on  the  thigh,  iliac  crests,  and  near  the  axilla 
followed  gradual  dilatation.  I  have  seen  a  case  in  which  an  abscess  of 
the  right  sterno-clavicular  articulation  appeared  during  the  treatment  of  a 
urethral  stricture  by  gradual  dilatation.  Such  complications  are,  however, 
exceedingly  rare. 

It  is  well  to  remember  the  old-time  cases  reported  by  Yoillemier  and 
Villeneuve,  in  which  patients  suffering  from  acute  gonorrhoea  "broke" 
their  chordee  and  developed  generalized    pyaemia,  which  caused  death. 

Several  years  ago  I  had  under  observation  a  case  of  chronic  pygemia 
due  to  an  abscess  at  the  side  of  the  bulb,  which  had  developed  as  a  result 
of  a  tight  stricture  just  anterior  to  the  part.  For  nearly  a  year  the 
patient  suffered  from  irregular  and  erratic  chills  and  fever,  which  were 
sometimes  mild  and  again  severe.  Nothing  then  was  known  of  a  urethral 
lesion,  for  the  patient  made  no  mention  of  such  trouble,  and  quinine  and 
Warburg's  tincture  were  given  in  large  doses  without  any  result.  The 
perineal  abscess  led  to  exploration  of  the  urethra  and  the  discovery  of  a 
very  tight  stricture.  I  performed  external  urethrotomy,  and  the  patient 
has  since  remained  well. 

A  study  of  the  various  cases  of  pyjemia  following  gonorrhoea  shows 
that  some  are  mild  in  character  and  end  in  recovery,  whilst  others  are  of 
a  malignant  type  and  end  in  death. 


CHAPTER    XXVII. 

AFFECTIONS  OF  THE  SPINAL  CORD. 

Within  a  few  years  cases  have  been  reported  in  which  there  was 
inherent  evidence  that  certain  spinal  affections  and  symptoms  had  their 
origin  in  urethral  gonorrhoea.  Such  a  pathological  relation  is  claimed  by 
Hayem^  and  Parmentier,  who  report  two  cases  in  which  spinal  symptoms 
supervened  upon  gonorrhoea!  rheumatism,  in  one  case  coincidently  with 
a  severe  attack  of  gonorrhoeal  inflammation  of  many  of  the  joints.  Dorso- 
lumbar  pain,  girdle  pain  around  the  lower  part  of  the  chest,  lightning 
pains  in  the  lower  limbs,  extreme  hyperaesthesia,  motor  paresis,  exaggera- 
tion of  the  reflexes,  and  epileptoid  trepidation  were  observed.  These 
symptoms,  referable  to  disease  of  the  cord  and  its  meninges,  recurred 
severely  on  these  occasions  coincidently  with  the  articular  lesions  and  the 
recurrence  of  the  gonorrhoeal  discharge.  In  the  second  case  in  the  second 
week  of  acute  gonorrhoea  the  patient  was  attacked  with  pain  in  the  region 
of  the  crural  nerves,  doul)le  hydrarthrosis,  tarsal  and  tibio-tarsal  arthritis, 
pains  in  the  head,  lightning  pains,  exaggeration  of  knee-jerks,  epileptoid 
trepidation,  tremor  and  spasm  of  the  limb  when  the  foot  was  placed  on 

^  "  Contribution  a  I'Etude  des  Manifestations  spinales  de  la  Blennorrhagie,"  Ptev.  de 
Med.,  Paris,  1888,  viii.,  pp.  433  et  seq. 

18 


274  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

the  ground,  muscular  weakness,  and  dorso-lumbar  pains,  followed  by 
muscular  atrophy. 

These  authors  refer  to  a  case  of  double  sciatica  following  gonorrhoea, 
reported  by  M.  Peter,  and  to  a  case  of  paraplegia  of  similar  sequence 
reported  by  Tixier,  and  another  by  Stanley,^  as  belonging  to  the  same 
class.  They  are  emphatic  in  their  opinion  that  gonorrhoea,  like  other 
infectious  diseases,  may  cause  affections  of  the  spinal  cord  in  the  form  of 
congestion  and  a  meningo-myelitis  involving  more  or  less  of  the  lateral 
and  posterior  portions  of  the  cord. 

Chavier  and  Fevrier^  report  a  case  similar  to  the  foregoing  of  a  soldier 
who  suffered  from  hypergesthesia  of  the  skin  and  involuntary  movement 
of  the  right  upper  and  lower  extremities  following  gonorrhoea.  The 
lower  part  of  the  spinal  column  and  the  sciatic  nerves  were  the  seat  of 
severe  pain,  the  lower  extremities  were  paretic,  the  reflexes  were  exag- 
gerated, and  there  was  slight  fever.  There  was  also  pain  in  the  left  knee 
and  hip,  with  atrophy  of  the  muscles  and  joint  structures.  A  cure  is  said 
to  have  been  produced  in  a  month. 

Jaroschewski^  reports  a  case  of  gonorrhoeal  rheumatism  which  was 
complicated  by  marked  atrophy  of  the  gastrocnemii  muscles,  exaggeration 
of  the  patellar  reflexes,  and  foot-clonus.  This  patient  had  previously 
suffered  from  mild  aphonia,  hemicrania,  and  diabetes  insipidus.  Jaros- 
chewski  thinks  that  in  cases  of  involvement  of  the  spinal  cord  by  gon- 
orrhoea thei'e  is  a  predisposition  of  the  nervous  system  to  inflammation 
— a  condition  of  locus  minoris  resistentioe. 

Dufour*  reports  the  case  of  a  young  man  who  in  the  third  month  of 
gonorrhoea  was  attacked  by  violent  pains  in  the  lumbar  region,  which 
lasted  for  a  day,  and  were  followed  by  a  tingling  sensation  in  the  lower 
extremities,  diminution  in  power  and  motility,  and  soon  after  complete 
paraplegia.  There  were  also  paralysis  of  the  bladder,  rectal  incontinence, 
and  exaggeration  of  the  patellar  reflexes.  Later  on  there  was  loss  of 
sensibility  of  the  lower  extremities,  which  were  the  seat  of  reflex  shocks. 
General  atrophy  of  muscles  and  lightning-like  pains  also  developed.  Death 
occurred  in  a  crisis  of  dyspnoea. 

A  study  of  the  various  published  cases,  according  to  Dufour,  shows 
many  clinical  differences.  The  lesion  in  the  medulla  varies  in  its  seat, 
its  gravity,  and  its  tendency  to  extension.  The  symptoms  are  mainly 
those  of  motility  and  sensibility,  and  they  may  be  mild  or  severe.  The 
most  common  clinical  picture  is  that  of  dorso-lumbar  myelitis,  partial  or 
diffuse,  acute  or  subacute,  with  moderate  fever,  pains  in  the  spinal  cord, 
girdle  pains,  tingling  sensations,  muscular  shocks  or  spasms  in  the  lower 
limbs,  rapid  loss  of  sensibility  and  motility,  troubles  in  urination  and 
defecation,  and  some  trophic  troubles.  The  course  is  that  of  all  infectious 
myelites,  and  the  prognosis  is  death  in  one-third  of  all  cases. 

The  lesion  is -due  to  microbic  infection  primarily  of  the  fibrous  struc- 
tures of  the  coverings  of  the  spinal  cord. 

We  have  no  knowledge  as  yet  as  to  the  part  played  by  the  gonococcus 

'  Med.-Chir.  Transactions,  1856. 

2  "  Manifestations  spinales  de  la  Blennorrhagie,"  Revue  de  Med.,  1888,  viii.,  pp.  1020 
et  seq. 

^  "  Ein  Fall  von  blennorrhoischen  Eheiimatisnius  mit  nachfolgenden  spinalen  symp- 
tomen,"  St.  Petersburg  med.  Wochensckr.,  1890,  No.  5. 

*  "  Des  Meningo-myelites  blennorrhagiques,"  These  de  Paris,  1890. 


CUTANEOUS  AFFECTIONS.  275 

in  this  formidable  affection,  nor  do  we  know  that  it  is  in  any  way  caused 
by  a  mixed  infection.  We  have  no  knowledge  of  the  involvement  of  the 
cerebral  meninges  by  the  gonorrhoeal  process. 

Panas^  reports  the  case  of  a  man  in  the  declining  stage  of  gonor- 
rhoea who  after  exposure  to  cold  had  a  severe  chill  followed  by  headache 
lasting  for  ten  days,  and  the  loss  of  the  sight  of  one  eye.  Severe  optic 
neuritis,  passing  to  atrophy,  was  found  in  the  blind  eye,  and  mild  neuritis 
in  the  opposite  one.  Panas  thinks  that  the  trouble  began  in  meningitis, 
and  then  spread  to  the  roots  of  the  optic  nerves,  and  that  it  was  of  gonor- 
rhoeal origin. 


CHAPTER    XXVIII. 

CUTANEOUS  AFFECTIONS. 

Within  the  past  twenty-five  years,  and  particularly  within  the  past 
ten  years,  many  authors,  notably  in  France,  have  written  essays  in 
which  cases  of  gonorrhoea  complicated  with  acute  skin  eruptions  have 
been  reported.  As  a  result  of  these  contributions  it  is  quite  widely  con- 
ceded that  gonorrhoeal  infection  may  give  rise  to  dermal  inflammation. 
Such  a  proposition  carries  with  it  nothing  of  a  startling  character,  now 
that  we  know  that  the  infectious  agent  of  the  disease,  its  morbid  secretions 
or  toxines,  together  with  other  pyogenic  microbes,  can  be  directly  absorbed 
into  the  circulation.  The  only  singular  part  of  this  question  is  that  so 
many  careful  observers  who  have  seen  and  studied  a  vast  number  of  cases 
of  gonorrhoea  have  lived  and  died  and  have  never  mentioned  having  seen 
a  case.  I  have  many  times  seen  patients  suffering  from  acute  and  de- 
clining gonorrhoea  who  have  been  attacked  by  eruptions  resembling  scar- 
latina, measles,  oedematous  erythema,  and  urticaria,  and  in  some  instances 
I  have  failed  to  find  that  gastric  disorder  produced  by  antiblennorrhagics 
has  been  the  exciting  cause.  In  my  experience,  copaiba,  cubebs,  and  oil 
of  santal-wood  are  the  most  common  causes  of  skin  affections  during 
gonorrhoea. 

Perrin,^  in  an  essay  in  which  he  analyzes  the  recorded  cases,  and  from 
which  the  reader  can  obtain  the  bibliography  of  the  subject,  reports  a 
case  in  which  a  scarlatiniform  eruption  occurred  in  a  gonorrhoea  patient 
who  had  not  taken  antiblennorrhagics.  Other  cases  have  been  reported 
by  Besnier,  Klippel,  Mesnet,  Andret,  and  others.  Some  of  these  cases 
seem  convincing,  while  in  others  the  statement  that  the  patient  had  taken 
copaiba,  cubebs,  and  oil  santal  several  days  before  the  onset  of  the  erup- 
tion gives  rise  to  doubt. 

Several  cases  have  been  reported  in  which  purpura  was  said  to  have 

^  "  N^vrite  Optique  blennorrhagique,"  La  Semaine  medicale,  1890,  p.  477. 
^  "  Des  Determinations  cutanees  de  la  Blennorrhagie,"  Annales  de  Dermal,  et  de  Syphil., 
1890,  pp.  773  and  859  et  seq. 


276  GONOEBHCEA  AND  ITS  COMPLICATIONS. 

been  produced  by  gonorrhoea.  Their  details,  however,  do  not  carry  abso- 
lute conviction  with  them,  since  the  exclusion  of  other  infections  is  not 
clearly  made  out.  Finger  ^  reports  three  cases  in  which  gonorrhoea  and 
cystitis  were  complicated  by  purpura  rheumatica,  and  in  one  of  them 
pleurisy  coexisted.  In  these  cases  relapses  of  the  gonorrhoeal  process 
were  followed  by  renewed  joint-swellings  and  purpura.  Balzer  and 
Lacour  ^  report  the  case  of  a  young  man  who  during  an  attack  of  severe 
urethro-cystitis  also  suffered  from  a  grave  form  of  purpura  haemorrhagica. 
Microscopical  examination  and  cultures  of  the  urethral  secretion  showed 
gonococci  and  other  microbes.  Similar  studies  with  the  blood  demon- 
strated the  presence  of  a  large  white  staphylococcus.  Other  cases  have 
been  reported  by  Mathieu  and  Lailler. 

The  most  common  of  these  eruptions  are  those  of  the  acute  erythema- 
tous and  the  multiform  erythematous  varieties.  There  is  usually  much 
gastric  disorder  and  more  or  less  fever  in  the  course  of  these  exanthemata. 

Vidal  ^  has  reported  a  case  which  is  unique  in  medical  literature.  It 
was  that  of  a  man  twenty-four  years  old  who,  after  two  attacks  of  gonor- 
rhoea (the  interval  between  which  being  two  years),  had  polyarthritis  and 
a  generalized  eruption  of  symmetrical  horny  placjues  or  crusts,  together 
with  loss  of  the  nails.  In  each  attack  the  cutaneous  lesions  were  similar. 
It  must  be  conceded  that  our  knowledge  of  the  relation  of  these  various 
dermal  inflammations  to  gonorrhoea  is  yet  wanting  in  many  essential 
points. 

Eruptions  following  the  Ingestion  of  Antiblennorrhagics. 

The  ingestion  of  copaiba  in  some  patients  causes  eruptions,  chiefly  of 
the  erythematous  type,  which  usually  appear  on  the  hands,  arms,  feet, 
knees,  trunk,  chiefly  anteriorly,  and  also,  rather  exceptionally,  on  the 
face.  In  some  cases  a  rash  strikingly  similar  to  scarlatina  is  produced, 
and  less  commonly  the  rash  resembles  measles.  The  most  common  rash 
is  a  diffuse,  irregularly  patchy  eruption  of  rose-colored  or  deep-red  spots 
of  gyrate  outline,  grouped  or  discreet.  In  some  cases  distinct  papula- 
tion and  vesiculation  may  occur  intermingled  with  the  general  rash. 
Urticarial  plaques,  together  with  small  papules,  may  constitute  the  whole 
eruption,  or  these  lesions  may  be  intermingled  with  the  erythematous 
rash. 

Copaiba  rashes  usually  appear  very  suddenly,  and  are  often  accom- 
panied by  pruritus,  which  may  be  intense  or  mild.  With  the  discon- 
tinued ingestion  of  the  drug  the  rash  rapidly  fades  away,  leaving  some 
desquamation  for  a  few  days.  In  some  cases  small  doses  of  copaiba  at 
once  cause  an  acute  and  general  cutaneous  outbreak,  while  in  others  the 
drug  may  be  taken  in  good-sized  doses  for  some  time  before  the  outbreak 
occurs.  There  is  generally  more  or  less  gastro-intestinal  distui'bance 
accompanying  copaiba  exanthems.  Cubebs  under  similar  conditions  may 
cause  a  general  acute  miliary  papular  eruption  and  rashes  resembling 
scarlatina  and  measles. 

^  "  Ueber  Purpura  rheumatica  als  Komplication  blennorrhagischer  Prozesse,"  Wiev. 
med.  Presse,  1880,  pp.  1532,  1.5(i4,  and  1593. 

^  "Ur^thro-cystite  blennorrhagique  compliquee  d'embl^e  de  Purpura  infectieux  tres 
grave,"  Annales  de  Derm,  et  de  Syphil.,  Sept.,  1894,  pp.  1015  et  seq. 

^  Bulletin  de  la  Societe  fran^.  de  Dermat.  et  de  Syph.,  1893,  pp.  6  et  seq. 


LYMPHANGITIS  AND  ADENITIS.  277 

Copaiba  and  cubebs  in  combination  not  uncommonly  cause  rashes 
similar  in  all  respects  to  those  just  described. 

Oil  of  santal-wood  is  very  rarely  the  cause  of  cutaneous  eruptions. 
In  the  few  cases  which  I  have  seen  the  rashes  resembled  scarlatina  and 
measles. 


CHAPTER     XXIX. 

LYMPHANGITIS  AND  ADENITIS. 

Lymphangfitis. 

In  the  early  days  and  throughout  the  acute  stage  of  gonorrhoea  the 
inflammation  may  extend  to  the  lymphatics  of  the  penis,  and  it  may 
localize  itself  in  the  inguinal  ganglia.  Gonorrhoeal  lymphangitis  may 
either  be  seated  in  the  principal  trunks  or  in  the  reticular  network  of 
these  vessels. 

I.  In  the  former  instance  the  course  of  the  inflamed  lymphatics  can  be 
traced  as  reddish  lines,  running,  as  is  usually  the  case,  along  the  dorsum 
of  the  penis  from  the  prepuce  toward  the  pubes.  There  may  be  one  or 
several.  In  the  latter  case  they  may  be  united  by  transverse  bands  of 
erythema  corresponding  to  the  anastomoses  of  the  vessels.  To  the  touch 
they  resemble  hard  or  knotted  cords  which  can  be  separated  by  the  fingers 
from  the  adjacent  tissues.  Their  sensitiveness  varies  with  the  amount  of 
inflammation.  There  is  often  some  oedema  of  the  prepuce  or  of  the  penis, 
and  tenderness  of  the  inguinal  ganglia.  This  state  of  things  almost  inva- 
riably terminates  in  resolution.  Suppuration  is  reported  to  occur  in  rare 
instances  in  the  form  of  several  small  circumscribed  abscesses,  which  are 
usually  of  little  moment,  but  which  may  undermine  the  skin  to  some 
extent  and  demand  surgical  interference.  Zeissl  says  he  knows  men  who 
have  lymphangitis  every  time  they  have  the  clap. 

Fournier  speaks  of  another  form  of  this  afi'ection  taking  place  {a  froid) 
without  any  signs  of  acute  inflammation,  and  recognizable  only  by  the 
hard  and  indolent  cord  or  cords  perceptible  to  the  touch  along  the  dorsum 
of  the  penis,  and  readily  mistaken  for  the  indurated  lymphangitis  attend- 
ant upon  the  initial  lesion  of  syphilis. 

Inflammation  of  the  lymphatic  trunks  along  the  dorsum  of  the  penis 
has  been  mistaken  for  dorsal  phlebitis.  According  to  Fournier,  the  latter 
is  an  exceedingly  rare  aff"ection,  a  few  cases  having  been  seen  by  Ricord. 
It  is  distinguishable  from  the  former  by  the  greater  amount  of  oedema,  by 
the  impossibility  of  grasping  and  isolating  the  vessel  between  the  fingers, 
and  bv  the  incruinal  gano-lia  remaining  unaff'ected. 

II.  The  second  form  of  lymphangitis,  the  one  in  which  the  general 
reticular  network  of  the  lymphatic  vessels  is  involved,  is  usually  confined 
to  the  prepuce,  and  is  responsible  for  many  of  the  cases  of  phimosis  and 
paraphimosis  and  their  sequelse  (abscesses,  perforation  of  the  prepuce,  etc.) 


278  OONOBBHOSA   AND  ITS  COMPLICATIONS. 

which  have  been  described  in  another  chapter.  The  part  affected  is  of  a 
uniform  rose  or  red  color,  more  or  less  tumefied  and  exceedingly  sensitive. 
The  trunks  of  the  vessels  along  the  dorsum  and  the  glands  in  the  groin 
usually  show  signs  of  participation. 

In  Y&cj  rare  cases  the  whole  penis  is  involved,  attains  an  enormous 
size,  is  twisted  upon  itself  at  its  extremity,  and  is  the  seat  of  the  most 
violent  pain.  Micturition  is  difficult  and  painful,  erections  excruciating. 
General  febrile  reaction,  chills,  fever,  loss  of  appetite,  and  even  delirium 
(it  is  said),  may  occur. 

In  most  cases  even  these  severe  symptoms  terminate  without  any  un- 
toward result.  Suppuration,  however,  is  a  consequence  to  be  feared. 
"  When  this  takes  place  it  is  almost  always  seated  in  the  prepuce.  Very 
rarely  it  involves  the  cellular  tissue  lining  the  sheath  of  the  penis.  The 
abscess  shows  great  tendency  to  destroy  the  mucous  membrane  of  the  pre- 
puce and  to  empty  itself  toward  the  glans.  When  finally  emptied,  the 
swelling  of  the  prepuce  subsides,  the  tension  disappears,  the  pains  cease, 
and  the  skin  can  be  felt  to  be  thinned  at  the  point  affected.  In  some 
cases  this  thinning  of  the  skin  is  so  great  that  the  membrane  loses  its 
vitality  and  is  affected  with  gangrene.  A  perforation  results,  through 
which  the  glans  may  be  seen.  This  accident  is  not  the  only  one  to  which 
the  patient  is  exposed.  One  of  the  most  common,  and  at  the  same  time 
least  serious,  consists  in  a  hard  oedema  limited  to  that  portion  of  the  pre- 
puce corresponding  to  the  frgenum,  and  which  may  be  very  persistent. 
In  other  patients  the  edges  of  the  opening  of  the  abscess  become  indu- 
rated, and  it  is  then  difficult  to  uncover  the  glans.  Finally,  in  persons 
predisposed  to  phimosis  there  remains  a  narrowness  of  the  preputial  orifice 
or  an  induration  of  the  whole  membrane  "  (Hardy). 

Treatment. — The  treatment  of  gonorrhoeal  lymphangitis  consists  in 
rest  in  the  horizontal  posture,  elevation  of  the  genitals,  full  baths,  local 
bathing  with  hot  water,  and  incision  of  any  abscess  as  soon  as  formed. 
Rules  for  treatment  in  cases  of  phimosis  have  already  been  given. 

Adenitis. 

It  is  rare  to  observe  anything  more  serious  in  the  inguinal  ganglia  in 
cases  of  gonorrhoea  than  slight  enlargement  and  tenderness,  which  disap- 
pear in  a  few  days.  It  is  at  once  recognized  by  the  physician  and  patient 
by  the  enlargement  and  tenderness  of  one  or  more  glands  in  the  groin, 
and  it  may  occasion  considerable  pain  and  uneasiness  in  walking  and 
standing.  Buboes  attendant  upon  gonorrhoea,  uncomplicated  with  chan- 
croid, are  "simple"  buboes,  of  which  a  fuller  description  will  be  given 
hereafter  in  speaking  of  buboes  in  general.  They  may  generally  be  made 
to  disappear  in  a  few  days  by  keeping  the  patient  quiet  and  applying  ice 
or  cooling  lotions,  and  later  on  producing  a  little  counter-irritation  by 
painting  the  skin  over  them  daily  with  tincture  of  iodine. 

Gonorrhoeal  adenitis  very  rarely  goes  on  to  suppuration,  except  in 
very  debilitated  or  tuberculous  subjects.  As  a  rule,  the  swelling  in  the 
ganglia  entirely  passes  away,  but  exceptionally  these  little  bodies  are  left 
in  a  somewhat  swollen  condition,  and  more  or  less  severe  recrudescences 
of  the  inflammation  follow  active  exercise  or  redevelop  with  a  succeeding 
attack  of  gonorrhoea. 


GONOBRHCEA  IN  THE  FEMALE.  279 

As  a  rule,  both  lymphangitis  and  adenitis  are  the  result  of  the  too 
actively  aggressive  treatment  of  gonorrhoea  or  of  unusual  bodily  strain. 

According  to  my  statistics,  adenitis  in  the  course  of  gonorrhoea  in  pri- 
vate practice  is  of  the  very  greatest  rarity,  and  in  public  practice  it  occurs 
about  once  in  one  hundred  cases. 


CHAPTER    XXX. 

GONORRHCEA  IN  THE  FEMALE. 

Within  the  past  ten  years  our  knowledge  of  gonorrhoea  in  the  female 
has  been  very  much  amplified,  many  doubtful  and  obscure  points  in  its 
nature  and  diagnosis  have  been  cleared  up,  and  a  flood  of  light  has  been 
thrown  upon  a  series  of  grave  consequences  which  supervene  in  its  course. 
While  to-day  it  may  be  said  that  our  knowledge  rests  on  a  very  satis- 
factory scientific  basis,  there  are  still  many  points  which  have  yet  to  be 
investigated,  and  several  questions  concerning  it  which  perhaps  may  be 
solved  in  the  future.  Undoubtedly,  the  studies  and  investigations  made 
by  gynecologists  have  been  the  chief  means  of  enlarging  and  rendering 
more  clear  our  ideas  upon  this  once  most  obscure  and  much-neglected  sub- 
ject. It  also  must  be  admitted  that  the  discovery  of  the  gonococcus  has 
been  a  very  great  help,  since  by  its  study  we  have  been  able  in  the  main 
to  distinguish  the  mucous-membrane  inflammations  produced  by  it,  and  to 
quite  sharply  distinguish  them  from  the  simple  forms  of  muco-purulent 
and  purulent  inflammations  due  to  other  causes.  In  earlier  days  the  free 
escape  of  very  green  pus  from  the  uterus  and  vagina  Avas  considered 
indubitable  evidence  of  gonorrhoeal  infection,  and  a  gelatinous,  mucoid 
secretion  in  fluid  or  plug-form  from  these  parts  was  regarded  as  evidence 
of  a  simple  non-infectious  process.  To-day,  in  the  light  of  our  more 
extended  and  precise  knowledge,  we  find  that  the  pus-secretion  may  be 
harmless,  while  infection  may,  in  some  cases,  lurk  in  the  seemingly  inno- 
cent mucous  plug. 

Notwithstanding  our  enlightenment,  it  must  be  confessed  that  there  are 
many  clinical  points  which  have  not  been  cleared  up  by  the  use  of  the 
microscope.  In  a  large  number  of  cases  male  patients  suffering  from 
gonorrhoea  in  the  pus  of  which  the  gonococcus  is  readily  detected  have 
contracted  the  disease  from  females  similarly  aff"ected.  On  the  other  hand, 
particularly  in  private  practice  and  in  the  better  class  of  patients,  Ave  fre- 
quently see  men  having  gonorrhoea,  even  first  infections,  which  they  con- 
tracted from  females  who  Avere  never  infected  Avith  that  disease,  who  may 
not  have  had  any  abnormal  discharge,  or  who  might  have  had  a  purulent 
or  muco-purulent  discharge  as  a  result  of  simple  processes — parturition, 
some  new  groAVth,  or  of  some  traumatism.  In  these  cases  the  microscope 
gives  us  no  help.  The  ardent  advocates  of  the  absolute  and  essential 
virulence  of  the  gonococcus  claim  that  in  these  cases  there  must  have 
been  in  times  past  a  gonorrhoea  Avhich  was  not  recognized,  and  that  faulty 
or  insufficient  search  and  examination  had  allowed  the  microbe  to  escape 


280  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

detection,  or  that  this  never-dying  micro-organism  existed  in  an  involution 
form  and  was  unrecognizable  by  means  of  our  present  methods  of  exami- 
nation. While,  therefore,  we  may  regret  that  our  knowledge  is  not  com- 
plete and  clear,  Ave  certainly  should  be  thankful  that  it  has  been  so 
broadly  increased  and  so  materially  systematized. 

Gonorrhoea  in  the  female  is  certainly  much  less  frequent  than  it  is  in 
the  male,  and  usually  runs  a  much  less  definite  course.  There  being  so 
much  more  surface  of  mucous  membrane  in  the  genito-urinary  tracts  of 
the  female,  and  so  many  more  communicating  mucous-membrane  passages 
than  in  the  male,  there  is  a  corresponding  complexity  in  the  situation  and 
course  of  the  disease.  In  the  main,  gonorrhoea  in  women  localizes  itself 
in  one  or  two  parts,  runs  an  acute  course,  becomes  subacute,  and  ceases. 
Then  in  many  cases  it  begins  and  remains  in  a  subacute  condition  for  a 
considerable  or  a  long  time.  Then,  again,  in  some  cases  it  progressively 
invades  the  whole  genital  tract. 

Having  become  lodged  in  the  cervix  uteri,  it  may  extend  to  the  body 
of  that  organ,  may  pass  through  the  ostia  interna,  attack  the  tubes  and 
ovaries,  and  then  the  peritoneum.  As  the  infectious  process  creeps  higher 
up,  the  gravity  of  the  disease  increases  and  the  sufferings  of  the  patient 
are  much  greater.  Then,  localizing  itself  in  the  tubes  and  the  ovaries, 
it  produces  foci  of  inflammation  which  lead  to  structural  changes  in  the 
pelvic  connective  tissues,  and  may  cause  intermittent  attacks  of  perito- 
nitis. Patients  thus  afflicted  are  usually  sterile,  they  suffer  intense  discom- 
fort and  pain,  their  health  becomes  impaired  until  they  may  become 
mental  and  physical  wrecks.  Not  only  do  they  become  the  subject  for 
capital  operations,  but  they  lapse  into  a  condition  of  poor  health  which 
renders  them  the  prey  to  acute  infectious  diseases  particularly  tuberculosis. 

These  sad  results  certainly  do  occur  in  a  relatively  quite  large  number 
of  cases.  Instances  are  not  infrequent  in  which  wives  are  infected  with 
gonorrhoea  by  their  husbands,  who  perhaps  regarded  themselves  as  cured. 
So  that,  instead  of  being  a  trifling  affair,  gonorrhoea  is  in  many  cases 
really  a  very  serious  disease,  and  it  constitutes  a  grave  social  danger. 

In  some  cases — not  very  common  ones,  however — the  bladder  becomes 
infected  by  extension  from  the  urethra,  and  from  there,  creeping  up  the 
ureters,  the  disease  settles  in  the  kidneys,  producing  pyelitis  and  pyelo- 
nephritis. In  these  cases  of  ascending  gonorrhoea  in  women  the  symptom- 
complex  is  very  similar  to  that  observed  in  men. 

It  is  very  difficult,  and  even  impossible,  to  get  reliable  statistics  as  to 
the  frequency  of  occurrence  of  acute  gonorrhoea  in  women.  It  of  course 
exists  largely  in  prostitutes,  particularly  in  quite  young  ones  and  those 
of  the  lower  walks  of  life,  and  it  is  not  uncommon  in  shop-girls  and 
others  who  for  various  reasons  leave  their  homes  and  cease  to  be  under 
parental  and  family  restraint. 

Fournier's  statistics  as  to  the  class  of  women  from  whom  gonorrhoea 
is  most  frequently  derived  are  interesting : 

Public  prostitutes 12 

Clandestine  prostitutes 44 

Kept  women,  actresses 138 

Shop-girls • 126 

Domestics 41 

Married  women 26 

^87 


GONORRHCEA   IN  THE  FEMALE.  281 

The  word  "actress"  used  in  these  statistics  is  rather  misleading. 
There  is  no  doubt  whatever  that  gonorrhoea  exists  in  full-fledged  actresses, 
but  not  to  the  extent  implied  by  this  table.  These  figures  refer  to  young 
women  in  general,  usually  under  and  not  much  over  twenty  years  of  age, 
who  are  employed  in  various  capacities  in  theatres,  music-halls,  and 
"dives."  They  dance  in  the  ballet,  sing  in  the  chorus,  and  are  other- 
wise employed  in  these  places.  Usually  these  girls  have  but  indifferent 
notions  as  to  personal  cleanliness.  They  are  unsophisticated  and  not  sus- 
picious of  men,  and  thus  fall  victims  of  gonorrhoea.  Carelessness  of  person 
and  indifference  to  discharges  from  the  genitalia  cause  them  often  to  allow 
their  disease  to  run  on,  while  at  the  same  time  they  accord  favors  to  many 
men.     Thus  it  is  that  these  women  so  frequently  give  gonorrhoea  to  men. 

There  are  several  reasons  why  gonorrhoea  in  women  not  infrequently 
passes  unrecognized.  In  many  cases  when  the  urethra  is  involved  the 
acuteness  of  the  symptoms  cease  rather  promptly,  and  the  woman  simply 
thinks  that  something  is  mildly  amiss  or  that  she  has  taken  cold.  Then, 
again,  invasion  of  the  cervix  uteri  may  be  attended  with  mild  symptoms 
which  do  not  alarm  the  patient,  and  which  may  exist  for  a  time,  long  or 
short,  without  the  knowledge  of  the  patient.  In  other  cases  many  women 
have  suffered  so  long  from  vaginal  discharges,  muco-purulent  and  puru- 
lent, that  they  become  quite  indifferent  to  them,  and  any  increase  of  their 
quantity  does  not  in  many  instances  cause  them  to  seek  medical  advice. 

As  regards  the  frequency  of  gonorrhoea  as  found  in  patients  who  seek 
relief  at  the  hands  of  gynecologists,  we  have  considerable  quite  accurate 
information.  Thus,  Schwartz  *  in  617  cases  found  112  in  Avhich  gonor- 
rhoea! infection  was  the  probable  causative  factor.  Of  these  112  cases, 
33  (5.3  per  cent.)  suffered  from  acute  gonorrhoea  (the  gonococcus  having 
been  found),  and  of  these  19  Avere  either  unmarried  or  widows.  Of  the 
remaining  79  cases,  the  gonococcus  was  found  in  44,  and,  though  absent 
when  looked  for,  Schwartz  thinks  from  their  clinical  histories  it  had  been 
present  in  the  remaining  35  cases.  Taking,  therefore,  only  the  77  cases 
in  Avhich  the  gonococcus  was  found,  out  of  the  617  cases  gonorrhoea  was 
proved  to  exist  in  12.4  per  cent. 

Sanger^  in  1930  gynecological  cases  in  private  and  hospital  practice 
found  230  of  gonorrhoeal  origin,  being  12  per  cent.,  or  one-eighth  of  all 
the  cases.  In  161  later  cases  there  were  29  of  gonorrhoeal  origin,  which 
would  be  18  per  cent.  As  a  general  statement,  he  thinks  that  in  one- 
eighth  of  all  gynecological  cases  gonorrhoea  is  the  underlying  cause. 

Steinschneider^  examined  55  prostitutes  in  the  venereal  hospital  of 
Breslau,  and  of  these  20  presented  no  symptoms  of  gonorrhoea.  But  of 
the  remaining  37  cases,  in  34  there  was  recent  gonorrhoea,  and  in  3  the 
infection  had  existed  three,  four,  and  five  months.  In  the  urethral  secre- 
tion of  the  34  cases  the  gonococcus  was  found,  but  it  was  absent  in  the 
urethral  secretions  of  the  3  chronic  cases. 

Laser*  examined  198  prostitutes,  and  from  their  secretions  600  speci- 
mens were  examined.     Of  these,  353  were  from  the  urethra,  180  from 

^  "  Die  Gonorrhoische  Infektion  beim  Weibe,"  Volkmann's  Sammlung  kltn.  Vortrage, 
No.  279,  1886. 

^  Die  Tripperansieckung  beim  Weihlichen  Geschlecht,  Leipzig,  1889. 

^  "  Ueber  ilen  Sitz  der  Gonorrhoischen  Infektion  beim  Weibe,"  Beii.  klin.  Wochenschr., 
No.  17,  1887,  p.  301. 

*  "Gonococcen  befund  bei  600  Prostituirten,"  Deut.med.  Wochenschr.,  No.  37, 1893,  p.  892. 


282  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

the  vagina,  and  67  from  the  cervix  uteri.  Of  the  67  cases,  in  21  the 
gonococcus  was  found,  that  being  30.3  per  cent.  In  these  21  cases  there 
were  clinical  symptoms  present  in  only  4.  In  the  180  cases  of  vaginal 
discharge  gonococci  were  found  in  only  7,  and  in  5  of  these  cases  the 
cervical  discharge  contained  gonococci.  In  only  1  case  was  it  evident 
that  the  microbe  grew  in  the  vagina.  Of  the  353  specimens  of  urethral 
pus,  the  gonococcus  was  found  in  112  cases,  which  is  31.7  per  cent.  The 
result  of  the  353  examinations  of  the  urethra  gives  gonococci  in  112  cases, 
in  61  cases  of  which  there  was  no  symptomatic  evidence  of  gonorrhoea. 
The  gonococci  were  alone  in  but  few  cases ;  leptothrix  was  present  in  6 
cases.  Among  the  241  cases  in  which  no  gonococci  were  found,  follicular 
catarrh  was  present  in  17  ;  the  mucous  membrane  was  red  and  swollen  in 
19.  In  31  cases  there  were  signs  that  would  lead  one  to  suspect  gonor- 
rhoea. In  8  of  these  cases  a  thick  purulent  discharge  could  be  squeezed 
out  of  the  urethra,  and  in  the  other  23  cases  a  more  mucoid  discharge 
was  present.  From  his  studies  Laser  has  convinced  himself  that  other 
micro-organisms  besides  the  gonococcus  may  produce  purulent  discharge 
in  the  female  genital  tract. 

In  the  light  of  recent  investigations  and  studies  it  is  clearly  proved 
that  in  women  over  twenty  years  of  age  the  urethra  and  the  cervix  uteri 
are  the  parts  most  commonly  attacked  by  gonorrhoea.  There  is  some  dis- 
cordance in  opinion  as  to  the  relative  frequency  of  these  two  forms  of 
gonorrhoea,  but  a  conservative  estimate,  I  think,  will  place  the  urethral 
trouble  as  a  little  more  frequent  than  that  of  the  os  uteri.  There  can  be 
no  doubt  of  the  existence  of  a  true  gonorrhoeal  inflammation  of  the  vulva, 
but  it  is  not  very  common.  It  is  sometimes  seen  in  young  girls  over  fif- 
teen and  less  than  twenty  years  of  age,  usually  as  a  result  of  their  first 
infection  and  of  their  earlier  attempts  at  intercourse. 

Though  the  existence  of  a  gonorrhoeal  vaginitis  has  been  denied,  there 
can  be  no  doubt  that  in  a  restricted  number  of  cases  gonorrhoea  primarily 
attacking  this  tube  does  occur.  It  is  also  not  infrequently  observed  to 
become  secondarily  infected  by  the  gonorrhoeal  secretion  from  the  os  uteri. 

Most  commonly,  therefore,  gonorrhoea  is  found  in  the  urethra,  cervix 
uteri,  vulva,  and  vagina. 

These  are  the  four  principal  forms  of  gonorrhoea  in  women,  and  from 
them  the  many  complications  of  the  genital  and  urinary  parts  above  may 
develop.  One  or  more,  and  perhaps  all,  of  these  forms  may  exist  in  a 
given  case.  Sometimes  we  find  simply  gonorrhoeal  urethritis,  or  coexist- 
ent with  it  may  be  vulvitis  and  even  endocervicitis.  Then,  again,  we 
find  inflammation  of  the  uterine  neck  as  the  sole  trouble,  or  it  may  be 
attended  with  vaginitis  and  urethritis.  In  other  words,  while  the  urethra 
and  cervix  uteri  are  the  parts  most  commonly  attacked,  other  parts  may 
severally  or  in  totality  be  coincidently  involved.  In  some  cases  follicular 
and  glandular  inflammation  may  be  present  with  any  of  the  foregoing 
inflammations  or  combinations. 

There  are  also  certain  minor  forms  of  gonorrhoea  which  are  localized 
in  the  peri-urethral  and  intra-urethral  follicles  and  in  Bartholin's  glands. 

The  essential  gonorrhoeal  process  in  women  has  been  carefully  studied 
by  Bumm,^  both  microscopically  and  clinically,  in  132  cases,  and  it  is 

^  "  Ueber  die  Tripperansteckung  beira  "Weibliclien  Geschlecht  und  ihre  Folgen," 
Munch,  med.  Wochenschr.,  1891,  pp.  853  et  seq. 


GONORRHCEA  IN  THE  FEMALE.  283 

from  his  essay  that  I  take  the  facts  of  pathological  histology.  The  mor- 
bid process  is  similar  to  that  of  the  male.  (See  p.  78.)  It  has  a  period 
of  incubation  of  two  or  three,  perhaps  even  more,  days.  The  microbes, 
being  deposited  on  the  mucous  membrane,  luxuriate  and  greatly  increase 
in  numbers.  Then  they,  as  already  described,  pass  through  the  mucous 
membrane  in  the  clefts  between  the  cells  and  reach  the  papillary  bodies. 
The  result  is  an  acute  exudative  inflammation  with  an  abundant  secretion 
of  pus.  When  in  favorable  cases  the  morbid  process  ceases,  the  epithelium 
is  restored  and  a  cure  is  produced.  There  is  a  tendency,  according  to 
Bumm,  for  the  microbes  to  remain  in  an  indolent  state  in  the  sticky 
mucous  secretion  of  the  parts  previously  inflamed.  It  has  long  been  con- 
tended by  Bumm  that  parts  covered  with  flat  pavement  epithelium  are 
very  resistant,  and  even  impregnable,  to  the  invasion  of  the  gonococcus, 
and  that  where  cylindrical  epithelium  covers  parts  they  are  readily  sus- 
ceptible to  invasion.  The  consensus  of  opinion  of  a  number  of  later 
observers  goes  to  show  that  parts  covered  with  flat  pavement  epithelium 
are  more  resistant  to  the  action  of  the  gonococcus  than  are  those  covered 
by  cylindrical  epithelium,  but  that  they  both  are  susceptible,  though  in 
varying  degrees. 

It  is  therefore  important  in  the  study  of  gonorrhoea  in  women  to  con- 
sider the  kind  of  mucous  membrane  which  covers  a  part.  Thus,  the 
vulva,  vagina,  and  the  vaginal  portion  of  the  external  surface  of  the  os 
uteri  are  covered  with  pavement  epithelium,  which  in  early  life  is  soft  in 
structure  and  becomes  harder  toward  puberty.  In  the  vulva,  on  each 
side  of  the  introitus  vaginae,  in  the  depression  between  the  nymphae  and 
the  remains  of  the  hymen,  Bartholin's  or  the  vulvo-vaginal  glands  open 
by  means  of  a  long  single  duct.  These  ducts  become  infected  in  gonor- 
rhoea, which  may  extend  deeper  and  invade  the  glands.  The  urethra  also 
opens  into  the  vulva. 

The  female  urethra  is  a  dense  structure  composed  of  yellow  and  white 
elastic  fibrous  tissue  in  which  involuntary  muscular  fibres  are  inextricably 
interwoven.  The  mucous  lining  is  firmly  adherent  to  the  tissue  of  the 
canal,  and  is  of  the  squamous  variety  in  nearly  its  whole  length,  while 
that  nearest  the  bladder  is  of  the  transitional  type.  In  the  intervals  of 
urination  the  mucous  membrane  is  thrown  into  longitudinal  folds.  There 
are  many  mucous  crypts,  called,  as  in  the  male,  Littre's  glands,  lined  with 
columnar  epithelium,  seated  along  the  course  of  the  canal. 

Besides  the  deep-seated  follicles,  there  are  two  large  racemose  glands 
seated  near  the  meatus,  w^hich  have  been  described  by  Dr.  Skene,^  and 
are  called  Skene's  glands.     He  describes  them  as  folloAvs : 

"  Upon  each  side  near  the  floor  of  the  female  urethra  there  are  two 
tubules  large  enough  to  admit  a  No.  1  pi'obe  of  the  French  scale. 

"  They  extend  from  the  meatus  urinarius  upw'ard  from  three-eighths 
to  three-quarters  of  an  inch. 

"  They  are  located  beneath  the  mucous  membrane,  in  the  muscular 
walls  of  the  urethra. 

"  The  mouths  of  these  tubules  are  found  upon  the  free  surface  of  the 
mucous  membrane  of  the  urethra,  within  the  labia  of  the  meatus  urinarius. 
The  location  of  the  opening  is  subject  to  slight  variation,  according  to 

^  "The  Anatomy  and  Pathology  of  Two  Important  Glands  of  the  Female  Urethra." 
Am.  Journ.  Obstetrics,  etc.,  vol.  xiii.,  1880,  p.  265. 


284  QONOBBHCEA  AND  ITS  COMPLICATIONS. 

the  condition  and  location  of  the  meatus.  In  some  subjects,  especially 
the  young  and  very  aged,  and  in  those  in  whom  the  meatus  is  small  and 
does  not  project  above  the  plane  of  the  vestibule,  the  orifices  are  found 
about  an  eighth  of  an  inch  within  the  outer  border  of  the  meatus.  When 
the  mucous  membrane  of  the  urethra  is  thickened  and  relaxed  so  as  to 
become  slightly  prolapsed,  or  when  the  meatus  is  everted — conditions  not 
uncommon  amongst  those  Avho  have  borne  children — the  openings  are 
exposed  to  view  upon  each  side  of  the  entrance  to  the  urethra. 

"  The  upper  ends  of  the  tubules  terminate  in  a  number  of  divisions, 
which  branch  off  into  the  muscular  walls  of  the  urethra.  By  injecting 
the  tubules  with  mercury  and  then  laying  them  open  the  openings  of  the 
branches  can  be  easily  seen. 

"  I  have  called  them  glands,  because  they  differ  in  size  and  structure 
from  the  simple  follicles  that  are  found  in  abundance  in  the  mucous  mem- 
brane." 

Besides  Skene's  glands,  there  are  certain  peri-urethral  follicles  seated 
around  the  urethra  one-third  or  one-half  an  inch  from  the  meatus.  In 
the  third  order  of  glands  belong  the  vestibulo-vaginal  glands  or  bulbs, 
which  are  seated  on  each  side  of  the  meatus  on  its  lower  part  near  the 
vagina.  There  are  also  certain  para-urethral  follicles,  which  are  sparsely 
scattered  over  the  vestibule  in  the  vicinity  of  the  urethra.  All  these  fol- 
licles and  glands  may  play  a  prominent  part  in  the  gonorrhoeal  process. 

There  are  also  a  number  of  large-sized  follicles  which  open  upon  the 
fourchette  or  on  the  anfractuous  surface  of  the  hymen  left  after  its  rupture 
in  childbirth,  which  may  be  attacked  by  simple  catarrhal  processes  and 
bv  gonorrhoea.- 

The  vagina  is  covered  with  a  thick,  hard,  and  horny  epithelial  layer 
of  the  flat  variety,  and  into  it  no  glands  open.  It  is  the  habitat  of  myriads 
of  various  forms  of  micro-organisms.  From  the  external  os  uteri  to  the 
abdominal  openings  of  the  tubes  the  genital  canal  is  covered  by  a  simple 
layer  of  ciliated  cylindrical  epithelium.  In  the  cervix  the  acinous  glands 
of  Naboth  penetrate  deep  down  in  the  tissues  and  open  on  the  surface  of 
the  mucous  membrane.  They  offer  a  peculiarly  deep  and  almost  impreg- 
nable nidus  for  microbic  invasion.  Indifferent  microbes  are  found  in  this 
part  in  healthy  subjects. 

In  the  body  of  the  uterus  the  mucous  membrane  is  supplied  with  tub- 
ular glands  and  lies  directly  on  the  muscle  without  the  intervention  of 
any  submucous  connective  tissue.  According  to  Winter,^  neither  the  nor- 
mal uterine  cavity  nor  the  tubes  contain  any  micro-organisms  or  contents 
of  any  kind.  The  tubes  possess  no  glands,  and  are  of  succulent  structure 
which  will  admit  of  much  swelling  and  distention.  In  the  course  of  the 
tubes  there  are  many  folds  which  make  of  the  canal  an  irregular  cavity 
with  many  depressions  and  nooks  which  are  favorable  to  the  long  exist- 
ence of  an  inflammatory  process.  The  structure  and  relations  of  the 
ovaries  are  described  in  works  on  anatomy  and  gynecology. 

In  the  lisht  of  the  foreffoins;  statements,  when  we  take  into  considera- 
tion  the  facts  that  gonorrhoea  in  women,  as  in  men,  consists  of  an  exudative 
inflammation  of  the  submucous  connective  tissue,  and  that  the  genital 
organs  of  women  are  so  extensive,  complex,  and  involuted,  and  so  profusely 

^  "Die  Microorganismen  im  Genitalcanal  der  Gesundenfrau,"  Zeitschr.filr  Geburtsch. 
und  Gyndk,  Stuttgart,  1888,  vol.  xiv.  pp.  443  et  seq. 


GONORRHCEA  IN  THE  FEMALE.  285 

supplied  by  blood-vessels  which  frequently  undergo  normal  engorgement, 
it  can  readily  be  understood  why  the  morbid  process  may  show  a  tendency 
to  become  chronic  and  to  lurk  and  to  hide  in  them. 

Although  gonorrhoea  in  women  in  many  cases  is  a  very  persistent  and 
chronic  aifection,  it  certainly  must  not  be  pronounced  an  incurable  one. 

The  So-called  Latent  Gonorrhoea. 

There  has  been  a  tendency  developed  within  the  past  ten  years  to  refer 
in  a  loose  and  unscientific  manner  nearly  all  female  ailments  to  gonorrhoea, 
and  attribute  to  many  husbands  who  in  earlier  days  had  gonorrhoea  a 
gonorrhoeal  infection  of  their  wives,  which  produced  serious  pelvic  inflam- 
mations which,  besides  causing  sterility,  often  entailed  lifelong  suiferina; 
and  invalidism,  and  frequently  ended  in  death. 

In  the  year  1872,  Dr.  E.  Noeggerath  ^  made  the  bold  statement  that, 
as  claimed  by  Ricord,  800  out  of  every  1000  men  living  in  large  cities  had 
gonorrhoea,  from  which  he,  Noeggerath,  claimed  they  never  recovered.  On 
marrying,  these  men  earlier  or  later  infected  their  wives,  90  per  cent,  of 
whom  then  suff'ered  from  the  ravages  of  gonorrhoeal  infection.  Though 
these  views  were  vehemently  combated  by  many  and  were  accepted  by 
only  a  few,  Noeggerath  ^  still  clung  to  them,  and  in  a  paper  read  in  1876 
he  formulated  the  following  conclusions : 

1.  Gonorrhoea  in  the  male,  as  well  as  in  the  female,  persists  for  life  in 
certain  sections  of  the  organs  of  generation,  notwithstanding  its  apparent 
cure  in  a  great  many  instances. 

2.  There  is  a  form  of  gonorrhoea,  which  may  be  called  latent  gonor- 
rhoea, in  the  male  as  well  as  in  the  female. 

3.  Latent  gonorrhoea  in  the  male,  as  well  as  in  the  female,  may  infect 
a  healthy  person  either  Avith  acute  gonorrhoea  or  gleet. 

4.  Latent  gonorrhoea  in  the  female,  either  the  consequence  of  an  acute 
gonorrhoeal  invasion  or  not,  if  it  pass  from  the  latent  into  the  apparent 
condition,  manifests  itself  as  acute,  chronic,  recurrent  perimetritis  or 
ovaritis,  or  as  catarrh  of  certain  sections  of  the  genitaL  organs. 

5.  Latent  gonorrhoea  on  becoming  apparent  in  the  male  does  so  by 
attacks  of  gleet  or  epididymitis. 

6.  About  90  per  cent,  of  sterile  women  are  married  to  husbands  who 
have  suffered  from  gonorrhoea,  either  previous  to  or  during  married  life. 

These  extreme  and  exaggerated  views  of  the  result  of  generalization 
and  deductions  based  on  faulty  diagnosis  and  false  premises  are  not  quoted 
here  with  approval,  but  simply  as  a  matter  of  medical  history. 

Since  the  discovery  of  the  gonococcus  Noeggerath's  views  have  attracted 
wide  attention,  and  they  certainly  have  been  of  great  benefit  in  causing 
gynecologists,  syphilographers,  and  bacteriologists  to  study  gonorrhoea  in 
women  from  all  standpoints.  L^nfortunately,  gynecologists,  as  a  rule, 
know  little,  if  anything,  of  gonorrhoea  in  men,  and  many  of  them,  not 
having  gone  into  its  study  carefully,  think  that  the  gonococcus  hides,  but 
never  dies,  and  that  a  husband,  once  having  had  gonorrhoea,  must  of 
necessity  be  the  cause  of  nearly  every  pelvic  inflammation  his  wife  may 

^  Die  Latente  Gonnrrhoe  im  Weibllehen  Geschlecht,  Bonn,  1872. 

^  "Latent  Gonorrhoea  in  the  Female,  etc.,"  reprint  from  the  Transactions  of  the  Ameri- 
can Gynecological  Society,  1876. 


286  GONORBHCEA  AND  ITS  COMPLICATIONS. 

suffer  from.  Sypliilographers  may  see  the  early  gonorrhoeas  in  women, 
but  they  rarely  see  these  cases  when  they  become  gynecological.  Hence 
the  present  unsettled  condition  of  our  knowledge  as  to  just  what  gonor- 
rhoea is  responsible  for  in  female  uterine  and  pelvic  inflammations.  The 
views  of  many  gynecologists  concerning  gonorrhoea  may  be  stated  about 
as  follows:  Some  of  them,  with  propriety,  claim  that  there  is  first  an 
acute  attack,  and  that  this  becomes  subacute  and  then  chronic.  In  the 
chronic  form  it  may  cease  or  may  lurk  indefinitely,  and  may  then  undergo 
exacerbations  which  may  lead  to  grave  pelvic  trouble.  On  the  other 
hand,  according  to  many  observers,  the  acute  form  of  the  disease  in 
women  is  rare,  but  a  latent  form  of  the  whole  genital  tract  is  very  fre^ 
quent.  Gonorrhoea  in  men  is  thought  to  exist  in  a  low,  smouldering  form 
for  years  without  producing  any  symptoms,  and  this  latent  form  may  be 
transmitted  in  coitus  to  the  wife,  who  will  only  receive  latent  gonorrhoea, 
which  for  a  long  or  short  time  may  cause  no  symptoms,  and  of  the  exist- 
ence of  which  the  woman  may  be  ignorant.  The  explanation  of  this 
curious  mode  of  infection  is  that  the  infecting  secretion  of  the  male  is 
deposited  in  the  female  genitals,  and  there  lies  dormant  until  some  cause 
like  menstruation,  pregnancy,  or  instrumental  manipulation  produces  con- 
ditions favorable  to  its  resuscitation,  when  it  again  becomes  hostile  and 
produces  disease. 

One  gentleman  very  naively  states  that  "  the  gonococci  are  few  and 
decrepit,  probably  altogether  absent  from  the  periodic  emissions  of  a  con- 
tinent man.  It  is  onl}'-  the  post-nuptial  sexual  excess  that  rouses  them 
into  sufficient  vigor  to  be  harmful." 

Of  this  vague  form  of  gonorrhoea  Feliki  ^  very  pertinently  remarks : 
"  According  to  this  theory,  the  gonococci,  having  penetrated  into  the 
female  genital  tract,  coming  as  they  do  from  a  latent  gonorrhoea  in  the 
male,  do  not  cause  the  well-known  typical  gonorrhoea,  but  a  morbid  pro- 
cess whose  beginning  we  cannot  observe,  and  whose  later  stage  would  cor- 
respond to  the  well-known  complications  of  a  typical  gonorrhoea.  It  is 
remarkable  that  according  to  these  observers  it  is  not  possible  in  gonor- 
rhoeas to  discover  the  gonococcus — first,  because  these  microbes  disappear 
among  the  bacteria  that  thrive  in  the  female  genital  tract;  and,  secondly, 
because  it  is  impossible  to  obtain  any  secretion  from  the  nooks  and  corners 
in  which  they  may  hide.  Thus  in  the  latent  gonorrhoea  of  the  female 
both  clinical  symptoms  and  the  bacteriological  criterion,  the  gonococcus, 
are  wanting." 

As  an  example  of  the  easy-going  manner  in  which  a  diagnosis  of  latent 
gonorrhoea  in  women  has  been  arrived  at,  I  will  quote  from  the  work  of 
Sinclair,^  who  says  that  he  will  "  mention  in  somewhat  general  terms  a 
few  fairly  typical  cases."  Case  I.  was  that  of  a  married  woman,  aged 
twenty  years,  who  had  been  married  a  year  and  had  not  become  pregnant. 
Three  months  after  marriage  she  complained  of  inguinal  and  hypogastric 
pains,  and  suffered  from  menstrual  disturbances.  She  failed  in  health 
and  strength,  and  became  a  dysmenorrhoeal  invalid,  in  all  probability  per- 
manently sterile.     The  gonococcus  was  not  found  in  her  genital  secretions, 

^  "Ueber  Sogenannte  latente  Gonorrhoe  und  die  Dauer  der  InfektiositJit  der  Gonor- 
rhoischen  Urethritis,"  Internal.  Centrulblatt  der  Ham  und  Sexualorgane,  vol.  iv.,  1893,  pp. 
15-22  and  60-77. 

'''  On  Qonorrhozal  Injection  in  Women,  London,  1888,  pp.  6  et  seq. 


GONORRHCEA  IN  THE  FEMALE.  287 

and  the  only  evidence  of  her  having  had  gonorrhoea  was  that  her  husband 
had  that  disease  a  year  before  his  marriage,  since  which  he  had  no  signs 
of  it.     Other  cases  in  a  similar  vein  are  reported. 

Now,  it  certainly  will  strike  a  critical  reader  that  such  loosely-observed 
cases,  in  which  the  clinical  history  and  the  most  essential  facts  are  not 
scientifically  ascertained  and  brought  out,  but  in  which  almost  everything 
is  assumed,  are  entirely  valueless  for  purposes  of  study  and  statistics. 
Unfortunately,  this  easy-going  method  of  arriving  at  a  diagnosis  has  been 
employed  very  generally,  and  as  a  result  gonorrhoea  is  considered  by  many 
as  the  prime  cause  of  all  pelvic  inflammations.  It  is  so  easy  and  con- 
vincing in  the  case  of  a  wife  suffering  from  pelvic  disease  to  ascertain  that 
at  a  more  or  less  remote  period  the  husband  has  had  gonorrhoea,  and  to 
fix  upon  that  infection  as  the  origin  of  the  wife's  trouble,  that  some  men 
by  routine  come  to  make  these  diagnoses. 

As  has  been  shown  elsewhere  (see  page  72),  the  gonorrhoeal  process  runs 
its  course,  and  when  not  cured  a  chronic  inflammation  is  left  with  Avhich 
microbes  have  no  relation  whatever,  since  they  have  played  their  part  and 
disappeared  from  the  scene.  In  very  many  cases  of  chronic  urethritis  in 
the  male  there  is  simply  submucous  thickening  with  purulent  secretion,  in 
which  no  microbes,  or  at  best  only  indiff"erent  ones,  are  found.  These  men 
cohabit  for  years  regularly  with  their  wives  and  mistresses,  and  at  intervals 
with  other  consorts,  and  never  do  them  any  harm.  The  reason  is  that  they 
simply  have  a  low  grade  of  urethral  inflammation  which  has  resulted  from 
the  initial  virulent  inflammation.  There  is  a  tendency  now-a-days  to  harp 
upon  the  longevity  of  the  gonococcus,  on  its  phoenix-like  power  of  resus- 
citation, and  on  its  relentless  virulence.  This  idea,  put  forth  by  some 
syphilographers,  has  had  undue  weight  with  many  gynecologists,  who  under 
its  influence  are  led  to  think  that  the  gonococcus  in  male  and  female  never 
dies,  but  that  it  is  ever  ready  to  produce  pelvic  mischief.  I  have  seen 
many  cases  of  young  women  who  have  suff'ered  from  uterine  and  pelvic 
diseases  after  marriage  whose  trouble  Avas  induced  by  instrumental  manip- 
ulation at  the  hands  of  energetic  young  men  possessed  of  an  ambition  to 
be  known  as  gynecologists.  Minor  surgical  gynecology  is  certainly  the 
cause  of  a  great  many  cases  of  uterine  and  pelvic  disease.  But  it  is  gen- 
erally so  easy  to  get  the  husband  to  acknowledge  to  having  had  a  previous 
gonorrhoea,  and  then  to  confidentially  inform  him  that  he  is  the  cause  of 
his  wife's  sickness. 

In  estimating  the  importance  of  gonorrhoeal  infection  as  the  cause  of 
female  pelvic  trouble  we  must  individualize  rather  than  generalize.  Some 
women  having  gonorrhoea  are  not  cured,  for  the  reason  that  their  condi- 
tions and  surroundings  are  bad,  and  that  they  cannot  or  will  not  take  the 
trouble  to  undero;o  treatment.  Some  suffer  on  in  sheer  ignorance  of  their 
peril.  But,  on  the  other  hand,  there  are  women  of  the  higher  walks  of 
life  who,  having  been  infected  with  gonorrhoea,  take  every  means  and  care 
to  rid  themselves  of  it,  and  they  succeed  in  many  instances.  Gonorrhoea 
of  the  urethra  is  pertinacious,  but  in  the  majority  of  cases  it  is  curable  if 
the  patient  seeks  and  follows  good  advice.  Gonorrhoea  of  the  cervix  uteri 
is  also  very  persistent  and  a  menace  to  the  woman's  health,  but  it  would 
be  rash  to  say  that  it  is  incurable.  In  clinics  and  hospitals  large  numbers 
of  cases  of  gonorrhoeal  pelvic  diseases  are  found,  and  the}^,  when  sub- 
mitted to  statistical  study,  make  a  formidable  showing.    But  such  statistics 


288  GONORBHCEA  AND  ITS  COMPLICATIONS. 

should  only  be  taken  for  what  they  are  worth.  I  have  for  more  than  a 
quarter  of  a  century  treated  men  and  women  for  gonorrhoea,  and  in  that 
time  have  been  able  to  observe  a  large  number  of  patients  during  a  period 
of  many  years.  Many  young  Avomen  had  gonorrhoea  and  recovered.  They 
married,  bore  children,  and  were  healthy  and  happy.  Some  few  suffered 
from  chronic  gonorrhoea,  and  later  developed  pelvic  trouble.  I  have  the 
evidence  of  scores  of  men,  some  of  whom  had  gonorrhoea  and  were  cured, 
others  who  had  chronic  urethral  discharge  from  localized  patches  of  thick- 
ening or  from  strictures,  who  have  lived  with  their  Avives  for  years,  have 
cohabited  with  them  without  the  least  injury  and  without  the  production 
of  a  single  symptom  referable  to  gonorrhoea.  On  this  subject  the  statistics 
of  the  late  Dr.  Thorburn^  of  Manchester  are  of  interest.  Thorburn 
denied  the  correctness  of  Noeggerath's  conclusions,  and  appealed  to  the 
statistics  of  81  families  carefully  collected  by  him.  He  showed  that  there 
had  been  33  per  cent,  of  male  gonorrhoeic  infections  previous  to  marriage, 
26  in  all,  and,  taking  all  cases  of  abortion,  sterility,  uterine  and  pelvic 
inflammations,  and  living  births  that  had  occurred  in  these  81  families,  he 
showed  conclusively  that  there  had  been  the  merest  fractional  difference 
in  their  proportion  between  the  previously  healthy  and  not  previously 
infected  classes.  As  regards  inflammatory  pelvic  afiections,  the  balance 
was  fractional  in  favor  of  the  free-gonorrhoeic  cases,  in  other  respects 
equally  fractional  in  favor  of  the  non-gonorrhoeic.  As  bearing  upon  Dr. 
Thorburn's  evidence  the  remarks  of  Dr.  Chadwick,  made  at  the  time  of 
the  discussion  of  Noeggarath's  second  paper,  are  interesting.  Chadwick 
said  that  he  "had  ascertained  in  conversation  with  twenty  difi"erent  physi- 
cians who  acknowledged  having  had  gonorrhoea  in  early  life  that  in  no 
single  case  had  any  such  symptoms  as  had  been  referred  to  been  devel- 
oped in  their  wives,  and  all  had  had  large  families  of  children." 

It  should  be  borne  in  mind,  in  considering  these  conspicuously  favor- 
able statistics  of  Chadwick,  that  the  gonorrhoeics  were  physicians  who 
naturally  would  follow  treatment  and  become  cured.  The  statistics  would 
not  show  up  as  favorably  if  the  twenty  men  were  'longshoremen  or  com- 
mercial travellers.  Intelligence,  pecuniary  resources,  and  a  life  of  com- 
parative leisure  have  much  to  do  with  lessening  the  proportion  of  gonor- 
rhoeal  pelvic  diseases  in  the  better  classes  of  patients.  Ignorance,  poverty, 
and  unhygienic  surroundings  are  the  underlying  causes  of  so  many  cases 
in  the  lower  walks  of  life. 

It  is  well  known  that  among  the  myriads  of  microbes  which  thrive  in 
the  female  genitals — the  vagina  and  os  uteri  especially — the  streptococcus 
and  the  staphylococcus  are  frequently  found.  Doederlein^  has  clearly  shown 
that  in  the  genitals  of  married  women  a  secretion  is  found  which  contains 
pyogenic  microbes.  Seeing  that  these  morbific  agents  infest  the  normal 
female  genital  tract,  is  it  not  warrantable  to  assume  that  these  microbes 
may  become  hostile  when  the  condition  of  the  tissues  as  a  result  of  engorge- 
ment, of  operations,  of  examinations,  of  instrumental  manipulations,  and 
of  pregnancy  becomes  favorable  to  their  vital  activity  ?     In  confirmation 

^  "Latent  Gonorrhoea  as  an  Impediment  to  Marriage,"  British  Medical  Journal,  Aug. 
25,  1877. 

'■^  Das  Scheidensecret  und  Seine  Bedeatung  fiir  das  Puerperalfieber,  Leipzig,  1892,  and 
"Ueber  Scheidenabsonderungen  und  Scheidenkeime,"  Arch,  fiir  Gynaek.  1891,  xl.,  pp. 
306  et  seq. 


GOXORRHCEA  IN  THE  FEMALE.  289 

of  this  view  we  have  the  evidence  of  many  microscopical  demonstrations  of 
pyogenic  bacteria  which  have  been  found  in  diseased  tubes  and  ovaries. 
Menge^  found  in  26  cases  of  tubal  disease  the  streptococcus  pyogenes  twice 
and  the  staphylococcus  albus  once,  and  thinks  that  he  found  the  gonococcus 
once.  It  has  struck  me  as  being  very  singular  that  so  very  much  insist- 
ence is  made  upon  the  presence  of  the  gonococcus  in  the  female  genital 
tract  (where  it  is  most  difficult  to  find  it),  and  so  little  is  said  of  the 
existence  of  pyogenic  microbes  which  abound  there  so  plentifully  and  are 
so  easy  of  detection. 

From  the  foregoing  survey  of  the  subject  I  think  we  are  warranted  in 
throwing  out  of  consideration  the  mythical  and  fanciful  latent  gonorrhoea 
in  women.  We  shall  see  a  little  farther  on  that  gonorrhoea  may  remain 
in  an  indolent  condition,  either  in  the  urethra,  the  cervix  uteri,  or  the 
parts  higher  up,  but  in  these  cases  it  is  a  gonorrhoea  with  distinct  tissue- 
changes.  These  gonorrhoeas  are  not  myths,  since  they  present  determinate 
symptoms,  which  may,  however,  be  very  mild,  and  in  very  many  cases 
their  secretions  will  reveal  the  gonococcus  if  it  is  properly  and  persistently 
looked  for. 

I  am  disposed  to  think  that  Sanger's  estimate  that  one-eighth  of  all 
gynecological  cases  is  due  to  gonorrhoea!  infection  is  conservative  and 
probably  nearly  correct.  But  we  need  further  light.  Instead  of  assump- 
tions and  generalizations,  close  observations  and  study  of  cases  are  needed 
in  order  that  we  may  have  unimpeachable  scientific  knowledge. 

We  now  come  to  the  consideration  of  the  various  forms  of  gonorrhoea 
in  women. 

In  many  cases  of  gonorrhoea  in  women  the  history  of  the  period  of 
invasion  is  very  obscure.  In  some  the  sudden  onset  of  the  affection  in  a 
previously  healthy  woman,  in  a  Avoman  recently  married,  or  in  a  woman 
having  had  but  a  single  intercourse  may  give  positive  clues  as  to  the  early 
stage  of  the  disease.  In  very  many  cases,  however,  the  patient  gives  the 
history  of  having  suffered  for  a  long  period  with  chronic  leucorrhoea,  and 
of  having  experienced  an  exacerbation,  and  then  examination  reverJs 
acute  inflammation  of  the  external  and  perhaps  internal  genitalia. 

Gonorrhoea  of  the  Urethra. 

Gonorrhoea  of  the  urethral  canal  is  the  most  common  form  observed  in 
women.  Formerly  gonorrhoea  of  the  vagina  ranked  first  in  importance 
and  frequency,  but  recent  observations  and  studies,  particularly  those  of 
Steinschneider,^  Horand,^  Aubert,^  and  firaud,^  have  conclusively  proved 
that  the  virulent  suppuration  caused  by  the  gonococcus  is  most  frequently 
found  in  the  urethra.  The  disease  may  be  limited  to  the  urethra,  and  it 
may  exist  at  the  same  time  with  gonorrhoea  of  the  os  uteri.     In  some 

^  "  Ueber  die  Gonorrlioische  Erkrnnknng  der  Tiiben  und  des  Bauchfells,"  Ztschr.  fur 
Geburfsh.  und  GynakoL,  1891,  vol.  xxi.  pp.  IIU  et  seq. 

'■'  "Ueber  den  Sitz  der  gonorrhoischen  Infection  beim  Weibe,"  Beii.  klin.  Woehensckr., 
1887,  No.  17,  p.  301. 

^"Note  pour  servir  a  I'Etnde  de  la  Blennorrhagie  cbez  la  Femme,"  iyow  3Iedical, 
No.  43,  1888. 

*  "Localisation  de  la  RIennorihagie  chez  la  Femnie,"  Annales  des  Mai.  des  Org.  Gcn.- 
urin.,  1888,  vol  vi.  pp.  SOI  et  scq. 

^  "De  la  Blennorrhagie  chez  la  Femme,"  Annides  de  Derm,  et  de  Syph.,  1890,  vol.  i.  p. 
57. 

19 


290  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

cases  there  is  a  coexistent  vulvitis,  and,  particularly  in  young  subjects, 
the  vagina  may  also  be  involved,  either  as  a  whole  or  in  part. 

Urethral  gonorrhoea  in  the  female  resembles  in  some  particulars  the 
same  form  in  the  male.  It  has  a  period  of  incubation,  as  shown  by  ex- 
perimental inoculations  both  with  virulent  pus  and  the  cultivated  gono- 
coccus,  of  about  two  days,  which  may,  according  to  Martineau,  be  pro- 
tracted to  five  days. 

As  a  rule,  the  invasion  of  the  urethra  in  the  female  is  much  the  same 
as  in  the  male.  There  is  the  slight  tickling  and  burning  sensation,  and 
the  same  sero-mucous  secretion  in  which  little  whitish  particles  may  be 
seen  suspended,  which  under  the  microscope  are  shown  to  be  epithelial 
cells  and  gonococci.  Then,  after  a  prodromal  period  of  a  few  hours  or  a 
day  or  two,  the  acute  stage  develops,  with  more  or  less  severe  burning  in 
the  urethra,  rendered  worse  on  urination,  which  soon  becomes  quite  fre- 
quent. Examination  of  the  parts  shows  the  urethral  orifice  to  be  very 
red  and  swollen,  with  perhaps  a  pouting  prominence  of  its  lips.  A  green- 
ish-yellow discharge  escapes  in  considerable  quantity,  and  may  cause  red- 
ness and  swelling  of  the  parts  around  and  beneath.  The  presence  of  the 
finger-tip  inserted  in  the  vagina  shows  that  the  urethra  is  swollen  and 
tender,  and  pressure  from  behind  forward  causes  pus  to  exude  from  the 
meatus.  The  urethra  being  such  a  short,  nearly  straight  tube,  ending 
directly  in  the  bladder,  that  viscus  may  be  early  involved  in  the  inflam- 
mation. Examination  of  the  urine  by  the  two-glass  test  will  always  show 
how  deeply  the  morbid  process  has  travelled.  If  the  first  specimen  is 
cloudy  and  the  second  clear,  it  is  certain  that  the  bladder  is  not  involved. 
If  the  second  specimen  is  turbid,  then  it  is  certain  that  the  bladder  has 
been  infected. 

In  some  'cases  of  acute  urethral  gonorrhoea  in  women  there  may  be 
mild  febrile  movement  and  malaise.  As  a  rule,  their  local  sufferings  are 
quite  acute  at  this  time,  and  they  usually  become  worse  when  the  bladder 
is  involved.  Then  in  bad  cases  there  is  constant  tenesmus,  and  as  a  result 
the  frequent  urinations  cause  great  agony  :  not  infrequently  the  patient's 
sufferings  are  increased  by  the  urine  scalding  the  inflamed  contiguous 
parts. 

In  the  majority  of  cases  of  the  acute  stage  of  urethral  gonorrhoea  in 
the  female  amelioration  of  the  symptoms  begins  in  about  a  week  or  ten 
days,  and  even  sooner.  The  burning  and  scalding  become  less  and  less 
severe,  the  tenesmus  is  less  imperative,  and  the  urinations  become  less 
frequent  and  painful.  The  redness  and  swelling  of  the  meatus  subside 
slowly,  and  the  pus  becomes  whitish  and  mucoid.  In  this  way  matters 
grow  progressively  better  until  the  chronic  stage  may  be  reached.  Then 
we  commonly  see  a  normal  or  only  slightly  red  meatus,  from  which,  by 
intravaginal  pressure  on  the  urethra,  a  drop  or  two  of  viscid  muco-pus  or 
a  thinner  milky-looking  fluid  may  escape.  In  this  condition  the  woman 
may  suffer  no  discomfort  whatever,  or  she  may  have  a  very  slight  smarting 
or  a  sensation  of  heat  on  urination. 

Microscopical  examination  of  the  pus  in  the  florid  stage  shows  pus- 
cells  with  many  gonococci.  As  the  secretion  becomes  more  mucoid,  epi- 
thelial cells  show  prominently  in  the  field,  with  a  diminished  number  of 
gonococci.  In  the  chronic  stage  there  are  usually  found  some  pus-cells, 
epithelial  cells,  a  few  gonococci,  and  the  usual  indifferent  microbes.    Later 


GONORRHCEA  IN  THE  FEMALE.  291 

on  no  gonococci  can  be  seen.  In  this  chronic  stage,  when  the  bladder  has 
remained  intact,  the  first  ounce  of  water  passed  into  the  first  vessel  will 
contain  some  clumps  and  filaments  of  pus  and  epithelium,  while  the  urine 
in  the  second  vessel  will  be  clear.  When  there  is  a  complicating  cystitis 
the  urine  in  the  second  glass  will  be  nearly  as  turbid  as  that  in  the  first 
glass. 

Many  women  have  this  chronic  form  of  urethral  inflammation  for  a 
long  time,  even  for  years.  Its  secretion  in  the  early  months  is  infectious. 
Later  on  the  process  is  simply  a  post-gonorrhoeal  urethritis,  and  the  pus 
then  is  harmless.  As  a  rule,  the  urethral  secretion  becomes  innocuous  in 
about  six  months  or  a  year  after  the  date  of  infection,  as  I  have  myself 
many  times  seen.  This  is  shown  by  the  impunity  with  which  men  co- 
habit with  women  who  have  this  emasculated  secretion.  In  its  active 
stages,  however,  the  pus  of  gonorrhoeal  urethritis  of  women  is  equally  as 
virulent  as  that  of  men  simiharly  afflicted. 

In  the  declining  and  chronic  stage  of  urethral  gonorrhoea,  in  the 
absence  of  symptoms  and  of  swelling  and  redness  of  the  urethral  orifice, 
the  way  to  diagnosticate  the  trouble  is  by  intravaginal  pressure  on  the 
urethra  from  behind  forward,  or  by  the  examination  of  the  urine  which 
is  passed  several  hours  after  a  previous  urination  which  has  cleansed  the 
canal.  Women  very  frequently  urinate  just  before  presenting  themselves 
to  the  surgeon,  who  then  fails  to  obtain  a  secretion  in  the  meatus  by  pres- 
sure on  the  urethra.  The  woman  under  suspicion  should  not  be  allowed 
to  urinate  or  use  injections  on  the  same  day  that  she  applies  for 
examination,  and  the  surgeon  should  decline  to  give  an  opinion  if 
she  does. 

In  chronic  urethritis  in  women  it  is  not  common  to  see  the  exacerba- 
tions of  the  trouble  Avhich  are  so  frequent  in  men.  In  the  majority  of 
cases  the  intra-urethral  and  peri-urethral  glands  only  become  infected  in 
the  declining  stage  of  the  urethritis.  Therefore  these  forms  of  inflamma- 
tion will  be  considered  farther  on  separately.  Since  there  are  no  mucous 
follicles  along  the  course  of  the  female  urethra  beyond  the  first  half  inch, 
as  there  are  in  man,  we  do  not,  as  a  rule,  find  those  deep-seated  follicular 
abscesses  which  are  almost  peculiar  to  men. 

The  morbid  appearances  of  the  female  urethra  affected  by  gonorrhoea 
have  been  studied  by  Janovsky.^  In  the  acute  stage  the  parts  are  red, 
swollen,  and  succulent,  and  erosions  are  seen  over  the  surface.  Much 
swelling  is  seen  around  Skene's  glands.  Minute  polypoid  growths  were 
seen  along  the  canal,  and  in  one  case  there  was  distinct  membranous  des- 
quamation. In  the  chronic  stage  a  granular  appearance  was  noted  as  a 
result  of  the  submucous  infiltration.  There  was  also  epithelial  thickening 
in  localized  and  diffuse  form,  and  decided  prominence  to  Skene's  glands. 

Chronic  urethritis  in  women  results  in  some  instances  in  stricture  of 
the  urethra,^  which  makes  itself  evident  by  increasing  difficulty  in  uri- 
nation, and  sometimes  by  retention.  In  women,  as  in  men,  urethral  stric- 
ture may  lead  to  cystitis  and  to  pyelo-nephritis. 

'  "  Endoscopische  Beitrlige  zur  Lehre  von  der  Gonorrhoe  des  Weibes,"  Archiv  filr 
Derm,  unci  Sijphilis,  1891,  pp.  911  et  seq. 

'*'  The  reader  is  referred  to  an  elaborate  essay  on  urethral  stricture  in  women  and  its 
treatment  by  Genouville,  entitled  "  Du  Retrecissement  blennorrhagicjue  de  I'Ur^thre  chez 
la  Femme,  etc.,"  Annales  des  Mai.  des  Org.  Gen.-urin.,  1892,  pp.  832  and  925  et  seq. 


292  GONOBBHCEA  AND  ITS  COMPLICATIONS. 


Gonorrhoea  of  the  Os  Uteri  and  Uterus. 

The  frequency  and  importance  of  gonorrhoeal  infection  of  the  os  uteri 
and  uterus  were  really  not  fully  appreciated  until  within  recent  times. 
Though  many  years  ago  Rollet^  published  an  admirable  paper  on  the  sub- 
ject, gonorrhoea  of  the  os  uteri  remained  obscure  among  the  catarrhal 
inflammations  of  this  part,  and  was  not  accorded  a  prominent  place  as 
a  distinct  morbid  condition.^  As  claimed  by  Bumm  ^  and  Steinschneider,* 
this  form  of  gonorrhoea  ranks  second  to  urethritis,  which  is  the  most 
common  form  of  the  disease  in  the  adult  female. 

The  chief  importance  of  gonorrhoea  of  the  os  uteri  resides  in  the  fact 
that  from  this  focus  the  uterus  itself  and  the  parts  above  in  direct  anato- 
mical connection  may  be  invaded  early  or  late  by  the  infection. 

Gonorrhoea  of  the  os  uteri  is  very  probably  contracted  in  intercourse 
with  men  who  are  in  the  declining  stage  of  acute  gonorrhoea.  During  the 
acute  stage  men,  by  reason  of  the  pain,  swelling,  and  discharge,  refrain 
from  coitus,  but  as  the  trouble  subsides  they  often  weary  of  continence, 
have  intercourse,  and  infect  their  consorts. 

The  anatomical  position  of  the  os  is  such  that  in  coitus  it  generally 
comes  in  contact  with  the  apex  of  the  glans  penis,  and  then  becomes 
bathed  with  the  ejaculation  which  carries  with  it  pus  from  the  still 
inflamed  urethra,  unless  the  latter  tube  has  been  thoroughly  flushed  by 
recent  urination.  When  the  vagina  is  short,  and  when  the  uterus  rests 
low  in  the  pelvis,  the  chances  of  infection  are  great.  Consequently,  when 
the  uterus  is  placed  high  up  the  os  may  escape  infection.  The  length  of 
the  penis  and  the  duration  of  the  sexual  act  also  have  bearing  upon  the 
infection  of  the  os. 

Gonorrhoea  of  the  os  uteri  may  be  the  sole  evidence  of  a  given  infec- 
tion, which  may  begin  in  this  part,  and  there  remain  until  cured.  It  also 
coexists  in  many  cases  with  a  urethritis  of  similar  origin.  Then,  again, 
the  pus  escaping  from  the  uterine  orifice  not  infrequently  infects  the 
vagina,  usually  in  a  localized  manner,  and  rarely  in  the  totality  of  the 
tube.  In  only  acute  and  very  severe  cases  is  the  os  infected  by  extension 
of  the  disease  from  the  urethra  up  the  vagina. 

According  to  Martineau,^  the  onset  of  gonorrhoea  of  the  os  uteri  may 
be  brusque  and  accompanied  by  dull  pain  and  weight  in  the  hypogastrium, 
with  radiating  pains  over  the  abdomen,  lumbar  region,  and  thighs.  With 
this  evidence  of  local  trouble  there  is  fever  and  all  its  attendant  symp- 
toms. Martineau  seems  to  be  alone  in  the  observation  of  such  severe 
initial  symptoms,  and  probably  based  his  description  on  cases  in  which 
there  was  extension  of  the  gonorrhoeal  process  from  the  os  to  the  body  of 
the  uterus. 

Verch^re,^  while  he  quotes  Martineau's  description  of  symptoms,  dis- 

^"Des  Maladies  veneriennes  et  syphilitiques  de  I'Uterus,"  Annates  de  Derm,  et  de 
Syph.,  vol.  i.,  1869,  pp.  100  et  seq. 

^  Audry  {Preck  des  Maladies  blennorrhagiques,  Paris,  1894,  p.  183),  speakins:  of  sjonor- 
rhoea  of  the  uterns,  says  that  prior  to  1884  an  experienced  clinician  had  no  hesitation  in 
stating  that  in  4000  women  (venereal  cases)  treated  at  the  Lourcine  Hospital  he  had  ob- 
served this  affection  only  in  10  cases. 

=*  Op.  cit.  ■*  Op.  cit. 

*  Lemons  cliniques  sur  la  Blennorrhagie  chez  la  Femme,  Paris,  1885,  p.  90. 

^  La  Blennorrhagie  chez  la  Femme,  vol.  i.  p.  87,  Paris,  1894. 


GONOBRHCEA  IN  THE  FEMALE.  293 

tinctly  states  that  he  never  observed  such  a  mode  of  evolution  in  his 
experience  at  the  St.  Lazare  Hospital. 

In  the  majority  of  cases  gonorrhoea  of  the  os  uteri  begins  in  an  insidi- 
ous manner  unattended  with  marked  symptoms.  The  external  and  inter- 
nal surfaces  of  the  os  become  red  and  swollen,  and  they  give  forth 
a  muco-purulent  secretion.  Some  women  will  complain  of  excessive  dis- 
charge, while  others,  who  have  long  had  vaginal  secretions,  may  pay  no 
attention  to  an  increase,  even  if  it  is  decidedly  copious.  Thus  it  is  that 
this  affection  is  seldom  seen  in  its  very  early  days. 

When  a  woman  suffering  from  gonorrhoea  of  the  os  uteri  is  examined 
by  means  of  the  speculum,  nothing  absolutely  characteristic  or  diagnostic 
can  be  seen.  The  os  is  swollen,  is  more  or  less  red,  even  to  a  purplish 
tint.  At  first  the  mucous  membrane  is  swollen  and  has  a  velvety  appear- 
ance. From  the  os  a  purulent  or  muco-purulent  discharge  escapes  in  large 
drops,  and  around  the  os  is  a  narrow  collarette  of  redness  and  erosion. 
Then,  when  the  os  is  much  enlarged,  it  may  be  eroded  in  totality  or  in 
part.  Sometimes  there  are  many  small  erosions,  and  again  there  may 
be  several  quite  large  ones.  Though  these  erosions  are  sometimes  called 
ulcerations,  they  are  simply  local  losses  of  epithelium,  such  as  we  see  in 
tolerably  well-marked  cases  of  erosive  balanitis.  When  the  inflammatory 
process  runs  higher  and  there  is  much  exudative  inflammation,  the  outer 
surface  of  the  os  presents  a  mammillated  appearance,  probably  from  the 
swelling  and  prominence  of  the  muciparous  glands.  This  condition  may 
become  so  well  marked  that  the  appearances  of  the  os  resemble  those  of 
a  very  rough  orange.  Then,  again,  the  surface  of  the  os,  in  cases  of  a 
severe  course,  may  become  quite  deeply  eroded  and  present,  as  pointed 
out  by  Rollet,  the  appearance  of  a  deep-red  cherry,  from  which  its  rind 
has  been  peeled  off".  With  a  still  greater  increase  in  the  morbid  process, 
granulations,  perhaps  a  few  and  perhaps  in  abundance,  may  develop  on 
the  external  surface  of  the  uterine  neck  and  on  the  contiguous  mucous 
membrane,  particularly  that  part  below  the  posterior  lip  of  the  os  uteri. 
These  granulations  may  be  of  millet-seed  size,  and  they  may  resemble  the 
papillae  of  raspberries  and  strawberries.  In  the  course  of  time  these 
granulations  may  go  on  and  develop  into  true  warty  growths,  which  may 
further  become  epitheliomatous.  Over  the  morbid  surface  we  frequently 
find  a  film  or  membrane  of  thick  greenish  pus,  and  from  the  os  a  purulent 
fluid  escapes.  In  many  of  these  cases,  Avhen  fully  developed,  the  patients 
complain  of  dysmenorrhoea  and  too  frequent  and  too  copious  menstruation. 
It  is  these  menstrual  symptoms  which  often  cause  the  patients  to  seek 
medical  advice,  and  then  a  correct  diagnosis  may  be  made. 

In  a  goodly  number  of  cases  the  tissue-changes  of  the  external  surface 
of  the  OS  are  yqtj  slight,  consisting  of  a  mild  increase  of  redness  with  or 
without  moderate  erosion. 

Even  when  there  is  a  marked  condition  of  erosion  the  external  epithe- 
lium may  be  restored,  while  at  the  same  time  the  morbid  process  persists 
in  the  lumen  of  the  os.  The  main  cause  of  the  chronicity  of  gonorrhoea 
of  the  uterine  neck  is  the  localization  of  the  process  in  the  numerous  and 
deeply-seated  glands  of  Naboth  with  their  plentiful  blood-supply.  As  the 
aff'ection  grows  old,  even  if  little  or  indifferent  treatment  is  followed,  the 
discharge  in  many  cases  becomes  less  purulent  and  more  mucoid,  so  that 
in  its  chronic  stage  this  form  of  gonorrhoea  may  only  give  as  an  objective 


294  GONORRHCEA  AND  ITS  COMPLICATIONS. 

symptom  the  well-known  glassy-white  mucous  plug  which  hangs  from  the 
OS  so  constantly.  This  plug  resembles  those  of  the  ordinary  simple  in- 
flammations of  these  parts,  and,  while  it  frequently  contains  gonococci  in 
its  meshes,  there  is  no  visible  sign  present  to  denote  its  virulent  character. 
In  many  cases  the  only  means  of  determining  the  presence  of  gonococci 
in  the  os  is  to  gently  curette  it,  and  then  examine  the  detritus  micro- 
scopically. 

Throughout  the  whole  course  of  gonorrhoea  of  the  os  this  segment  may 
not  be  the  seat  of  pain,  and  its  examination  by  bimanual  manipulation 
may  give  rise  to  little  if  any  unpleasant  sensation.  Pain,  however,  is 
quite  exceptionally  felt,  either  spontaneously  or  as  a  result  of  physical 
examination. 

Now,  it  must  be  confessed  that  with  all  the  objective  phenomena  just 
presented  there  are  no  appearances  which  may  not  be  found  in  simple 
troubles  of  the  uterine  neck.  How,  then,  can  we  establish  a  diagnosis  of 
gonorrhoea  ?  In  some  cases  the  facts  of  an  infecting  coitus  may  be  estab- 
lished. In  others  (when  the  trouble  is  known  or  found  out)  the  onset  of 
an  endocervicitis  in  a  healthy  young  woman,  who  has  not  been  tampered 
with  to  produce  abortion,  who  has  not  undergone  any  form  of  minor  gyne- 
cological treatment,  and  who  has  not  had  any  disturbance  of  menstruation, 
may  cause  the  suspicion  of  gonorrhoeal  infection  in  coitus.  In  many  cases 
early  in  their  course  it  is  very  easy  to  find  the  gonococcus  in  the  pus, 
which  must  be  taken  by  means  of  a  platinum  loop  from  within  the  cervical 
cavity,  the  orifice  of  which  has  been  rendered  clean  and  sterile.  Then, 
again,  we  frequently  meet  with  cases  in  which  a  profuse,  very  yellow, 
purulent  discharge  escapes  from  the  os,  in  which  discharge  the  most 
scrutinizing  examination  fails  to  reveal  the  gonococcus  and  perhaps  any 
hostile  microbe.  A  further  surprise  often  awaits  us.  From  a  SAvollen  and 
eroded  or  only  a  mildly-reddened  os  a  glairy  mucous  plug  hangs,  which 
looks  so  innocent  that  a  diagnosis  of  gonorrhoea  seems  unwarrantable. 
But  perhaps  the  woman  may  be  under  suspicion  of  having  given  gonor- 
rhoea to  a  man,  and  further  examination  is  necessary.  Then,  the  secre- 
tion having  been  gathered  and  prepared,  great  is  one's  surprise  to  see 
typical  gonococci  in  large  or  small  numbers.  Then,  again,  in  very  many 
of  these  mucous  plugs  nothing  but  a  few  pus-cells  and  indifferent  microbes 
are  found. 

The  conclusion  warranted  by  all  these  facts  is,  that  while  it  is  certain 
that  gonorrhoeal  infection  of  the  os  uteri  is  of  very  frequent  occurrence, 
it  is  often  overlooked.  It  may  present  no  objective  or  subjective  symp- 
toms which  distinguish  it  from  simple  processes,  while  the  facts  of  the  case 
may  occasionally  point  to  gonorrhoeal  infection  in  coitus.  In  these  cases, 
when  recent,  the  microscope  may  reveal  the  gonococcus,  and  thus  dispel 
all  doubt.  Then,  again,  as  the  morbid  process  grows  old,  even  the  micro- 
scopic evidence  may  grow  less  and  less  striking  and  certain,  so  that  in 
many  cases,  in  the  absence  of  the  gonococcus,  it  having  played  its  part 
and  disappeared,  there  is  no  diagnostic  evidence  of  any  kind  to  prove  that 
the  case  started  out  by  gonorrhoeal  infection. 

On  this  subject  the  words  of  Ricord  ^  deserve  to  be  quoted  and  em- 
phasized.    He  says :   "  Whatever  uterine  catarrh  may  be,  an  experience 
of  more  than  twenty  years  has  taught  me  that  it  is  the  most  common 
^  Clinique  iconogmphique  de  I'Hdpital  des  Veneriens,  Paris,  1862,  p.  8. 


GONOBRHCEA  IN  THE  FEMALE.  295 

source  of  gonorrhoea  in  men,  even  when  we  have  not  the  right  to  attribute 
it  to  a  venereal  cause." 

Gonorrhoea  of  the  os  uteri  very  often  presents  in  a  clear  manner  the 
fallibility  of  the  doctrine  of  the  gonococcus.  In  many  cases  gonorrhoea 
in  men  can  be  traced  to  gonococci-containing  pus  or  muco-pus  from  the 
OS  uteri  of  an  infected  woman.  In  many  other  cases,  where  this  is  the 
only  segment  of  the  genital  tract  that  is  the  seat  of  inflammation,  the 
most  elaborately  careful  examination  of  the  secretion,  even  when  pro- 
cured by  scraping,  fails  utterly  to  show  any  gonococci,  while  other 
microbes  may  be  seen.  Yet  the  men  who  have  cohabited  Avith  these 
women  may  have  florid  gonorrhoea,  with  gonococci-containing  pus. 

In  the  larger  number  of  cases  the  gonorrhoeal  process  ceases  at  the  os 
internum.  Whether  this  normal  constriction  of  the  parts  has,  as  claimed 
by  some,  any  tendency  to  act  as  a  barrier  to  the  infection,  we  cannot 
positively  say. 

GoNORRHCEAL  ENDOMETRITIS. — By  the  extension  of  the  gonorrhoeal 
process  beyond  the  os  internum  the  mucous  membrane  of  the  body  of  the 
uterus  is  attacked  by  its  characteristic  inflammation.  When  the  uterus  is 
attacked,  there  may  be  fever,  a  sensation  of  heat,  and  bearing-down  pains 
in  the  pelvis  which  radiate  to  the  back.  There  may  also  be  nausea  and 
vomiting.  In  this  acute  form  the  uterus  is  tender  on  pressure,  and  Avhen 
practicable  bimanual  palpation  shows  that  the  organ  is  much  swollen  in 
all  directions.  There  may  be  suppression  of  the  menses  or  monorrhagia. 
The  uterine  secretion  is  abundant,  purulent,  or  muco-purulent  in  charac- 
ter, and  perhaps  mixed  with  blood,  and  in  it  the  gonococcus  can  readily 
be  demonstrated.  The  vagina  is  hot  and  the  cervix  is  red,  swollen,  and 
eroded.  Where  the  history  of  the  case  points  to  gonorrhoea,  the  diagnosis 
may  be  made  with  the  aid  of  the  microscope.  There  are  no  pathogno- 
monic symptoms  whatever,  either  objective  or  subjective,  by  which  a  posi- 
tive diagnosis  of  gonorrhoea  can  be  arrived  at.  In  some  cases  acute 
recent  gonorrhoea  of  the  husband,  followed  by  symptoms  of  acute  infec- 
tion in  the  wife,  clearly  points  to  the  virulent  origin  of  the  process,  which 
may  be  confirmed  by  the  aid  of  the  microscope. 

Acute  gonorrhoeal  metritis  passes  into  the  chronic  form,  in  which  the 
diagnosis  becomes  more  and  more  difficult,  since  in  the  absence  of  a 
clear  history  the  gonococcus  is  the  only  criterion,  and  this  microbe  grows 
less  numerous,  and  even  disappears,  in  proportion  as  the  process  grows 
old.  In  the  chronic  stage  the  case  belongs  to  the  domain  of  the  gyne- 
cologist (and  it  is  to  be  hoped  that  the  one  consulted  is  a  cool  and  con- 
servative man),  whose  advice  should  be  sought  unless  the  attendant  is 
especially  skilled  in  women's  diseases. 

Gonorrhoea  of  the  Vagina. 

In  former  years  the  vagina  was  looked  upon  as  the  stronghold  of 
gonorrhoea  in  the  female,  but  to-day  there  are  observers  who  claim  that 
there  is  no  such  afl'ection  as  true  gonorrhoea  of  this  part,  and  that,  if 
this  tube  is  gonorrhoeically  aff'ected,  its  infection  has  been  caused  by  the 
virulent  pus  pouring  down  from  the  os  or  the  uterus.  The  reason  as- 
signed  by   Bumm^  and   Steinschneider^  is   that   the   epithelium   of  the 

^  Op.  cit.  ^  Op.  cit. 


296  GONORRHCEA   AND  ITS  COMPLICATIONS. 

vagina  is  of  the  pavement  variety,  which  is  tough  and  horny,  and  fully 
capable  of  resisting  the  invasion  of  the  gonococcus.  Bumm  says  that  he 
kept  gonorrhoeal  pus  in  contact  with  the  vagina  for  twelve  hours  and 
failed  to  produce  any  inflammatory  reaction.  It  is  further — and  truth- 
fully— claimed  that  gonococci  do  not  thrive  exuberantly  in  the  vagina. 
Bumm,  however,  does  admit  that  the  mucous  membrane  of  the  vagina  is 
soft  and  susceptible  before  the  age  of  sexual  maturity,  and  that  during 
that  period  the  parts  may  be  successfully  attacked  by  the  gonococcus. 
Schwartz  ^  denies  Bumm's  contention,  and  claims  that  the  gonococcus 
does  thrive  in  the  deep  parts  of  the  epithelium,  and  that  there  may  be 
true  gonorrhoeal  vaginitis  without  the  infection  of  the  uterus. 

This  position  of  the  ardent  advocates  of  the  virulency  of  the  gono- 
coccus is  in  keeping  with  many  of  their  attempts  to  formulate  laws  based 
on  microscopic  and  bacteriological  investigations.  In  a  measure,  they  are 
correct  in  their  claim,  but  clinical  facts  must  not  be  utterly  subordinated 
to  conclusions  reached  by  study  with  the  microscope.  Speaking  from  the 
standpoint  of  both  microscopists  and  clinical  observers,  the  matter  may  be 
summed  up  as  follows :  True  gonorrhoea  of  the  vagina  may  be  found  in 
young  girls  Avhose  vaginal  mucous  membrane  is  yet  succulent,  and  who 
have  not  been  accustomed  to  sexual  intercourse,  which  tends  to  the  corni- 
fication  of  its  epithelium.  In  some  rather  older  girls  or  women,  in  whom 
the  mucous  membrane  is  still  soft  and  normally  quite  hypergemic,  gonor- 
rhoeal infection  may  occur.  Then,  again,  in  women  whose  vaginae  possess 
the  normal  resistance  the  continued  contact  of  the  gonorrhoeal  pus  from 
the  cervix  or  uterus  produces  a  localized  vaginal  gonorrhoea. 

In  the  foregoing  considerations  Ave  have  kept  strictly  in  the  line  of 
true  gonococcus  infections,  but  clinically  Ave  must  not  be  thus  hampered, 
but  must  go  farther.  Any  one  Avho  has  seen  in  a  long  stretch  of  years 
large  numbers  of  Avomen  suffering  from  various  venereal  diseases,  and  has 
observed  and  studied  them  carefully,  wull  call  to  mind  many  women  with 
chronic  purulent  vaginitis  in  the  secretion  of  whom  no  gonococci  could  be 
found,  but  who  in  coitus  Avith  men  communicated  to  them  florid  gonor- 
rhoea, in  the  pus  of  Avhich  gonococci  could  be  found. 

Gonorrhoea  of  the  vagina  may  be  local  or  general,  acute  or  chronic. 
Very  commonly,  little  can  be  learned  of  its  onset,  since  it  is  liable  to 
occur  in  Avomen  the  subjects  of  uterine  or  vaginal  leucorrhoea.  Then, 
again,  women,  as  a  rule,  are  less  communicative  and  truthful  regarding 
their  amours  than  men  are ;  consequently,  the  date  and  source  of  conta- 
gion are  always  with  difficulty,  and  many  times  are  never,  ascertained. 
Carelessness  of  the  person,  and  the  indifference  Avhich  comes  to  many 
Avomen  about  vaginal  discharges,  very  frequently  tend  to  prevent  the 
surgeon  obtaining  a  satisfactory  history  of  the  case. 

When  seen  early  the  vagina  affected  Avith  gonorrhoea  presents  a  dry 
red  surface,  which  is  the  seat  of  a  sensation  of  heat.  Very  soon  a  mucoid 
fluid  is  seen,  which  soon  becomes  muco-purulent.  In  its  fully-developed 
stage  the  secretion  of  vaginal  gonorrhoea  is  a  pus  of  considerable  consist- 
ence and  of  a  milky  color,  due  to  the  admixture  of  large  quantities  of 
epithelial  scales. 

When  gonorrhoea  of  the  vagina  is  due  to  the  extension  of  the  inflam- 
mation from  the  external  genitalia,  it  is  attended  with  all  the  symptoms 

1  Op.  cit. 


GONORRHCEA  IN  THE  FEMALE.  297 

incident  to  the  latter,  together  with  a  sense  of  burning  heat  which  is 
referred  by  patients  as  deep  down  in  the  pelvis.  The  vaginal  orifice  and 
caruncLilfe  myrtiformes  are  reddened,  swollen,  and  eroded,  and  constantly 
bathed  with  pus.  In  the  cases  under  consideration,  if  treatment  is  adopted 
promptly,  only  a  small  portion  of  the  lower  vagina  may  be  involved. 
Untreated,  however,  the  tendency  of  the  disease  is  to  become  firmly  fixed 
and  chronic,  and  to  localize  itself  in  the  upper  parts  of  the  vagina,  par- 
ticularly in  its  posterior  fornix  or  Douglas's  cul-de-sac.  In  some  cases  it 
is  found  to  attack  the  anterior  fornix,  and  in  others  both  recesses,  anterior 
and  posterior  to  the  uterus. 

Acute  gonorrhoea  originating  in  the  vagina  proper  is  sometimes  seen 
to  involve  its  lower  third,  but  may  occur  at  any  part,  particularly  on  its 
posterior  aspect.  When  severe  and  extensive,  it  gives  rise  to  great  sufi'er- 
ing  in  the  form  of  a  continuous  burning  pain  in  the  pelvis,  which  is  much 
aggravated  by  motion,  walking,  and  even  by  sitting  down.  So  great  is 
the  swelling  of  the  vaginal  orifice,  and  such  is  the  tenderness,  that  the 
introduction  of  the  finger  or  of  an  instrument  is  impossible,  and  patients 
beg  that  the  nozzle  of  the  syringe  shall  not  be  inserted,  and  if  at  all  a 
very  small  one.  When  the  acute  stage  is  fully  developed,  the  sufferings 
of  the  patient  are  often  further  increased  by  the  extension  of  the  disease 
to  the  urethra  and  vulva.  Under  these  circumstances  her  condition  is 
often  pitiable,  as  may  well  be  imagined  from  the  extent  of  surface  in- 
volved. The  duration  of  the  acute  stage  is  very  variable,  and  depends 
largely  upon  the  efficacy  of  treatment  and  upon  the  regularity  with  which 
it  is  followed.  In  general,  a  week  or  ten  days  elapse  before  topical  treat- 
ment can  be  instituted  in  the  vaginal  canal.  Then  much  can  be  done, 
provided  the  woman  can  be  kept  in  bed  and  properly  attended  to.  But 
women  thus  afflicted  are,  as  a  rule,  careless  patients,  and,  though  the 
gravity  of  their  case  be  pictured  to  them  in  the  clearest  manner,  they  in 
very  many  instances  backslide.  Then,  again,  the  recurrence  of  the 
menstrual  epoch,  with  its  engorgement  of  the  genito-urinary  tract  and 
sometimes  its  irritating  secretion,  is  often  a  very  serious  setback.  In 
private  and  dispensary  practice  we  constantly  see  these  patients  reach  a 
subacute  condition,  and  then  they  disappear,  and  even  in  the  hospital 
they  often  consider  themselves  well  and  demand  their  discharge  long 
before  the  surgeon  deems  it  prudent. 

Subacute  gonorrhoeal  vaginitis  is  seen  in  two  principal  forms — the  one 
limited  to  the  lower  segment  of  the  tube,  and  usually  rather  more  severe 
on  its  posterior  wall ;  the  other  and  more  frequent  one  in  the  cul-de-sac 
behind  the  uterus.  Besides  these,  the  affection  may  be  seen  to  be  seated 
anterior  to  the  uterus  and  in  the  middle  third  of  the  vagina.  When 
occurring  in  the  lower  two-thirds  of  the  vagina,  the  membrane  is  found 
to  be  red,  swollen,  in  places  eroded,  thrown  into  large  folds,  and  bathed 
with  pus.  When  the  inflammation  is  seated  low  down,  the  introitus  vaginae 
and  the  tissues  immediately  around  it  are  more  or  less  inflamed. 

Gonorrhoea  of  the  posterior  vagina  or  Douglas's  cul-de-sac  is  of  not 
infrequent  occurrence.  In  this  position  it  is  very  liable  to  escape  detec- 
tion unless  carefully  looked  for.  To  this  end,  the  best  opportunity  for  a 
thorough  examination  is  offered  by  the  genu-pectoral  position,  though 
very  often,  from  feelings  of  delicacy,  we  cannot  insist  upon  it.  The  next 
best  position  is  that  of  Sims  with  his  own  speculum,  but  it  is  inferior,  in 


298  GOXOREHCEA  ASD  ITS  COMPLICATIONS. 

my  experience,  to  the  genu-pectoral  position.  In  the  latter  Sims'  spec- 
ulum may  be  used  or  one  made  of  thin  nickel-plated  wire,  such  as  is  found 
in  the  shops.  Thus  exposed,  the  mucous  membrane  is  seen  to  be  deep 
red,  cedematous,  and  more  or  less  excoriated  and  covered  with  copious 
creamy  greenish  pus  mixed  with  glairy  mucus.  In  most  cases  there  is 
coexistent  inflammation  of  the  os  uteri  in  the  form  of  a  deep-red,  easily- 
bleeding,  inflammatory  areola,  and  from  it  a  muco-purulent  plug  may 
hang.  In  some  cases  the  gonorrhoeal  inflammation  extends  only  as  far 
as  the  OS  internum,  but  in  others  the  uterine  cavity  is  aff"ected. 

Besides  the  cases  of  gonorrhoea  of  the  vagina  which,  from  the  sudden 
onset  of  the  affection  and  from  its  violent  nature,  are  regarded  as  due  to 
direct  contagion,  we  frequently  see  vaginitis — or,  as  it  is  of  late  years 
termed,  elytritis — develop  in  persons  subject  to  cervical  and  corporeal 
endometritis  and  chronic  subacute  inflammation  of  the  vagina.  The 
history  of  the  beginning  of  the  trouble  is  usually  very  vague,  though  in 
some  cases  excessive  and  unnatural  coitus  and  uncleanliness  seem  to  be 
the  exciting  causes.  Morbid  constitutional  conditions  may  tend  to  inten- 
sify this  inflammation. 

Vaginitis  or  elytritis  of  more  or  less  severity  occurs  in  the  young, 
middle-aged,  and  old  in  less  severe  form  than  that  alreadv  described. 
This  variety  is  termed  by  authors  simple  vaginitis,  and  Martineau  says 
that  it  can  be  difi"erentiated  from  the  severe  forms  by  the  fact  that  in  the 
latter  the  secretion  is  acid  in  reaction,  while  in  the  former  it  is  alkaline. 
The  clinical  description  of  the  severe  form  has  been  given,  and  it  is  only 
necessary  to  say  that  in  every  feature  the  mild  aff"ection  is  much  less 
severe.  In  these  mild  cases,  however,  exacerbations  may  be  observed, 
and  the  affection  may  become  as  severe  as  those  of  gonorrhoeal  origin. 

Verchere  ^  describes  a  rare  form  of  diphtheroid  or  croupal  vaginitis 
which  he  observed  in  two  cases  of  young  girls  suffering  from  acute  gonor- 
rhoea. The  vaginal  mucous  membrane  was  red  and  swollen,  and  scattered 
over  it  in  small  and  large  areas  were  yelloAvish-white  patches  of  false 
membrane  which  were  very  adherent  to  the  vagina.  They  showed  a 
decided  tendency  to  reappear  after  removal.  The  mucous  membrane 
under  these  plaques  gave  the  appearance  of  hospital  gangrene.  There 
was  an  abundant  flow  of  pus  of  bad  odor,  and  the  parts  were  the  seat  of 
heat  and  pain.  In  spite  of  an  energetic  treatment,  the  affection,  which 
was  strictl}''  limited  to  the  vagina,  lasted  about  three  weeks. 

As  a  result  of  gonorrhoeal  vaginitis,  the  mucous  membrane  is  some- 
times found  to  be  thickened  and  granular.  These  granulations  are  due 
to  exuberant  epithelial  proliferation  and  new  vessel-formation,  and  may 
be  scattered  over  the  whole  tube,  or  may  be  localized  particularly  in  its 
posterior  Avail. 

Some  observers,  notably  gynecologists,  claim  that  simple  vegetations 
or  warts  are  symptomatic  of  gonorrhoeal  inflammation.  This  state- 
ment is  incorrect  and  misleading.  Vegetations  result  from  any  chronic 
irritative  process  by  which  the  parts  are  kept  hot  and  moist.  They  are 
frequently  seen  in  women  Avho  never  had  connection  and  Avere  uncleanly. 
They  may  occur  during  the  course  of  any  catarrhal  process  of  the  vagina 
or  vulva,  and  may  develop  in  the  course  of  gonorrhoea. 

In  the  study  of  gonorrhoea  in  the  female  Ave  must  not  alloAv  ourselves 

^  Op.  cit.,  vol.  i.  pp.  82  et  seq. 


GONORRHCEA  IN  THE  FEMALE.  299 

to  be  fettered  with  too  sharply-drawn  laws  based  on  the  infallibility  of 
the  gonococcus,^  since  at  almost  every  step  we  find  that  clinical  facts  are 
at  variance  with  microscopical  deductions,  or  at  least  not  in  direct  con- 
formity with  them.  It  is  these  considerations,  which  have  for  years  been 
forcing  themselves  on  my  mind,  which  cause  me  to  give  myself  more  lati- 
tude in  describing  gonorrhoeal  vaginitis  than  the  followers  of  Neisser  are 
willing  to  accord  to  themselves  and  to  others. 

As  an  instance  of  the  susceptibility  of  the  vagina  the  following  striking 
case,  reported  by  Welander,^  is  of  great  interest :  A  man  having  gonor- 
rhoea attempted  coitus,  without  successful  intromission,  during  two  days 
with  his  newly-married  wife.  Violent  inflammation  of  the  vulva,  urethra, 
and  introitus  vaginae  was  soon  set  up.  In  the  profuse  purulent  secretion 
many  gonococci  were  found.  The  infection  travelled  upward  and  involved 
the  vagina,  but  not  the  cervix  uteri.  Hardy,  quoted  by  Verchere,^  also 
reported  an  interesting  case.  It  was  that  of  a  young  girl  who,  having  no 
trouble  previously,  had  a  single  and  only  connection  with  a  man.  A  few 
days  later  there  was  a  purulent  discharge  from  the  cervix  uteri,  which  ran 
down  and  infected  the  vagina.  The  whole  morbid  process  was  carefully 
watched  by  Hardy. 

1  Conrad  of  Berne  {British  Med.  Journal,  Oct.  17,  1887,  p.  854)  has  tried  to  solve  the 
question  as  to  whether  it  is  possible  to  differentiate  a  gonorrhoeal  affection  of  the  female 
genitals  from  a  non-gonorrhoeal  one  by  means  of  the  microscopic  examination  of  secre- 
tions and  cultivation-experiments.  He  gathered  with  much  care  and  at  different  times  the 
secretions  of  acute  purulent  and  mucoid  catarrh  of  the  vagina,  womb,  and  urethra  from 
cases  which  had  from  time  to  time  recurred  with  exacerbations,  and  submitted  them  to 
bacterioscopic  examinations  with  the  assistance  of  three  experienced  bacteriologists. 
Sixty  cases  of  supposed  gonorrhoea  were  thus  studied,  and  only  in  five  recent  and  two 
chronic  cases  was  the  gonococcus  found,  though  numerous  bacilli  and  cocci  were  seen. 
Conrad  reaches  the  following  conclusions  :  1.  The  detection  of  the  gonococcus  succeeds 
more  easily  in  men  than  in  women.  It  is  so  because  the  latter  (a)  experience  compara- 
tively less  discomfort  from  acute  gonorrhoea  where  the  microbe  is  most  frequently  demon- 
strated;  (6)  they  generally  seek  medical  advice  and  help  later  than  men;  (c)  as  a  rule, 
they  pass  water  before  undergoing  a  gynecological  examination,  and  thus  wash  away 
or  dilute  their  urethral  discharge;  [d)  they  sometimes  come  to  be  examined  only  after 
treatment  by  injections  or  other  local  means.  It  is  possible  also  that  detection  becomes 
more  difficult  in  consequence  of  gonococci  being  destroyed  by  micro-organisms  of  other 
species,  which  often  grow  luxuriantly  in  discharges  of  genital  mucous  membranes.  2. 
While  in  recent  cases  of  female  gonorrhoea  Neisser's  gonococcus  may  be  almost  always 
detected,  it  cannot  possibly  be  found  in  many  chronic  cases.  3.  Hence  both  acute  and 
chronic  gonorrhoeal  affections  may  be  present  in  women  in  spite  of  our  inability  to  demon- 
strate the  pathogenic  microbe  in  a  given  case.  If  so,  the  gonococcus  may  have  merely 
a  limited  diagnostic  value,  the  practitioner  being  often  compelled  to  rely  on  etiological 
and  clinical  facts.  Emmert,  a  colleague  of  Conrad,  drew  attention  to  the  fact  that  the 
genuine  habitat  of  the  gonococcus  appeared  to  be  the  discharge  of  the  urethra,  and  not 
of  the  vagina,  since,  when  the  microbe  was  found  in  the  former,  artificial  inoculation  of 
the  vaginal  mucous  membrane  almost  invariably  produced  gonorrhceal  vaginitis,  while 
inoculation  of  the  vaginal  discharge  from  a  gonorrhoeal  woman  in  the  vagina  of  a  healthy 
one  had  no  effect. 

Sahli,  another  of  Conrad's  colleagues,  also  thought  that  the  gonococcus  very  often 
could  not  be  demonstrated  in  the  gonorrhoeal  pus  of  women,  and  states  that  he  was  unable 
to  detect  it  in  a  patient  with  a  profuse  purulent  vaginal  discharge  who  had  recently  been 
infected  by  a  man  with  typical  gonorrhoea  and  with  masses  of  cocci  in  his  urethral 
discharge.  Only  some  extracellular  diplococci  were  discovered  in  tiie  woman.  Sahli 
ascribes  the  difliculties  in  finding  the  gonococci  in  the  female  to  the  possibility  of  their 
being  crowded  out  by  other  vaginal  micro-organisms  of  non-pathogenic  and  iialf-patho- 
genic  varieties ;  by  which  he  means  microbes  which  give  rise  to  pathological  processes 
only  when  they  are  present  in  considerable  numbers  or  when  the  system  is  already  weak- 
ened by  any  cause. 

'■^"Gibt  es  eine  Vaginitis  gonorrhoica  bei  erwachsenen  Frauen?"  Jre/«t' /«>•  Derm, 
und  Sijph.,  1892,  pp.  78  et  seq.  ^  Op.  cit. 


300  GONORBHCEA  AND  ITS  COMPLICATIONS. 

Gonorrhoea  of  the  vagina,  therefore,  may  be  caused  by  the  extension 
upward  of  the  infection  from  the  vulva,  and  it  may  also  result  from  infection 
by  virulent  pus  from  the  cervix  uteri.  True  gonorrhoea,  limited  to  the 
vao-ina  proper,  may  be  seen  rather  exceptionally  in  quite  young  women. 

Gonorrhoea  of  the  Vulva. 

Gonorrhoea  may  originate  primarily  in  the  vulva,  or  it  maybe  caused 
by  contact  with  gonorrhoeal  pus  from  the  vagina  and  parts  above.  As 
a  primary  affection  it  is  not  very  common,  and  is  usually  seen  in  young 
girls  of  from  fifteen  to  twenty  years  of  age  as  a  result  of  rape  or  coitus 
which  is  difficult  of  accomplishment,  owing  to  the  then  compact  and 
unstretched  condition  of  the  parts.  It  is  this  natural  impediment  to 
intromission  which  causes  the  external  infection  by  the  gonorrhoeal  pus 
from  men. 

Gonorrhoea  of  the  vulva  begins  with  a  sensation  of  itching,  soon  fol- 
lowed by  intense  burning.  At  first  the  secretion  is  mucoid  and  in  excess 
of  the  normal  fluid  of  the  parts  ;  it  then  becomes  muco-purulent,  and 
finally  of  a  glairy,  purulent  character.  Examination  usually  shows,  par- 
ticularly in  hospitals  and  dispensaries,  and  often  in  private  practice, 
matting  of  the  hairs  on  the  mons  Veneris  and  of  the  hairs  of  the  labia 
majora  in  the  form  of  little  tufts.  Upon  separation  the  greater  and 
lesser  labia  are  seen  to  be  very  red,  much  swollen,  with  more  or  less 
superficially  eroded  areas,  and  in  the  reflections  of  the  mucous  mem- 
brane. The  whole  surface  is  bathed  with  a  creamy  pus  which  stains 
and  stiffens  the  drawers  and  back  portion  of  the  chemise  in  spots.  Per- 
haps there  may  be  erythematous  or  even  eczematous  patches  on  the 
upper  and  inner  coapted  surfaces  of  the  thighs  from  the  irritation  of 
the  discharge  which  has  flowed  over  them,  and  which  may  even  severely 
irritate  the  anus.  In  uncleanly  subjects  the  retention  and  decomposition 
of  the  discharge  give  rise  to  a  characteristic  nauseating  and  disgusting 
odor.  When  the  inflamed  surfaces  have  been  carefully  bathed,  numerous 
minute  follicular  elevations,  many  perhaps  superficially  eroded,  may  be 
seen,  mostly  on  the  labia  minora,  but  also  on  the  labia  majora.  Unless 
appropriate  treatment  is  instituted,  the  swelling  becomes  very  great,  the 
eroded  surfaces  become  larger  and  coalesce,  and  in  consequence  of  the 
swollen  condition  examination  of  the  urethra  and  vulva  is  very  difficult 
and  painful.  In  cases  of  long  labia  minora  the  swelling  is  sometimes 
so  great,  and  the  constriction  offered  by  the  labia  majora  is  so  firm,  that 
strangulation  seems  imminent.  This  condition  has  been  considered  by 
some  authors  as  analogous  to  paraphimosis  in  the  male,  while  others 
think  that  acute  vulvitis  is  the  analogue  of  balanitis  and  balano-posthitis. 
The  inflammatory  process  may  be  thus  intense,  and  yet  limited  to  the 
vulva ;  and,  although  the  urethral  and  vaginal  orifices  are  red  and 
inflamed,  these  canals  may  yet  remain  unaffected.  Thus  it  is  that  urina- 
tion is  excruciatingly  painful,  particularly  when  the  urine  runs  over  the 
vestibule,  vaginal  orifice,  and  fourchette,  and  that  digital  or  instrumental 
examination  is  rendered  impossible. 

Taking  all  its  features  into  consideration,  gonorrhoea  of  the  vulva  of 
the  severe  form  is  a  distressingly  painful  affection.  Its  heat,  attendant 
itching,  and  burning  give  rise  to  erotic  desires,  even  to  nymphomania, 


GONORRHCEA   IX  THE  FEMALE.  301 

while  handling  or  manipulation  of  the  parts  or  sexual  intercourse  is 
utterly  impossible.  Not  uncommonly,  the  irritation  of  the  anal  orifice 
by  the  escaping  discharge  gives  rise  to  tenesmus,  diarrhoea,  and  even 
incontinence  of  the  rectum.  Such  patients  are  frequently  forced  to 
assume  the  recumbent  position,  since  sitting  and  walking  are  attended 
by  increased  pain.      Occasionally  malaise  with  mild  fever  is  noticed. 

Arising  as  it  does  from  aborted  and  perhaps  violent  attempts  at  coitus 
in  rape,  in  mediate  contagion  from  gonorrhoeal  pus,  the  date  of  the  onset 
of  vulvar  gonorrhoea  is  very  often  clearly  marked.  The  evolution  of 
the  affection  is  prompt  and  rapid,  and  but  one  or  two  days  may  elapse 
from  the  time  of  the  commencement  of  the  premonitory  pruritic  burning 
sensation  to  its  full  development.  The  course  is  entirely  dependent  upon 
the  efficiency  and  vigor  of  treatment.  In  dispensary  practice  it  is  often 
very  difficult  to  make  these  girls  give  themselves  proper  care.  Hence 
this  affection  in  the  lower  classes  often  runs  on  into  a  chronic  condition. 
In  many  of  these  cases  the  inflammation  settles  itself  in  the  cleft  between 
the  large  and  small  labia  and  around  the  introitus  vaginas.  In  private 
practice  patients  are  more  attentive  to  treatment,  and  then  the  severity 
of  the  trouble  subsides  in  about  a  week  or  ten  days.  Becoming  sub- 
acute, it  then  may  rapidly  subside  and  disappear. 

In  acute  gonorrhoea  of  the  vulva  there  is  frequently  invasion  of  the 
urethra,  and  in  some  cases  the  infection  extends  into  the  vagina.  Not 
uncommonly  Bartholin's  glands  are  attacked,  and  rather  less  frequently 
Skene's  glands  and  the  periurethral  glands  may  become  implicated. 
These  complications  naturally  prolong  the  course  of  the  inflammation. 

There  is  a  chronic  form  of  vulvitis,  which  consists  in  an  inflammation 
of  the  sebaceous  and  mucous  follicles,  which  may  or  may  not  be  of  gon- 
orrhoea! origin.  Examination  of  the  parts  shows  a  large  or  small  num- 
ber of  minute  red  follicular  elevations  seated  on  the  inner  surface  of  the 
labia  majora  and  minora.  This  is  the  "  sebaceous  "  or  follicular  vulvitis 
described  by  Huguier.^  If  properly  treated,  it  is  an  ephemeral 
affection. 

The  vulvo-vaginitis  of  children  is  described  in  the  following  chapter. 

Inflammation  of  the  Periurethral  and  Para-urethral  Follicles  and 

Glands. 

IXFLAMMATIOX    OF    SkENE'S    UrETHKAL    GlA?s^DS. 

Skene's  glands,  which  open  a  little  Avithin  the  orifice  of  the  urethra, 
may  be  the  seat  of  a  mild  form  of  inflammation  Avhich  causes  the  patient 
very  little  discomfort.  The  orifices  are  seen  to  be  enlarged,  and  around 
them  is  a  thin  rim  of  redness.  A  more  severe  condition  is  sometimes 
seen  in  which  there  is  active  inflammation  of  the  ducts  and  the  surround- 
ing tissues  and  the  escape  of  a  purulent  fluid.  In  this  condition  the 
meatus  is  so  swollen  that  it  is  somewhat  prolapsed  and  everted,  and  thus 
it  happens  that  the  orifices  of  the  ducts  are  rendered  visible  and  look 
like  little  A^ello wish-gray  ulcers  seated  on  a  deep-red  papillomatous  base. 
Skene  "^  says  that  the  appearance  of  the  parts  reseiubles  caruncle  or 
papilloma,  and  he  records  a  case  under  his  own  care  in  which  the  diag- 

^  Memoires  de  I' Academic  de  Med.,  1850,  p.  529.  '''  Op.  cit. 


302  GOyOBEHCEA  AXD  ITS  COMPLICATIONS. 

nosis  was  not  made  for  many  months.  The  patient  suffered  from  pain 
on  sitting  and  walking,  and  was  debarred  from  sexual  intercourse.  A 
probe  could  be  passed  into  the  orifices  of  the  glands  for  more  than  half 
an  inch,  and  on  withdrawal  and  by  downward  pressure  on  the  urethra 
pus  escaped.  This  patient  under  a  false  diagnosis  was  treated  twenty- 
one  months  with  no  relief,  but  was  promptly  cured  in  two  months  after 
a  correct  diagnosis  had  been  made. 

These  glands  may  be  affected  during  and  after  acute  gouorrhoeal 
inflammation.      This  affection,  however,  is  not  of  frequent  occurrence. 

G0X0RRH(EAL    FOLLICULITIS. 

Around  the  urethra  for  a  distance  of  a  third  or  half  of  an  inch  a 
number  of  small  follicles  open  by  means  of  very  minute  ducts.  These 
follicles  may  become  inflamed  during  acute  or  chronic  gonorrhoea  and 
in  women  with  simple  vaginal  discharges.  These  little  foci  of  inflam- 
mation, of  which  there  may  be  as  few  as  two  and  as  many  as  ten,  called 
by  French  authors  foHiculite  hlennorrJiagique,  are  very  apt  to  escape 
observation,  for  the  reason  that  they  do  not  present  a  strjking  appearance. 
They  simply  look  like  inflamed  pinhead-sized  elevations,  on  which  per- 
haps there  may  be  a  small  pus  crust.  They  cause  the  patient  very  little 
trouble  beyond  a  very  slight  sensation  of  heat  and  pricking.  Pressure 
on  the  parts  will  usually  cause  a  small  quantity  of  pus  to  exude.  Then 
a  very  fine  probe  may  be  inserted  into  the  orifice  thus  revealed  for  a 
quarter  of  an  inch  or  even  deeper.  Unless  properly  treated,  these  peri- 
urethral folliculites  of  women  may  persist  indefinitely.  Martineau  is  the 
only  author  Avho  claims  the  frequency  of  occurrence  of  these  lesions. 

Under  the  title  urethrite  externe  Guerin^  described  a  gonorrhoeal  pro- 
cess involving  two  goodly-sized  glands,  to-day  known  as  the  vestibulo- 
vaginal  bulbs,  the  orifices  of  which  open  on  each  side  of  the  meatus,  and 
perhaps  a  little  distance  from  it,  but  on  its  lower  border  near  the  vagina. 
This  affection  rapidly  passes  from  the  acute  to  the  chronic  stage,  in  which 
it  may  linger  for  long  periods.  This  variety  of  gonorrhoea  m  women  is 
considered  by  Guerin,  owing  to  its  chronicity,  analogous  to  the  goutte 
militaire  of  men.  On  examination  we  find  a  red  elevation,  which  may  be 
covered  with  pus  or  from  which  on  pressure  a  little  pus  may  exude.  This 
lesion  may  escape  detection  unless  very  scrutinizing  search  is  made  for  it. 
Women  frequently,  before  coming  to  the  surgeon,  wash  the  parts  or  in 
urination  the  secretion  is  carried  away.  When  by  careful  pressure  the 
orifice  of  the  gland  is  detected,  the  passage  of  a  fine  probe  to  the  depth 
of  half  an  inch  or  more  will  show  the  source  from  which  the  suppuration 
comes.  It  can  readily  be  understood  that  such  a  chronic  lesion  might  be 
a  persistent  source  of  infection  in  men,  since  it  is  not  uncommon  for  it  to 
undergo  exacerbations. 

These  glands  may  rather  rarely  become  the  seat  of  abscess.  Gobel  ^ 
reports  the  case  of  a  young  girl  suffering  with  gonorrhoea  who  had  a  pain- 
ful abscess  of  the  size  of  a  pigeon's  egg  which  bulged  into  the  vaginal 
canal.     The  microscopical  examination  of  the  pus  evacuated  by  incision 

^  Maladies  des  Organes  f/enitaiix  externes  de  la  Femme.  Paris.  1864,  p.  307. 
^  "  Gonorrhoische  urethritis  beim  "Weibe  mit  Periurethralem  Abscess,"  Inauq.  Dissert., 
Erlangen,  1889. 


OONORRHCEA  IN  THE  FEMALE.  303 

was  negative.  Cory  ^  also  reports  a  similar  case,  in  which  the  history  of 
gonorrhoea  is  not  clear,  but  in  which  there  was  much  local  inflammation, 
together  with  severe  febrile  symptoms. 

Inflammation  of  these  glands  may  be  cured  by  treatment,  but  it  may 
result  in  sinuses  and  fistulse.  Lormand  ^  reports  an  interesting  case.  It 
was  that  of  a  young  woman  suff'ering  from  gonorrhoea  who  had  a  swelling 
of  the  size  of  a  small  nut  to  the  left  of  the  urethral  orifice.  Pressure  on 
the  swelling  caused  pus  to  exude  from  the  meatus,  and  Avhen  a  solution  of 
permanganate  of  potassa  was  injected  into  its  ducts,  then  fluid  ran  from 
the  meatus.     A  probe  passed  into  the  fistula  could  be  felt  in  the  urethra. 

Harmonic  ^  also  reports  a  case  in  which  to  the  right  and  a  little  below 
the  meatus  was  a  small  red  warty  or  papillomatous  elevation  through 
which  a  fine  probe  could  be  passed  into  the  urethra.  In  this  case  lanci- 
nating pains  in  the  vulva  were  complained  of. 

Para-urethral  Folliculitis. 

Scattered  over  the  vestibule,  at  a  distance  of  half  an  inch  or  a  little 
more  from  the  meatus  (according  to  the  natural  size  of  the  parts),  is  a 
number  of  mucous  follicles  which  may  be  affected  by  gonorrhoea  of  the 
urethra,  vulva,  and  vagina.  These  follicles,  when  inflamed,  look  like 
small  red  papillas,  from  which,  upon  pressure,  a  little  muco-pus  or  pus  Avill 
exude.  Unless  cured,  these  lesions  may  remain  in  a  chronic  and  indo- 
lent condition,  and  they  may  end  in  sinuses  or  in  true  fistulae.  These 
fistulse  may  end  in  the  urethra  near  the  meatus  or  farther  down  the 
urethral  canal.  They  also  may  extend  toward  the  vagina  in  an  incom- 
plete form,  or  they  may  open  into  that  tube.  On  this  subject  Marti- 
neau's^  brochure  may  be  consulted. 

Around  the  fourchette  and  near  the  posterior  wall  of  the  vagina  a 
number  of  mucous  follicles  are  seated,  and  they  are  sometimes  invaded 
by  the  gonorrhoea!  process.  These  lesions  look  like  small  red  swellings, 
from  Avhich,  on  pressure,  a  little  pus  may  exude.  These  follicular  inflam- 
mations ai'e  very  chronic  in  character  and  rebellious  to  treatment.  They 
may  result  in  sinuses  and  fistulge.  In  some  cases  the  sinus  or  fistula 
extends  toward  the  vagina,  and  in  others  toward  the  rectum.  As  a  result, 
therefore,  there  may  be  vulvo-vaginal  or  vulvo-rectal  fistulse.  These 
fistulne  are  usually  very  small,  they  cause  little  trouble  during  long  periods 
of  time,  and  frequently  they  pass  unrecognized  for  years. 

Many  cases  of  genital  folliculitis  in  Avomen  will  be  met  in  which  abso- 
lutely no  history  of  gonorrhoea  can  be  obtained. 

Inflammation  of  Bartholin's  Glands. 

Bartholin's  or  the  vulvo-vaginal  glands  are  situated  one  on  either 
side  of  the  entrance  to  the  vagina,  in  the  triangular  space  bounded  by 

^  "Abscess  of  the  Female  Urethra,"  Transact,  of  Obstet.  Society  of  London,  1870,  vol. 
xi.  pp.  65  et  seq. 

'■*  "  Note  sur  un  Cas  de  Fistule  vestibulo-nrethrale  d'Origine  blennorrliagique,"  La 
France  medicale,  Sept.  27,  1883,  pp.  433  et  seq. 

^  "  Fistule  vestibulo-iir^thrale  consecutive  a  une  Folliculite  bleunorrhagique  pr^- 
urethrale,"  Annales  de  Derm,  el  de  Syph.,  1884,  pp.  344  et  seq. 

*  Op.  cit.,  pp.  61  et  seq. 


304  GONOBRHCEA   AND  ITS  COMPLICATIONS. 

the  ascending  ramus  of  the  ischium,  the  vaginal  orifice,  and  the  trans- 
versus  perinsei  muscle,  and  are  covered  by  the  superficial  perineal  fascia 
and  some  fibres  of  the  constrictor  vaginae.  They  are  conglomerate 
glands,  having,  when  fully  developed,  a  diameter  of  six-tenths  of  an 
inch.  The  ducts  of  these  glands  are  about  six  lines  in  length,  and 
they  open  just  in  front  of  the  hymen  near  the  lateral  and  posterior 
carunculge  myrtiformes.  These  glands  pour  out  in  coitus  and  in  genital 
excitation  a  copious  secretion  of  albuminous  fluid,  which  lubricates  the 
vulva  and  the  vagina.  The  vulvo-vaginal  glands  may  be  the  seat  of 
two  forms  of  inflammation,  the  one  simple,  and  the  other  gonorrhoea!. 

Simple  acute  Bartholinitis  is  mostly  seen  in  young  girls,  married  or 
single,  and  generally  follows  early  eff"orts  at  coitus.  In  many  cases  it 
results  from  the  violence  attendant  upon  rape.  In  some  cases  the 
simple  rupture  of  the  hymen  causes  local  irritation,  and  as  a  result  one 
or  both  vulvo-vaginal  glands  become  inflamed.  Its  frequence  in  very 
young  married  women  has  caused  it  to  be  called  "the  bride's  abscess." 
It  is  particularly  liable  to  develop  in  girls  who  have  leucorrhoea  and 
who  are  not  careful  as  to  the  cleanliness  of  the  genital  parts.  It  some- 
times results  from  excessive  coitus  and  also  from  masturbation. 

The  symptoms  are  usually  quite  strongly  marked.  The  patient  com- 
plains of  pain  or  soreness  in  the  vulva,  and  inspection  reveals  a  small 

Fig.  89. 


Abscess  of  vulvo-vasrinal  a-land. 


rounded  swelling  at  the  lower  or  posterior  third  of  the  vaginal  orifice. 
This  swelling  rapidly  increases  until  it  may  reach  the  size  of  a  quite 
small  egg.  Then  the  labium  major  becomes  pear-shaped  and  is  pushed 
outward,  and  we  see  a  deep-red,  rounded,  fluctuating  swelling,  which 
may  extend  an  inch  and  even  more  from  the  level  of  the  vaginal  orifice. 
The  parts  are  the  seat  of  throbbing,  dragging  pain,  and  are  exquis- 
itely sensitive  to  the  touch.  In  this  condition,  in  severe  cases,  the 
patients   can   neither   walk,  stand,  nor  sit.      They  have  chills,  malaise, 


GONORRHOEA  IN  THE  FEMALE.  305 

and  febrile  movement.  In  some  cases  there  is  spontaneous  rupture 
through  the  duct,  but  in  most  cases  it  is  necessary  to  incise  the  abscess. 
Sometimes  it  bursts  spontaneously,  most  commonly  near  the  glandular 
outlet,  and  rarely  over  the  convexity  of  the  tumor.  The  pus  is  usually 
thick  and  yellow,  but  it  may  be  thin  and  serous.  Exceptionally,  it  has  a 
fetid  odor.  In  most  cases,  after  incision  into  or  bursting  of  the  abscess, 
the  parts  heal  and  the  gland  seems  to  return  to  its  natural  condition. 

In  several  cases  I  have  observed  that  the  abscess  was  periglandular, 
and  that  the  suppuration  left  the  gland  itself  and  developed  itself  in 
the  connective  tissue  outside  of  it.  This  condition  is  the  same  as  that 
which  we  sometimes  observe  in  abscess  of  follicles  of  the  male  urethra. 
With  the  discharge  of  the  pus  the  gland  promptly  becomes  normal  and 
the  surrounding  inflammation  ceases.  In  many  cases,  however,  after 
abscess-formation  and  pus-extrusion  have  taken  place,  the  gland  seem- 
ingly returns  to  its  normal  state,  yet  exacerbations  and  relapses  are 
liable  to  occur.  Thus,  after  menstruation  the  gland  may  swell  and 
become  painful,  and  in  this  condition  it  may  remain  a  little  time,  and 
then  subside.  Such  exacerbations  as  these  may  be  very  frequent,  and 
they  keep  the  patients  in  a  continuous  state  of  dread.  Excessive  venery, 
masturbation,  and  leucorrhoeal  discharges  may  also  light  up  the  suppu- 
rative process,  with  all  its  local  and  general  disturbances.  As  the  inter- 
val of  time  between  exacerbations  becomes  longer  the  tendency  to  them 
seems  to  lessen,  and  generally  it  dies  out.  But  it  is  not  uncommon  to 
see  a  Avoman  suffer  from  acute  Bartholinitis  several  years  after  her  first, 
second,  or  third  experience. 

In  most  cases  of  simple  acute  Bartholinitis  the  parts  heal  and  appear 
normal.  In  some  cases  a  sinus  is  left,  and  in  very  exceptional  cases  a 
vulvo-  or  vagino-rectal  fistula  is  formed. 

Usually  but  one  gland  is  affected,  and  most  commonly  it  is  the  left 
one.  The  affection  may,  however,  occur  bilaterally.  In  all  probability 
the  simple  form  of  Bartholinitis  is  caused  by  pus-cocci  acting  upon  a 
bruised  or  hyperaemic  part  thus  rendered  susceptible  to  infection. 

During  the  course  of  gonorrhoea,  acute  or  chronic,  the  ducts  of  Bar- 
tholin's glands,  or  the  glands  themselves,  may  be  the  seat  of  a  suppu- 
rating inflammation.  Of  late  years  there  has  been  a  tendency  to  mag- 
nify the  frequency  of  occurrence  of  these  complications  of  gonorrhoea  in 
women.  In  acute  gonorrhoea  the  duct  and  the  gland  itself  are  sometimes 
the  seat  of  inflammation.  In  chronic  gonorrhoea  it  is  more  common  to 
find  only  the  duct  or  the  ducts  involved. 

Gonorrhoeal  inflammation  of  the  duct  of  the  vulvo-vaginal  glands 
may  be  attended  with  very  mild  symptoms  of  heat  and  pricking,  and 
these  may  be  wholly  absent.  On  inspection  we  find  the  opening  of 
these  ducts  red  and  a  little  swollen ;  the  red  spots  thus  produced  are 
called  by  Sanger  "  macul?e  gonorrhoeica."  Pressure  on  the  parts 
against  the  ramus  of  the  ischium  causes  a  drop  of  milky  or  greenish 
pus  to  exude.  In  some  cases  this  localized  inflammation  is  the  only 
remnant  of  the  gonorrhoeal  process.  It  causes  little  or  no  discomfort, 
so  that  frequently  the  patient  does  not  know  that  she  has  such  a  trouble. 
In  this  indolent  condition  it  may  remain  for  long  periods,  or  it  may,  as 
a  result  of  exciting  and  irritating  causes,  become  acute.  The  body 
of  the  gland  may  become  infected,  in  which  event  there  may  be  an 

20 


306  QONOBRHCEA  AND  ITS  COMPLICATIONS. 

acute  suppuration,  but  usually  the  condition  is  rather  indolent  and  sub- 
acute. The  gland  swells  to  the  size  of  a  nutmeg  or  walnut,  and  may  be 
grasped  and  its  contour  clearly  made  out  between  the  finger-tips.  The 
swelling  presents  a  smooth,  quite  firm  structure  of  roundish  or  oval  out- 
line. Not  infrequently  the  duct  of  the  gland  can  be  felt  like  a  firm 
round  cord.  Pressure  causes  a  whitish  pus  to  exude.  This  condition 
of  affairs  is  found  in  prostitutes,  particularly  in  old  ones.  It  is  the 
cause  of  much  trouble  and  worry  to  them,  since  they  are  always  in 
dread  of  a  recrudescence  of  the  acute  inflammation,  which  may  result 
from  sexual  excess  or  any  inflammation  about  the  genitals  or  in  the 
pelvic  cavity.  Very  exceptionally  I  have  seen  chronic  gonorrhoeal 
inflammation  of  Bartholin's  glands  take  on  the  characters  of  a  simple 
acute  affection,  develop  into  an  abscess,  and  burst.  The  usual  tend- 
ency is  for  the  glands  to  become  hard  and  swollen,  and  to  remain  unin- 
fluenced by  any  treatment,  except  surgical. 

The  infectiousness  of  the  pus  of  specifiic  Bartholinitis  is  now  generally 
conceded.  In  1877,  prior  to  the  era  of  the  gonococcus,  Le  Pileur  ^  traced 
an  acute  gonorrhoea  of  a  medical  friend  to  the  pus  of  a  discharging  vulvo- 
vaginal gland,  there  being  absolutely  no  other  seat  of  gonorrhoeal  infec- 
tion in  the  woman  with  whom  the  medical  man  had  cohabited. 

Owing  to  the  mild  chronicity  of  the  morbid  process  and  to  the  hidden 
condition  of  the  orifice  of  the  duct,  gonorrhoeal  Bartholinitis  may  very 
readily  escape  recognition  unless  carefully  looked  for.  Women  coming 
for  examination  and  public  prostitutes  become  aware  of  this  focus  of  in- 
flammation in  their  genitals,  and  take  pains  to  deceive  the  examining 
physician.  They  squeeze  out  the  contents  of  the  glands  and  wash  and 
syringe  their  genitals,  thus  frequently  removing  for  a  time  all  traces  of 
the  inflammation.  This  point  must  be  borne  in.  mind  when  examining 
women  under  suspicion  of  having  gonorrhoea.  They  must  be  compelled 
to  present  themselves  without  any  preliminary  preparation. 

Arning  ^  placed  gonorrhoeal  vulvo-vaginitis  on  a  scientific  basis  when 
he  clearly  demonstrated  the  presence  of  the  gonococcus  in  the  pus  of  seven 
inflamed  vulvo-vaginal  glands. 

Teuton^  has  recently  submitted  an  excised  vulvo-vaginal  gland  and  its 
duct  to  an  elaborate  and  interesting  microscopical  examination  and  study, 
and  has  clearly  shown  that  the  micro-organism  attacks  the  pavement  epi- 
thelium of  the  duct  and  produces  typical  inflammation,  and  by  extension 
attacks  the  gland  itself. 

Gonorrhoea  of  the  Tubes,  Ovaries,  and  Peritoneum. — When  gonorrhoea 
ascends  and  passes  from  the  uterus  to  the  tubes  and  beyond,  the  case  then 
enters  the  domain  of  the  gynecologist.  I  shall  not  attempt  to  give  a 
detailed  description  of  the  pelvic  troubles  in  women  caused  by  gonorrhoea, 
but  shall  confine  myself  to  a  general  consideration  of  the  subject,  leaving 
it  to  the  reader  to  fully  inform  himself  from  the  various  works  on  gyn- 
ecology. 

We  have  already  seen  that  there  is  at  present  a  tendency  to  exaggerate 

'  "  Blennorrhagie  ur^thrale  ayant  pour  origine  I'inoculation  de  Pus  d'une  Glande  de 
Bartholin  abcedee,  etc.,"  Annales  de  Derm,  et  de  Syph.,  vol.  ix.,  1878,  pp.  374  et  seq. 

^  "Ueber  das  Vorkommen  von  Gonococcen  bei  Bartholinitis,"  Vierteljahresschr.  fur 
Derm,  vnd  Syph.,  1883,  pp.  371  et  seq. 

^  "  Die  Gonococcen  im  Gewebe  der  Bartholini'schen  Driise,"  Archiv  fur  Derm,  und 
Syph.,  1893,  pp.  181  et  seq. 


GONORRHCEA  IN  THE  FEMALE.  307 

the  frequency  of  gonorrhoeal  pelvic  disease  and  to  make  such  a  diagnosis 
oft-hand  on  very  insufiicient  data.  That  the  tissues  around  the  uterus, 
the  tubes,  the  ovaries,  and  peritoneum  may  be  attacked  by  the  gonorrhoeal 
process  is  undeniably  true,  but  it  does  not  occur  in.  the  majority  of  cases. 
In  reporting  cases  it  is  necessary  first  to  establish  the  facts  of  a  gonorrhoeal 
infection  beginning  in  some  part,  such  as  the  urethra,  vulva,  uterine  neck, 
and  vagina,  and  if  possible  to  find  out  from  Avhom  the  infection  Avas 
derived.  Then  the  symptoms  and  course  of  the  disease  must  be  such  as 
will  accord  Avith  the  clinical  history  of  gonorrhoea.  Then  it  is  necessary 
to  establish  the  fact  that  the  cervix  uteri  has  been  infected  primarily  or 
secondarily,  and,  if  this  is  done,  there  can  be  no  doubt  whatever  as  to  the 
gonorrhoeal  origin  of  any  pyosalpinx,  oophoritis,  perimetritis,  and  peri- 
tonitis. These  requirements  may  be  difficult  of  fulfilment,  but  accurate 
knowledge  of  the  subject  can  only  be  obtained  as  a  result  of  painstaking 
observation  and  examination,  which  will  generally  warrant  a  correct 
diagnosis.  There  is  no  such  thing  as  a  latent  gonorrhoea  without  well- 
defined  pathological  conditions.  Gonorrhoea  may  lurk  in  a  latent  or 
dormant  condition  in  some  part  of  the  genito-urinary  tract  of  the  woman, 
but  it  is  always  a  well-defined  pathological  process,  and  it  may  be  clearly 
established  if  we  take  the  pains  to  search  for  it  clinically  and  micro- 
scopically. 

V.  Rosthorn^  gives  a  very  clear  general  clinical  history  of  a  case  of 
severe  gonorrhoeal  infection  in  a  woman.  "  Having  been  infected  by  her 
husband,  a  previously  healthy  Avoman  shortly  after  marriage  begins  to  feel 
poorly  and  becomes  tired  easily.  Menstruation  becomes  profuse,  and 
there  is  dysmenorrhoea  and  leucorrhoea.  She  has  severe  colicky  pains 
resembling  those  of  labor,  and  constant  pains  in  the  groins  and  back, 
which  interfere  with  locomotion  and  the  pleasures  of  life.  She  has  mental 
depression,  and  even  may  become  melancholy.  Suddenly  an  acute  attack 
of  peritonitis^  comes  on,  from  Avhich  she  partly  recovers,  and  can  Avalk 
around,  but  is  forced  to  avoid  all  exertion,  and  particularly  jolting  in  cars 
or  carriages.  Coitus  may  bring  on  another  attack.  Indeed,  throughout 
her  life,  until  after  the  menopause,  she  is  liable  to  relapses  from  slight 
causes.  The  uterus  is  enlarged  and  tender.  The  tubes  are  dilated  to 
the  size  of  a  finger  or  a  sausage,  and  the  ovaries  are  enlarged,  suppura- 
ting, and  perhaps  cystic,  covered  with  inflammatory  products,  and  per- 
haps displaced  and  bound  down  by  adhesions  in  Douglas's  cul-de-sac. 
The  peritoneum  is  thickened,  hypersemic,  and  produces  displacements  of 
the  uterus.      Sterility  is  observed  in  the  majority  of  these  cases." 

In  some  cases  it  is  very  difficult,  and  even  impossible,  to  get  a  clear 
consecutive  history  of  gonorrhoeal  inflammation  and  invasion,  and  in  these 
the  microscope  may  or  may  not  be  of  assistance.     In  the  examination  of 

^  "  Ueber  die  Folgen  der  Gonorrhoischen  Infection  bei  der  Frau,"  Prag.  med.  Woclien- 
■schr.,  vol.  xvii.,  1S92,  IS'os.  2  and  3. 

^  The  usual  mode  of  invasion  of  pelvic  organs  of  the  female  by  gonorrhoea  is  slow 
and  insidious,  sometimes  developing  suddenly  into  an  acute  condition.  In  a  case,  how- 
ever, reported  by  Penrose  ("Acute  Peritonitis  from  Gonorrhoea,"  ]\[ed.  Neirs,  July  5,  1890, 
pp.  16  and  17),  only  six  days  elapsed  between  the  sexual  act  in  man  and  wife  and  the 
development  in  the  latter  of  an  intense  and  threatenina;  i)eritonitis  which  required  opera- 
tive relief.  The  peritoneum  was  characteristically  intiamed  and  the  tubes  were  the  seat 
of  an  exudative  purulent  inflammation.  The  husband  at  the  time  suffered  from  very 
severe  gonorrhoea  with  epididymitis.  The  microbes  found  in  the  tubal  pus  had  the 
.appearance  of  some  of  the  staphylococci  of  suppuration. 


308  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

pus  from  the  uterus  and  tubes  the  finding  of  the  gonococcus  is  not  at  all 
frequent  or  constant,  and  the  supposition  is  warranted  that  other  micro- 
organisms take  part  in  the  morbid  process. 

Bumm  ^  has  advanced  the  theory  of  mixed  or  compound  infections  in 
women.  Reasoning  on  the  hypothesis  that  the  bacteria  of  pneumonia 
destroy  the  epithelial  lining  of  the  pulmonary  alveoli,  and  cause  an  exu- 
dation which  forms  a  cultivating  medium  for  the  bacillus  tuberculosis  and 
pyogenic  micro-organisms  Avhich  result  in  phthisis  and  abscess  of  the 
lungs,  he  thinks  that  the  gonococcus  likewise  acts  upon  the  female  geni- 
tal mucous  membranes,  and  produces  a  suitable  culture-ground  for  other 
organisms  which  do  not  attack  them  in  the  healthy  state.  Bumm  is  con- 
vinced that  the  gonococcus  only  involves  mucous  membranes,  and  that 
for  this  reason  women  suffering  from  gonorrhoea  are  not  attacked  by 
pelvic  cellulitis.  The  latter,  he  thinks,  is  due  to  compound  infection, 
since  in  two  cases  of  the  trouble  complicated  by  abscess  he  found  large 
quantities  of  the  staphylococcus  aureus  in  the  pus.  He  thinks  that  the 
micro-organisms  penetrated  the  erosions  in  the  cervix,  and  were  carried 
by  the  lymphatics  into  the  connective  tissue  of  the  pelvis. 

Bumm  also  states  that  the  further  the  inflammation  extends  from  the 
vagina,  the  less  are  the  chances  for  compound  infection,  and  that  in 
gonorrhoea  of  the  uterus  there  are  usually  feAv  germs  besides  the  gono- 
coccus, and  that  in  the  tubes  the  latter  alone  is  usually  found.  In  the 
tubes  the  specific  action  of  this  microbe  may  be  seen  in  the  form  of  puru- 
lent inflammation  of  the  mucous  membrane  only,  the  connective  tissue 
not  being  invaded.  He  is  under  the  impression  that  the  escape  of  gonor- 
rhoeal  pus  from  the  tubes  into  the  peritoneal  cavity  is  not  followed  by 
suppurative  peritonitis,  but  that  a  circumscribed  adhesive  inflammation  is 
set  up  which  seals  up  the  tube,  and  that  the  woman  may  suffer  afterward 
from  chronic  pyosalpinx.  Should  pyogenic  micrococci  be  present  in  the 
pus,  Bumm  thinks  that  purulent  peritonitis  and  death  might  ensue.  As 
in  man  gonorrhoeal  epididymitis  may  be  followed  by  tuberculosis  of  the 
organ,  so  in  the  woman,  according  to  Bumm,  may  the  tubes  the  seat  of 
gonorrhoea  be  attacked  by  tuberculosis,  both  cases  being  instances  of 
"mixed  gonorrhoeal  infections." 

Later  observations  by  Wertheim  ^  have  shown  that  Bumm  too  narrowly 
restricts  the  pathological  action  of  the  gonococcus.  AVertheim  clearly 
shows  that  the  gonococcus  can  invade  the  connective  tissues  like  ordinary 
pus-microbes.  Thus,  he  shows  that  the  deeper  inflammations,  other  than 
those  of  the  mucous  membrane,  in  the  female  may  be  caused  by  the  gono- 
coccus, such  as  parametritic  infiltrations,  perimetritic  exudations,  and 
plastic  adhesions  and  inflammatory  changes  in  the  ovaries.  Wertheim 
shows  that  the  gonococcus  can  penetrate  the  walls  of  the  tubes  into  the 
peritoneum,  and  there  produce  inflammation.  Peritonitis  is  also  caused 
by  the  escape  of  gonorrhoeal  pus  through  the  tubal  orifices  into  the  peri- 
toneum.    The  tendency  of  peritonitis  produced  by  the  gonococcus  is  to  be- 

^  "Ueber  Gonorrhoische  Mischinfectionen  beim  Weibe,"  Deutsche  med.  Wochenschrift, 
Dec.  8,  1887,  pp.  1057  et  seq. 

^  Op.  cit.  In  Wertheim's  two  essays  the  bibliography  of  tlie  observations  (all  foreign) 
of  the  gonococcus  in  the  tubes  is  given.  In  this  country  Dr.  Howard  A.  Kelly  ("The 
Gonococcus  in  Pyosalpinx,"  TJie  Johns  Hopkins  Hospital  Reports,  vol.  ii.,  Isos.  3  and  4, 
1890)  reports  finding  a  diplococcus  characteristically  grouped  within  the  pus-cells  from 
the  tube  least  affected  in  a  case  of  double  pyosalpinx. 


GONOBRHCEA  IN  THE  FEMALE.  309 

come  walled  in  by  adhesions  and  to  run  a  less  severe  and  prolonged  course 
than  other  forms. 

From  what  has  already  been  published  it  seems  conclusive  that  the 
gonococcus  may  in  some  cases  live  and  thrive  in  the  tubes,  and  from  these 
invade  the  neighboring  parts.  It  also  seems  clear  that  in  some  cases  the 
microbes  die  in  the  tubal  pus,  perhaps,  as  is  claimed,  as  a  result  of  the 
poisons  they  secrete.  There  can  be  no  doubt  of  the  presence  of  the  pyo- 
genic micro-organisms  in  the  majority  of  cases  of  tubal  disease.  Wertheim's 
observations  certainly  restrict  the  scope  of  Bumm's  mixed-infection  theory, 
but  they  do  not  absolutely  invalidate  it,  since  he  has  not  by  any  means 
proved  that  the  gonococcus  is  uniformly  found  in  the  pus  of  tubes  the  seat 
of  gonorrhoeal  inflammation.  This  subject  needs  further  elucidation  and 
elaboration. 

Prophylaxis. — The  question  of  the  prevention  of  gonorrhoea  in  women  is 
one  of  great  gravity,  and  should  attract  more  attention  than  it  does,  particu- 
larly in  this  country.  Much  can  be  done  by  physicians  in  lessening  the  num- 
ber of  cases  of  gonorrhoea  in  men  by  impressing  on  kept-women  and  prosti- 
tutes, who  so  numerously  come  under  our  care,  the  necessity  of  absolute 
cleanliness  and  of  the  use  of  antiseptic  (bichloride)  injections  and  douches. 
While  Ave  can  hardly  agree  with  Broese,^  Avho  says  that  "  one  can  scarcely 
err  if  he  assumes  that  all  prostitutes  are  infected  with  gonorrhoea,  espe- 
cially if  they  have  exercised  their  profession  for  any  length  of  time,"  we 
can  look  upon  them  as  a  dangerous  class,  and  should  treat  them  as  such. 
There  being  no  registration  of  prostitutes  in  this  country,  the  physician's 
influence  over  them  is  very  limited.  When,  however,  they  do  come  under 
medical  care  in  hospitals,  dispensaries,  and  in  private  practice,  we  should 
endeavor  to  follow  as  far  as  we  can  the  requirements  laid  down  by  Sanger 
and  V.  Rosthorn,  which,  though  some  of  them  are  impracticable  with  us, 
are  deserving  of  being  emphasized.  They  are — 1.  A  careful  watch  over 
registered  prostitutes  and  relentless  efforts  directed  against  the  unregistered 
class.  (We  can  do  nothing  in  this  direction.)  2.  Pi'olonged  treatment  of 
infected  prostitutes  by  physicians  having  special  training. ,  3.  The  compul- 
sory use  of  bichloride  douches  for  the  vagina  and  vulva.  Care  should  be 
taken  by  the  physicians  to  teach  these  women  how  to  use  these  douches 
eff'ectively.  4.  Have  the  male  wash  the  penis  with  bichloride  solution 
after  each  coitus.  5.  Rational  and  prolonged  treatment  of  men  having 
the  disease,   and  forbidding  marriage  until  the  gonorrhoea  is  cured. 

Broese  lays  great  stress  on  the  danger  of  reinfection  of  the  Avife,  after 
having  been  cured  of  one  attack  of  gonorrhoea,  by  her  husband,  in 
whom  the  disease  remains  in  an  infectious  condition.  This  is  a  very  im- 
portant subject.  The  surgeon,  having  satisfied  himself  that  the  woman 
has  gonorrhoea,  has  the  double  duty  on  his  hands  of  curing  the  Avoman 
and  of  seeing  to  it  that  she  is  not  again  infected.  To  this  end  he  must 
consult  the  husband  (using  all  tact  and  prudence)  and  impress  upon  him 
the  necessity  of  being  absolutely  cured  of  his  trouble.  Much  good  can 
be  done  in  hospitals  and  maternity  institutions  by  the  examination  of  the 
secretions  of  the  genitals  of  pregnant  Avomen,  and  by  instituting  an  in- 
telligent and  vigorous  treatment  which  will  benefit  the  woman  and  perhaps 
prevent  the  gonorrhoeal  infection  of  the  eyes  of  her  infant  Avhen  it  arrives. 

^"Zur  Aetiologie  Diagnose,  und  Tiierapie  der  Weiblichen  Gonorrhoe,"  Deut.  med. 
Wochenschr.,  1892,  pp.  370,  398,  and  419. 


310  60N0RRHCEA  AND  ITS  COMPLICATIONS. 

Treatment  of  Gonorrhoea  in  the  Female. — In  the  treatment  of  gonor- 
rhoea in  the  female  the  prime  essentials  are  scrupulous  cleanliness, 
copious  antiseptic  injections  and  flushings,  and  constant  care  as  to 
details.  The  patient  should  be  made  to  clearly  understand  the  gravity 
of  the  disease  and  its  tendency  to  further  ^upward  extension  and  to 
localize  itself  in  the  recesses  and  crypts  of  the  genitalia  ;  and  she  should 
be  urged  to  continue  under  observation  until  she  is  pronounced  cured 
by  the  surgeon.  It  is  the  duty  of  the  latter  to  make  thorough  and 
painstaking  examinations  of  the  whole  genito-urinary  tract,  and  to 
acquaint  himself  with  the  full  extent  of  the  disease.  The  various  mor- 
bid secretions  should  be  examined  by  means  of  the  microscope  with  a 
high-power  lens  and  oil-immersion. 

In  acute  cases  the  recumbent  position  should  be  insisted  upon.  The 
diet  should  be  of  the  simplest  character,  and  preferably  of  milk.  A 
brisk  cathartic  may  be  given,  and  throughout  the  course  of  the  disease 
one  or  more  full  movements  of  the  bowels  should  occur  each  day. 

For  the  purpose  of  lucidity  of  description  and  orderly  arrangement 
the  treatment  of  gonorrhoea  will  be  given  on  the  lines  of  the  anatomical 
situation  of  the  parts  and  regions  involved,  rather  than  on  the  clinical 
basis  and  the  relative  frequency  of  the  various  forms  of  gonorrhoea  in 
the  female. 

For  gonorrhoea  of  the  vulva,  with  all  its  painful  accompaniments  in 
the  acute  stage,  very  hot  sitz-baths,  repeated  four  or  more  times  daily 
if  possible,  should  be  used,  taking  care  that  the  water  is  brought  into 
free  contact  with  the  whole  surface  affected.  Very  often  the  itching 
and  burning  are  much  allayed  by  affusions  of  hot  alkaline  solutions 
(powdered  borax  or  supercarbonate  of  soda,  3ij  to  water  gxxxij),  to 
which  may  be  added  two  to  four  drachms  of  wine  of  opium  or  lauda- 
num.    Then  a  lotion  as  follows  may  be  employed: 

I^.  Pulv.  boracis,  5j  ; 

Liq.  plumbi  subacetatis,  giss  ; 

Ext.  opii  aquos,  3j  ; 

Aquae,  §vj._M. 

With  this  may  be  saturated  pledgets  of  lint  or  of  absorbent  gauze,  which 
should  be  carefully  and  thoroughly  applied  to  the  surfaces  in  order  to 
keep  them  apart,  and  renewed  very  frequently,  since  they  soon  become 
saturated  with  pus.  So  soon  as  the  vulvar  orifice  will  permit  a  soft 
catheter.  No.  15  F.,  or  the  long  tube  of  a  Davidson's  or  fountain  syringe, 
should  be  introduced  as  far  as  it  will  go,  and  several  copious  injections 
of  very  hot  alkaline  water  should  be  made  every  day.  As  the  inflam- 
mation declines  it  may  be  necessary  to  paint  the  parts  to  their  smallest 
recesses  with  a  solution  of  nitrate  of  silver,  thirty  grains  to  the  ounce  of 
water,  followed  by  hot  ablutions  with  a  solution  of  common  salt.  After 
a  very  hot  sitz-bath  the  lead-opium-and-borax  lotion  may  again  be  ap- 
plied. In  twenty-four  hours  after  this  application  to  the  old  or  the 
young  much  improvement  will  be  noted  in  the  lessened  oedema  and  red- 
ness and  in  a  less  painful  condition.  Then  a  1  per  cent,  solution  of 
alum,  with  laudanum,  may  be  used,  and  later  on  the  parts  may  be 
dusted  with  subnitrate  of  bismuth  or  powdered  boracic  acid  on  a  pledget 
of  lint  or  absorbent  gauze. 


GONOBBHCEA  IN  THE  FEMALE. 


311 


GoNoRRHCEA  OF  THE  Urethra. — Vulvar  gonorrhoea  is  very  fre- 
quently, sooner  or  later,  accompanied  "with  implication  of  the  urethra 
and  increase  in  the  patient's  sufferings.  The  solution  of  bicarbonate  of 
potassa  with  hyoscyamus  recommended  for  acute  gonorrhoea  of  the  male 
may  be  given  in  order  to  relieve  the  urine  of  its  acidity,  and  diluent 
drinks,  such  as  flaxseed  and  slippery-elm  teas  and  barley-water,  may  be 
taken  ad  libitum.  As  soon  as  the  inflammation  in  the  urethra  has 
somewhat  subsided  by  use  of  the  foregoing  measures  suitable  for  the 
acute  stage  of  vulvitis,  intra-urethral  injections  of  very  hot  Avater  with 
borax  or  boracic  acid,  siij  to  sxxxij,  frequently  made  by  means  of  any 
recurrent  syringe  or  catheter,  or  preferably  by  means  of  Skene's  reflux 
catheter,  may  be  used.  As  the  inflammation  subsides,  intra-urethral 
injections  of  hot  water,  containing  carbolic  acid  in  the  proportion  of  J 
of  1  per  cent.,  are  very  beneficial.  In  many  instances  where  the  pain 
on  urination  is  very  great  the  instillation  into  the  urethra  by  means  of 
a  small  cylindrical  dropping-pipe  of  a  solution  of  opium  in  glycerin,  or 
of  cocaine  muriate  in  glycerin  and  water,  is  followed  by  marked  relief. 
As  the  urethral  lesion  further  declines,  a  2  per  cent,  solution  of  nitrate 
of  silver  may  be  injected  as  far  down  the  urethra  as  possible,  since  it  is 
commonly  involved  in  its  whole  length ;  or  a  thirty -grain-to-the-ounce 
solution  of  nitrate  of  silver  may  be  carefully  and  sparingly  applied  by 


Sims's  urethral  forceps. 

means  of  a  cotton-holder,  facilitated  either  by  the  endoscope  or  by  the 
fenestrated  forceps  of  Dr.  H.  M.  Sims. 

An  essentially  antiseptic  treatment  is  used  at  the  Antiquaille  Hos- 
pital by  Rollet.^  A  catheter  like  that  of  Mitchell's  reflux  form  is  intro- 
duced into  the  urethra  as  far  as  its  vesical  neck  ;  then  the  canal  is  irri- 
gated with  solutions  of  sublimate,  1  :  2000,  or  permanganate  of  potassa, 
1 :  250.  An  antiseptic  pencil  (see  Medicated  Bougies,  p.  152)  may  be 
inserted  into  the  urethra,  which  is  washed  with  a  solution  of  resorcin, 
1  :  10  or  30.  Antiseptic  irrigations  of  the  vagina  are  used  to  prevent 
the  ascent  of  the  disease. 

Vigneron,^  in  Chdron's  service,  used  injections  of  a  saturated  solution 
of  picric  acid.  The  urethra  was  first  irrigated  wnth  boric-acid  water, 
and  then  by  means  of  a  uterine  syringe  ten  cubic  centimetres  of  the  solu- 
tion were  thrown  into  the  bladder.  The  vulva  was  carefully  cleansed. 
A  cure  is  said  to  follow  a  few  injections  in  from  ten  to  twenty  days. 

It  is  only  in  the  subacute  and  chronic  stages  that  antiblennorrhagics 
are  to  be  used,  and  then  in  rather  smaller  doses  than  in  the  male.  (See 
section  on  Gonorrhoea  in  the  Male.)  In  some  cases  these  agents  produce 
marked  relief  in  the  symptoms  and  a  lessening  of  the  discharge,  and, 

1  Gazette  de  Gynecol,  1894,  vol.  ix.  pp.  IS  et  seq.  ^  Tlihe  de  Partis,  1894. 


312  GONORBHCEA  AND  ITS  COMPLICATIONS. 

again,  they  seem  to  be  of  no  benefit  at  all ;  from  which  it  follows  that 
local  measures  are  always  the  most  certain. 

It  is  necessary  to  repeat  that  in  chronic  urethral  and  vulvar  gonor- 
rhoea in  women  the  patients  are  apt  to  be  careless  and  indifferent  in  the 
stage  of  decline,  which,  added  to  the  setbacks  incident  to  menstruation, 
tends  to  perpetuate  their  trouble.  At  this  time  the  surgeon  should 
accentuate  his  injunctions  to  follow  treatment,  to  be  as  quiet  as  possible 
in  every  Avay,  and  to  abstain  from  any  errors  in  eating  or  drinking. 

GoNORRHCEA  OF  THE  Vagina. — Gonorrhoea  of  the  lower  part  of  the 
vagina,  which  is  commonly  accompanied  with  the  same  affection  of  the 
vulva  and  perhaps  of  the  urethra,  should  be  treated  on  the  principles 
already  given.  As  soon  as  the  acute  symptoms  subside,  copious  irriga- 
tions of  very  hot  water  well  into  the  canal  should  be  made.  Then,  as 
soon  as  the  irritability  of  the  parts  will  permit,  the  surgeon  should  make 
a  thorough  examination,  having  at  his  command  a  perfect  light,  natural 
or  artificial.  In  my  judgment,  the  genu-pectoral  position,  though  objec- 
tionable to  patients  by  reasons  of  delicacy  of  feeling  and  of  its  uncom- 
fortableness,  is  by  far  the  best  to  obtain  a  thorough  view  of  the  whole 
vagina,  including  the  cervix  uteri  and  the  posterior  and  the  anterior 
fornix  vaginae.  The  blade  of  a  Sims  speculum  carefully  introduced  ele- 
vates the  posterior  vaginal  wall,  and  free  inspection  is  possible.  Where 
the  surgeon  works  without  the  aid  of  an  assistant  the  adjustment  to  the 
Sims  speculum  devised  by  Dr.  Cleveland  may  be  used,  Avith  much  help. 
When  the  very  acute  symptoms  of  gonorrhoeal  vaginitis  have  begun  to 
subside,  the  inflamed  surfaces  may  be  carefully  and  thoroughly  cleansed 
by  means  of  a  cotton-holder.  Then  the  whole  surface  may  be  exposed 
by  the  wire  speculum,  and  then  gently  and  sparingly  touched  with  a 
thirty-grain-to-the-ounce  solution  of  nitrate  of  silver,  after  which  the 
canal  should  be  thoroughly  irrigated  with  hot  water  to  Avhich  a  little 
common  salt  has  been  added.  Another  and  less  commendable  and  pre- 
cise way  of  applying  the  nitrate-of-silver  solution  is  to  pass  a  Ferguson's 
speculum  so  as  to  encircle  the  cervix  uteri,  which  is  touched  with  the 
solution  on  a  cotton-holder.  Then  one  or  two  drachms  of  it  are  poured 
into  the  speculum,  when,  on  withdrawal  with  a  rotary  motion,  the  solu- 
tion will  come  in  contact  with  the  vaginal  walls.  After  this  application, 
which  should  be  thoroughly  made  in  the  posterior  and  in  the  anterior 
fornix,  and  also  to  the  uterus,  usually  as  far  as  the  os  internum,  the 
vagina  should  be  thoroughly  tamponed  with  iodoform  gauze.  Currier  ^ 
claims  that  benefit  will  sometimes  follow  the  application  by  means  of  the 
tampon  of  a  mixture  of  subnitrate  of  bismuth  and  glycerin,  one  drachm 
to  the  ounce.  In  this  I  think,  from  experience,  that  as  regards  many 
cases  he  is  perfectly  right,  though  my  preference  is  for  a  mixture  con- 
taining double  the  quantity  of  bismuth.  In  my  experience,  tampons 
made  of  absorbent  gauze  are  preferable  to  those  of  absorbent  cotton, 
since  they  absorb  more  freely  and  do  not  give  rise  to  the  unpleasant 
and  sometimes  painful  sensations  caused  by  the  bolus  of  cotton.  In 
many  cases,  the  nitrate-of-silver  solution  having  been  applied  once  or 
twice,  much  benefit  will  follow  the  deposition  deep  into  the  vagina  of  a 
considerable  amount  of  powdered  boracic  acid,  which  must  be  retained 
by  the  gauze  tampon.     Whatever  form  of  tampon  is  used,  it  should  be 

1  N.  Y.  Med.  Journ.,  Oct.  24,  1885,  p.  454. 


GONORRHCEA  IN  THE  FEMALE. 


313 


removed  with  great  care  every  twenty-four  or  forty-eight  hours,  and 
then  copious  hot-water  injections  should  be  made.  The  frequency  and 
strength  of  the  nitrate-of-silver  applications  should  be  determined  by  the 


Fig.  91. 


Wire  speculum  for  applications  to  the  vagina. 

progress  of  the  case.  Usually,  several  days  should  elapse  before  a  sec- 
ond is  made,  and  if  the  patient  is  under  control  two  or  three  are  enough. 

It  is  well  to  bear  in  mind  that  vaginal  injections  may  be  given,  the 
patient  lying  on  her  back  with  her  hips  elevated,  either  by  means  of  a 
Davidson  or  a  fountain  syringe,  or  by  Dr.  Foster's  excellent  vaginal 
douche. 

In  chronic  vaginitis  extract  of  Pinus  canadensis  may  be  used  on 
tampons.  Bichloride-of-mercury  irrigations  may  in  a  measure  allay  the 
irritation,  but  they  generally  fail  to  produce  a  cure. 

Schwartz  ^  of  Halle,  believing  that  the  annihilation  of  the  gonococcus 
means  the  cure  of  gonorrhoea,  recommends  the  following  heroic  anti- 
parasiticide  treatment :  The  vagina  and  vulva  are  thoroughly  cleansed 
with  a  1  :  1000  solution  of  the  bichloride.  Then  by  means  of  a  Sims 
or  Bozeman  speculum  all  the  parts  are  swabbed,  with  the  utmost  care, 
with  cotton-Avool  saturated  with  a  1  per  cent,  bichloride  solution,  taking 
care  to  rub  off  the  superficial  layers  of  the  epithelium  and  to  reach  the 
folds  of  the  introitus  vaginae.  Then  the  vulva  and  vagina  are  dusted 
with  iodoform,  which  to  be  effective  should  be  rubbed  in,  and  then  the 
vagina  must  be  packed  with  iodoform  gauze,  which  should  remain  three 
days,  at  the  end  of  which  the  process  should  be  repeated.  Another 
tampon  of  iodoform  gauze  is  then  inserted  and  allowed  to  remain  five 
days,  upon  the  removal  of  which,  during  eight  or  fourteen  days,  copious 
irrigations  of  the  vagina  with  sublimate  solution,  1 :  2000,  should  be 
employed.  It  is  stated  that  after  the  second  tampon  the  vagina  is  red 
and  raw  and  the  seat  of  a  copious  purulent  discharge.  While  it  is 
claimed  that  in  Germany  marked  benefit  has  followed  this  method  of 
treatment,  I  think  that  its  employment  should  be  much  modified  in  the 
reduction  of  the  solutions  of  the  sublimate.  It  is  well  known  that  con- 
tinuous irrigation  of  the  vagina  with  a  solution  1 :  5000  is  commonly 
attended  in  a  short  time  with  irritation,  which  also  sometimes  affects 

1  Op.  cit. 


314  OONORRHCEA  AND  ITS  COMPLICATIONS. 

the  hands  of  the  nurse  or  surgeon.  Then,  again,  many  persons  are 
subject  to  the  iodoform  idiosyncrasy,  and  the  application  of  the  drug 
causes  violent  local  reaction  and  sometimes  systemic  poisoning.  There- 
fore it  should  never  be  put  recklessly  in  large  quantities  into  any  cavity, 
natural  or  artificial.  I  think,  however,  that  with  modifications  and 
toning  down  Schwartz's  treatment  may  be  of  benefit. 

A  number  of  new  drugs  have  been  used  in  the  form  of  injections  in 
the  treatment  of  gonorrhoeal  vaginitis. 

D'Aulnay^  first  thoroughly  swabs  the  vagina  with  a  1  per  cent,  sub- 
limate solution,  and  then  tampons  the  cavity  with  absorbent  cotton  or 
gauze  moistened  with  a  solution  composed  of  methyl  blue  10,  alcohol  15, 
caustic  potassa  0.2,  and  water  200.  The  application  is  left  in  the  vagina 
for  two  days ;  then  a  copious  irrigation  is  given  and  the  remedy  applied 
in  the  same  manner  again.  It  is  claimed  that  this  treatment  soon  pro- 
duces a  cure. 

Retinol  is  well  spoken  of  by  Barbier,^  who  used  it  in  Balzer's  ser- 
vice. The  parts  are  first  freely  irrigated,  then  gauze  or  cotton  tampons 
moistened  with  the  balsam  are  inserted  in  the  vagina.  A  cure  is  said 
to  be  produced  in  from  twelve  to  fifteen  days. 

Subacute  and  chronic  gonorrhoeal  vaginitis  may,  according  to 
Schwimmer,^  be  cured  by  the  use  of  alumnol,  by  insufflation  or  irriga- 
tion of  the  canal,  in  two  to  eight  weeks. 

In  Hirtz's  service  at  the  Lourcine  Hospital,  Dubard*  used  on  tam- 
pons and  by  smearing  a  solution  consisting  of  12  per  cent,  of  resorcin 
in  glycerin.     If  the  application  caused  pain,  cocaine  was  used  locally. 

Treatment  of  Gonorrhoea  of  the  Os  and  Uterine  Cavity. — There  is  no 
form  of  gonorrhoea  in  women  that  demands  greater  skill,  judgment,  and 
conservatism  than  gonorrhoeal  infections  of  the  os  and  uterine  cavity. 
In  these  delicate  parts  energetic  treatment  should  be  promptly  insti- 
tuted in  order  to  prevent,  if  possible,  the  further  upward  spread  of 
the  infection.  Unfortunately,  the  general  practitioner  is,  as  a  rule, 
not  sufficiently  versed  in  the  course  of  the  disease  and  skilled  in  its 
handling  to  warrant  his  active  intervention  in  these  cases,  and  my  ad- 
vice to  any  one  not  thus  equipped  is,  when  he  has  these  cases  under 
his  care,  to  promptly  call  in  the  aid  of  a  wide-awake  but  conservative 
gynecologist. 

Tixeron  ^  has  shown  that  intra-uterine  irrigations  with  solution  of 
permanganate  of  potassa,  1 :  1000  and  1 :  500,  may  be  of  benefit. 

It  is  well  for  the  surgeon  to  bear  in  mind  these  facts :  In  these  cases 
the  disease  quickly  localizes  itself  deeply  in  the  mucous  membrane  of 
the  cervix,  and  there  assumes  a  chronic  condition  which  at  any  time 
under  stimulation  may  become  acute.  To  treat  these  cases  properly 
the  OS  must  be  dilated,  and  then  the  mucous  membrane  must  either  be 
curetted  or  to  it  must  be  applied  quite  strong  caustic  solutions  (chloride 
of  zinc,  Lugol's  solution,  etc.).  These  operations  should  be  done  with 
special  skill  and  good  judgment  under  favorable  home  or  hospital  con- 

^  Bull.  qen.  de  Therapeut.,  1893,  vol.  cxxiv.  pp.  396  et  seq.   . 

'^  These  de  Paris,  1890. 

^  Archiv  fur  Derm,  und  Syph.,  vol.  xxix.,  1894,  p.  157. 

*  These  de  Paris,  1889. 

*  Annates  des  Mai.  des  Org.  Gen.-urin.,  vol.  xi.,  1893,  pp.  47  et  seq. 


VULVO-VAGINITIS  IN  INFANTS  AND   YOUNG   CHILDREN.     315 

ditions  and  with  the  utmost  regard  for  asepsis  and  antisepsis.  Therefore 
I  say  that,  as  a  rule,  these  cases  do  not  belong  to  the  genito-urinary  sur- 
geon, but  should  be  treated  by  men  well  versed  in  women's  diseases. 

In  the  treatment  of  abscess  of  Bartholin's  glands  general  surgical 
principles  should  prevail.  If  an  incision  is  necessary,  it  should  be 
freely  made  over  the  most  fluctuating  part  of  the  tumor.  Then,  after 
thorough  antiseptic  irrigation,  the  parts  should  be  well  packed  with 
iodoform  gauze,  which  when  the  inflammatory  symptoms  have  subsided 
may  be  replaced  by  balsam-of-Peru  gauze.  These  packings  should  be 
carefully  applied  until  full  healing  has  been  produced.  In  chronic  cases 
it  is  good  surgery  to  extirpate  the  gland  as  soon  as  possible,  since  it  is 
almost  certain  that  exacerbations  will  occur  sooner  or  later. 

Whenever  the  anatomical  arrangement  of  the  parts  will  allow  of  the 
slitting  up  of  the  various  follicles  in  the  vulva  and  urethra  when  the 
seat  of  chronic  gonorrhoea,  this  little  operation  should  be  performed 
with  all  antiseptic  care.  Then,  after  cauterization  with  a  solution  of 
nitrate  of  silver  (3ss  to  5j  water),  the  little  cavity  should  be  packed  and 
caused  to  heal  from  the  bottom.  Sometimes  these  little  inflammatory 
foci  cause  much  trouble  to  the  surgeon,  and  ultimately  it  is  necessary  to 
extirpate  them. 


CHAPTEK    XXXI. 

VULVO-VAGINITIS    IN  INFANTS  AND  YOUNG  CHILDREN. 

Within  the  last  twelve  years  much  light  has  been  thrown  on  the 
subject  of  inflammation  of  the  vulva  and  vagina  of  young  children  by  a 
number  of  essays  which  contain  important  information  as  to  its  clinical 
history,  etiology,  and  bacteriology.  Prior  to  the  year  1879  little  of  a 
definite  character  was  known  concerning  this  affection :  to-day  our 
knowledge  is  greater  and  clearer.  Yet  even  now  there  are  many  ob- 
scure points  which  the  future  may  perhaps  clear  up. 

Yulvo-vaginitis  may  occur  in  the  newly-born  infant  shortly  after 
birth  and  during  its  first  half  year  of  life,  and  it  has  been  observed  in 
the  latter  part  of  the  first  and  in  the  second  year.  There  is,  however, 
a  remarkable  unanimity  of  statement  that  it  occurs  most  frequently  be- 
tween the  ages  of  two  and  ten  or  twelve  years.  In  other  Avords,  when 
the  child  is  cared  for  by  its  mother  or  nurse  it  is  usually  less  likely  to 
become  aff'ected  with  vulvo-vaginitis.  When,  however,  it  begins  to 
mingle  with  other  children  or  to  sleep  with  older  persons,  then  it  be- 
comes more  liable  to  the  aff"ection.  This  fact  is  well  brought  out  by 
Comby,^  who  found  in  151  cases  of  vulvo-vaginitis  that  in  84  the  chil- 
dren were  over  two  and  under  ten  years  of  age. 

Yulvo-vaginitis — or  urogenital  blennorrhoea,   as   Cahen-Brach  ^  pro- 

^  "  Etude  sur  la  Vulvo-vaginite  des  Petites  filles,"  Bidl.  et  Mem.  cle  la  Soc.  med.  des 
Hopit.  de  Paris,  3d  Series,  1891,  vol.  viii.,  pp.  395  et  seq. 

'^  "  Die  Urogenitalblcnorrhoe  (gonorrhoe)  der  kleinen  Mildchen,"  X>eM<.  med  Wochen- 
schr.,  1892,  vol.  xviii.  pp.  724:  et  seq. 


316  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

poses  to  call  it,  being  more  precise  and  anatomically  correct — occurs  in 
an  epidemic,  an  endemic,  and  a  sporadic  form.  A  number  of  classifica- 
tions of  this  affection  have  been  offered,  but  for  purposes  of  clearness 
and  simplicity  of  description  it  is  only  necessary  to  consider  the  simple 
or  catarrhal  and  the  severe  or  so-called  gonorrhoeal  varieties.  The  so- 
called  phlegmonous  vulvitis  is  simply  one  or  the  other  of  these  forms 
complicated  by  abscess-formation,  and  is  sometimes  the  result  of  trau- 
matism, while  aphthous  or  diphtheritic  vulvitis  is  an  accident — an  acute 
infective  process  occurring  usually,  and  complicating  a  simple  vulvo- 
vaginitis in  subjects  suffering  from  diphtheria,  the  exanthemata,  and 
typhoid  fever.  In  like  manner  a  gangrenous  form  has  been  spoken  of, 
but  it  has  not  a  distinct  entity,  for  the  gangrene  develops  as  an  accident 
in  poorly-nourished,  sickly  children  usually  suffering  from  an  infectious 
disease. 

Vulvo-vaginitis  in  infants  and  children  is  mostly  seen  among  poor, 
ignorant,  careless,  and  dirty  people,  and  therefore  is  found,  for  the  most 
part,  at  dispensaries,  hospitals,  and  maternities. 

Before  considering  the  disease  it  is  well  to  think  of  the  structures 
and  tissues  attacked  by  it.  The  external  genitals  of  the  young  female 
differ  from  those  of  girls  approaching  maturity.  In  the  young  child  the 
nymphse  are  commonly  more  prominent  than  the  labia  majora  and  the 
vulva;  the  urethra  and  the  hymen  are  comparatively  prominent,  even 
protuberant.  Further,  there  are  no  pudendal  hairs  to  serve  as  a 
protection  to  the  parts.  All  the  structures  are  therefore  much  exposed 
and  liable  to  traumatisms  of  all  kinds  and  to  irritation  from  secretions 
of  the  vagina  and  rectum,  and  to  dirt  and  general  uncleanliness. 
Further,  the  tegumentary  tissues  are  soft,  very  vascular,  and  prone  to 
become  hypersemic.  In  fact,  everything  about  the  female  genitals  in 
early  life  tends  to  offer  a  favorable  soil  to  any  infective  process,  mild  or 
severe.  In  this  connection  it  is  well  to  bear  in  mind  the  facts  stated 
by  Epstein,^  based  on  careful  observation.  He  says  that  we  often  see  in 
new-born  girls  a  more  or  less  abundant  secretion  in  the  form  of  a  viscid, 
gelatinous,  glassy,  milk-like  mass  lying  in  the  vulva.  This  mass  may 
be  continuous  with  an  extension  or  plug  of  similar  nature  seated  in  the 
vagina,  and  is  composed  mostly  of  flat  epithelium.  In  a  few  days  the 
mass  breaks  up  into  a  paste-like  or  creamy  secretion,  which  may  look 
like  pus  and  in  which  large  quantities  of  round  cocci  are  found.  This 
condition,  which  Epstein  calls  the  "  desquamative  catarrh  of  the  new- 
born," may  last  two  or  three  weeks,  and  on  disappearing  may  leave  the 
parts  in  a  healthy  condition.  Further,  Epstein  remarks  that  a  catarrhal 
vulvo-vaginitis  may  be  added  to  this  normal  desquamative  process ;  the 
mucous  membrane  may  become  hyper^mic,  then  inflamed,  and  the  secre- 
tion may  become  muco-purulent  and  then  purulent.  All  this  may  occur 
from  uncleanliness,  dirt,  decomposition  of  urine,  and  lodgement  of 
faeces.  A  low  and  depraved  condition  of  the  system  renders  the  infant 
very  susceptible  to  this  purulent  form  of  inflammation. 

Thus  we  see  at  the  very  outset  that  the  topography  of  the  parts  and 
the  conditions  to  which  they  are  subjected  all  tend  to  render  them  vul- 
nerable to  irritations  inherent  in  them  and  to  invasion  from  without. 

1  "  Ueber  Vulvo-vaginitis  gonorrhoica  bei  Kleinen  Miidchen,"  Archiv  fur  Derm,  und 
Syphilis,  1891,  vol.  xxiii.,  Erganzungsheft  2,  pp.  3  et  seq. 


VULVO-VAGINITIS  IN  INFANTS  AND    YOUNG   CHILDREN.      317 

Further  than  this,  it  must  be  remembered  that  the  urethra,  the  vulva, 
and  the  vagina  harbor  as  hosts  innumerable  and  varied  micro-organisms, 
many  of  Avhich  under  all  circumstances  are  harmless,  but  some  of  Avhich 
in  altered  conditions  of  the  tissues  may  become  active  and  harmful. 

Simple  Vulvitis. — This  form  may  be  found  in  very  young  infants 
and  in  children  from  two  years  onward,  and  exceptionally  even  up  to 
puberty. 

The  attention  of  the  mother  is  first  called  to  the  trouble  by  the  cries 
of  the  child  on  urination  and  by  the  frequency  of  the  act.  Examination 
shows  the  vulva  alone  to  be  involved,  or  this  part  and  the  urethra 
together,  or  these  external  parts  and  the  vagina  are  found  affected. 

If  there  is  simple  vulvitis,  we  find  redness  and  swelling  of  the 
nymphre  and  the  labia  majora  (as  much  of  them  as  is  developed),  and  at 
first  a  sero-epithelial  secretion  looking  like  milk,  then  later  on  a  muco- 
purulent discharge.  The  surface  of  the  mucous  membrane  is  eroded  in 
minute  spots  and  goodly-sized  patches.  The  child's  pain  is  then  mainly 
caused  by  the  scalding  sensations  caused  by  the  urine  lodging  on  the 
excoriated  surface.  Spontaneous  pain  may  result  from  the  vulvar  in- 
flammation. 

A  further  form  of  simple  vulvitis  consists  in  moderate  heat,  redness, 
and  swelling  of  the  parts,  from  which  pus  or  muco-pus  exudes.  Thus 
there  are  in  these  young  infants  two  forms  of  vulvitis — the  one  mild 
and  ephemeral,  with  a  sero-epithelial  discharge  moderate  in  quantity, 
and  the  other  more  severe  and  attended  with  greater  inflammation  and 
a  muco-purulent  discharge. 

Care  and  proper  medication  will  soon  cure  these  conditions.  When, 
however,  cases  are  neglected  the  morbid  process  extends  to  the  con- 
tiguous parts. 

VuLVO-VAGiNiTis. — This  affection  is  found  in  very  young  infants  and 
in  children  from  two  to  thirteen  years  old. 

In  infants  vulvo-vaginitis  usually  begins  as  a  vulvitis,  ■which,  being 
uncared  for,  becomes  more  intense  and  spreads  either  to  the  vagina  or 
to  the  urethra,  or  to  both.  As  a  result  there  is  produced  a  very  formid- 
able aff'ection  for  such  a  young  subject.  In  many  cases  the  urethra  is 
not  infected,  but  there  seems  to  be  a  tendency  for  the  morbid  process  to 
extend  through  the  hymeneal  introitus  and  to  involve  the  vagina  and 
perhaps  the  cervix  uteri. 

Examination  shows  a  reddened,  eroded  surface  of  the  vulva,  hymen, 
and  vagina.  A  copious  purulent  or  muco-purulent  secretion  escapes 
from  the  parts,  and  it  may  dry  in  crusts  on  the  labia  majora  or  even  on 
the  thighs.  The  pus  may  k..  thin,  and  again  thick,  even  to  being  so 
gelatinous  that  it  can  be  taken  up  by  the  forceps.  In  this  condition  the 
infant's  suff'erings  are  quite  severe. 

The  tendency  of  the  disease  is  to  persist  unless  proper  treatment  is 
adopted,  and  even  then  it  may  run  on  for  months  and  end  in  a  mild  and 
chronic  catarrhal  process.  When  the  urethra  is  involved  the  child's 
suff'erings  are  much  increased. 

When  simple  vulvo-vaginitis  attains  a  very  severe  grade  of  intensity, 
it  is  practically  impossible  to  diagnosticate  it  from  the  so-called  gonor- 
rhoeal  form.  It  will  be  seen  later  that  the  microscope  often  gives  us 
very  little  aid. 


318  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

The  statement  has  been  made  that  the  pus  of  simple  vulvo-vaginitis 
is  not  infectious,  but  there  are  many  facts  in  existence  to  prove  that  it 
is  often  highly  infectious.  It  is  sometimes  noted  that  an  infant  becomes 
affected  with  this  disease,  and  soon  after  the  other  children  are  attacked 
by  it  or  by  purulent  ophthalmia.  I  saw  a  severe  epidemic  of  vulvo- 
vaginitis in  Charity  Hospital  which  was  traced  to  a  child  suffering  from 
the  simple  form  of  the  affection.  This  fact  has  been  observed  in  other 
epidemics. 

The  clinical  features  of  phlegmonous  vulvitis  are  those  of  follicular 
abscesses  or  even  abscess-formations  usually  involving  a  labium,  in 
addition  to  the  vulvar  inflammation.  In  the  aphthous  or  diphtheritic 
variety  there  are  present,  besides  the  severe  catarrhal  process,  patches 
of  false  membrane  of  a  dirty-white  or  brownish  color  seated  on  an  ex- 
coriated surface. 

Gangrenous  vulvitis  is  an  analogous  condition  to  noma  as  seen  in  the 
mouth.  It  occurs  in  poorly-nourished  and  uncared-for  infants.  More 
or  less  tissue  sloughs  away,  but  it  is  astonishing  how  thoroughly  Nature 
repairs  the  injury,  so  that  in  some  cases  little  trace  of  the  destructive 
process  is  left.  Diphtheritic  and  gangrenous  vulvitis  is  usually  a  con- 
comitant of  some  general  infective  process. 

The  So-called  Gonorrhceal  Vulvo-vaginitis. 

It  must  be  distinctly  understood  that  vulvo-vaginitis  is  very  rarely 
of  venereal  origin,  and  that,  if  the  suppuration  does  originate  in  gonor- 
rhceal pus,  the  infection  in  most  cases  takes  place  in  an  indirect  manner 
through  some  medium  or  agent. 

Since  so  little  is  really  known  as  to  the  mode,  of  origin  of  this  form 
of  vaginitis,  and  as  its  onset  is  unlooked  for  and  insidious,  the  affection 
is  well  on  in  its  course  before  it  is  seen  by  the  surgeon.  We  have  no 
precise  data  as  to  the  period  of  incubation,  but  we  are  warranted  in 
assuming  that  the  morbid  process  begins  in  mild  and  localized  hyper- 
semia.  When  first  seen  these  children  present  the  evidence  of  suffering 
in  their  uneasiness  and  their  cries.  When  the  cervix  uteri  is  involved 
they  also  suffer  from  bellyache.  We  find  an  intensely  red  and  tumefied, 
superficially  eroded,  and  even  bleeding  condition  of  the  vulvar  struc- 
tures of  the  introitus  vaginae,  of  the  vagina  itself,  and  also  of  the  cervix 
uteri,  from  which  pus  may  drip.  A  profuse  yellowish-green  discharge 
escapes  from  the  hymeneal  orifice  and  is  found  smeared  over  the  vulva. 
Very  often  this  pus  dries  into  crusts  upon  the  labia  majora  and  upon 
the  inner  surface  of  the  thighs.  There  is  very  often  intertrigo,  even  of 
a  severe  type,  on  the  latter  regions.  When  the  urethra  is  involved 
urination  is  frequent  and  painful.  Then  when  the  urine  flows  over  the 
inflamed  vulva  the  child's  sufferings  are  great. 

The  course  of  the  affection  is  dependent  upon  the  care  given  the 
child  and  the  nature  of  the  treatment  adopted.  Under  the  most  favor- 
able conditions  the  affection  is  often  very  obstinate,  and  in  neglected  or 
insufiiciently  cared-for  infants  it  runs  on  indefinitely  unchecked.  If  a 
child  afl[licted  with  this  disease  is  cured  in  two  or  three  months,  the 
result  may  be  pronounced  to  be  brilliant.  In  very  many  cases  the  dis- 
ease runs  on  and  ends  in  a  chronic  catarrhal  condition. 


VULVO- VAGINITIS  IN  INFANTS  AND   YOUNG   CHILDREN.      319 

In  some  cases  the  inguinal  ganglia  become  swollen  and  painful. 
There  are  well-attested  cases  on  record  in  which  peritonitis  resulted 
from  this  form  of  vulvo-vaginitis.  Those  reported  by  Hatfield,'  Loren,^ 
and  Huber^  are  of  much  interest.  As  stated  by  Martin,  Dr.  R.  Curtin 
has  seen  endometritis  as  a  complication  of  this  affection.  Currier*  says 
that  it  seems  to  him  very  probable  that  many  of  the  deformed  and  unde- 
veloped uteri,  with  which  are  associated  so  much  dysmenorrhoea  and 
anguish,  sterility,  and  domestic  unhappiness,  are  the  legitimate  conse- 
quence of  vulvo-vaginitis  which  had  travelled  from  the  vagina  to  the 
uterus  and  tubes  in  early  life. 

There  can  be  no  question  as  to  the  infectious  quality  of  pus  derived 
from  this  disease,  since  there  are  many  cases  on  record  in  which  it  has 
produced  severe  vulvo-vaginitis  and  also  intense  purulent  ophthalmia, 
which  as  a  complication  of  the  disease  stands  first.  This  form  of  the 
affection  is  seen  in  babes  in  the  arms  and  in  young  children  from  two 
to  ten  years  old.  In  families  we  see  sporadic  outbreaks,  and  in  hospi- 
tals and  maternities  more  or  less  severe  and  extensive  epidemics. 

Gonorrhoeal  rheumatism  is,  according  to  statistics,  a  rather  rare 
complication  of  purulent  vulvo-vaginitis.  Hartley^  reported  a  case  of 
joint-swelling  in  a  child,  in  whom  it  appeared  that  the  infection  origi- 
nated in  rape.  Two  other  cases  are  also  reported  by  Koplik,^  and  a 
fourth  by  Goldenberg." 

Etiology. — In  the  cases  of  young  infants  it  is  often  impossible  to 
learn  any  facts  as  to  the  source  of  infection.  It  is  claimed  by  Pott^ 
that  he  has  seen  specific  vulvo-vaginitis  in  the  child  contracted  from  its 
mother  (who  suffered  from  gonorrhoea)  during  the  process  of  delivery. 
Such  a  mode  of  infection  is  certainly  possible,  but  before  it  is  accepted 
in  an  unqualified  manner  we  must  have  the  facts  concerning  it  clearly 
proved  in  a  number  of  cases,  and  fortified  with  an  entire  concordance 
in  the  microscopical  findings  in  mother  and  infant. 

Usually  infants  are  brought  suffering  from  vulvo-vaginitis  when  they 
are  some  weeks  or  months  old.  In  very  many  instances  the  only  assump- 
tion warranted  is  that  the  more  or  less  severe  process  began  in  the  phys- 
iological hypergemia  which  is  constantly  present  in  young  children.  In 
absence  of  negative  proof  it  may  be  confidently  asserted  that  many 
cases  of  this  affection  originate  de  novo,  without  the  implantation  of 
an  infectious  secretion. 

Undoubtedly,  many  infants  are  infected  by  some  means  from  pus 
from  the  vaginae  of  their  mothers  or  nurses.  I  have  heard  of  mothers 
and  nurses  who  quieted  their  infants  and  charges  by  placing  a  finger  in 
the  vulva,  and  I  can  understand  that  a  soiled  finger  might  carry  infec- 
tion.     Then,  again,  sponges  used  by  mothers  suffering  from  leucorrhoea 

^  Archives  of  Pediatric^:,  1886,  p.  641. 

^  Higiea,  vol.  xlviii.  p.  607  ;  and  Jahr.fur  Kinderheilkunde,  vol.  xxvi.  p.  410. 

3  Archives  of  Fediatries,  Dec,  1889,  p.  887. 

*  "  Vulvo-vaginitis  in  Children,"  3Ied.  News,  July  6,  1889. 

^  "  Gonorrhceal  Rheumatism,  especially  in  the  Female,"  N.  Y.  Med.  Journ.,  April  2, 
1887. 

*  "Arthritis  complicating  Vulvo-vaginal  Inflammation  in  Children,"  ibid.,  3m\e  21, 
1890. 

'  "Gonorrhoeal  Rheumatism  in  Early  Childhood,"  ibid.,  July  23,  1892. 

*  "  Zur  Aetiologie  der  Vulvo-vaginitis  im  Kindesalter  und  ihre  Behandlung,"  Jahr, 
fiir  Kinderheilkunde,  vol.  xix.,  1883,  pp.  71  et  seq. 


320  GOyOERHCEA  AND  ITS  COMPLICATIONS. 

have  been  also  used  upon  their  infants,  who  became  affected  -with  vulvo- 
vaginitis. It  is  claimed  that  pieces  of  soap  used  on  infected  infants  have 
conveyed  the  disease  to  the  healthy.  The  details  of  Hatfield's  case  war- 
rant the  suspicion  that  infection  of  the  child  resulted  from  use  of  a 
syringe  used  by  its  father,  who  suffered  from  gonorrhoea.  It  sometimes 
happens  that  excited  mothers  bring  children  thus  affected,  claiming  that 
they  have  been  tampered  with  and  infected  by  a  man.  Such,  certainly, 
may  be  the  case,  but  most  commonly  older  children  are  selected  for  pur- 
poses of  rape.  Walker'  reports  21  cases  in  which  there  was  a  history 
of  contact  with  parents  who  had  the  disease  or  with  other  infected  per- 
sons who  had  committed  assault  and  rape. 

When  the  child  of  poverty  and  squalor  gets  out  of  arms  and  sleeps 
and  mingles  with  older  girls  and  women,  it  is  liable  to  contract  vulvo- 
vaginitis accidentally,  conveyed  by  means  of  infected  fingers,  and 
mainly  by  soiled  under-wear,  sponges,  and  towels.  From  one  suffering 
child  other  members  of  the  family  or  its  playmates  may  be  infected  in 
the  vulva  or  the  eyes  by  either  the  simple  catarrhal  or  the  so-called  gon- 
orrhoeal  form  of  the  disease. 

Among  older  girls  direct  gonorrhoea!  infection  may  occur  as  a  result 
of  attempted  or  complete  coitus  with  young  boys.  There  are  many  such 
instances  in  medical  literature.  Then,  again,  infection  may  occur  among 
several  or  many  young  girls  through  their  own  bad  habits.  Atkinson^ 
relates  the  facts  of  a  small  epidemic  of  purulent  vulvo-vaginitis  in  young 
girls  at  a  boarding-school,  by  which  it  appears  that  they  crept  into  each 
other's  beds  and  titillated  each  other's  genitals.  In  this  epidemic  puru- 
lent ophthalmia  and  stomatitis  Avere  also  prevalent. 

The  records  of  a  number  of  epidemics  bring  out  many  interesting  and 
important  facts,  and  unfortunately  leave  many  in  doubt  and  uncertainty. 

Ollivier^  states  that  in  his  asvlum  there  were  three  voung  children 
suffering  from  this  disease,  and  that  within  three  Aveeks  twelve  others 
Avere  attacked.  It  Avas  found  that  after  caring  for  the  original  three 
infected  children  the  nurses  did  not  wash  their  hands  before  attending 
to  the  uninfected,  and  that  they  used  on  the  healthy  the  same  sponges 
Avith  which  they  Avashed  the  infected  children.  They  passed  presumably 
pus-soiled  chambers  from  infected  to  healthy  children,  and  alloAA-ed  all 
to  sit  on  the  same  wooden  seat  of  the  water-closet,  Avhich  was  no  doubt 
smeared  Avith  infecting  pus.  These  facts  throw  a  flood  of  light  upon  the 
matter  of  prophylaxis. 

The  details  of  the  great  epidemic  of  Posen,  recorded  by  Skutsch,^ 
carry  with  them  an  awful  lesson.  In  an  institution  for  children  within 
fourteen  days  236  female  children  became  affected  Avith  purulent  vulvo- 
vaginitis. The  origin  of  the  infection,  Avhether  from  one  child  or  several 
children,  is  not  known,  but  it  is  very  evident  that  the  massing  together 

^  Archives  of  Peiliatrics,  1886,  p.  269. 

^  "Keport  of  Six  Cases  of  Contagious  Vulvitis  in  Children,"  Am.  Jour }i.  Med.  Sciences, 
vol.  xcv.,  1878,  pp.  444  et  seq. 

^ "  Note  sur  la  Contagiosite  de  la  Vaginite  des  petites  Filles,"  Bull,  de  I'Acad.  de  Med., 
3d  Series,  vol.  xix.,  1888,  p.  56. 

*  "  Ueber  Vulvo-vaginitis  Gonorrhoica  bei  Kleinen  Miidchen,"  Inavg.  Dissert.,  Jena, 
1891.  Other  interesting  essays,  giving  histories  of  epidemics,  are  as  follows :  Cs^ri,  Wien. 
med.  Wochenschr.,  vol.  xxxv.,  1885,  pp.  703-739;  Friinkel,  ArchivfUr  Path.  .Anatomie,  vol. 
xcix.,  1885,  pp.  276  et  seq. ;  Von  Dusch,  Deut.  med.  Worhen.'ichr.,  vol.  xiv.,  1888,  pp.  831  et 
seq. ;  and  Martin,  Journal  of  Cutaneous  and  Gen.-urin.  Diseases,  1892,  pp.  415  et  seq. 


VULVO-VAGINITIS  IN  INFANTS  AND    YOUNG   CHILDREN.      321 

of  large  numbers  of  children  in  brine-baths  afforded  the  opportunity  for 
the  dissemination  of  the  disease. 

Basing  their  opinion  on  microscopical  findings,  many  authors  to-day, 
following  the  lead  of  Pott,  unreservedly  consider  the  majority  of  cases 
of  vulvo-vaginitis  as  of  gonorrhoea!  origin,  the  infection  having  taken 
place  in  an  indirect  and  often  unknown  manner.  We  find  that  in  this 
affection  also  many  authors  claim  that  they  have  found  the  gonococcus, 
when  it  is  evident  from  their  writings  that  their  examinations  have  been 
superficially  made. 

In  some  cases  of  the  simple  variety  the  microscope  affords  definite 
aid.  Thus,  as  has  been  well  shown  by  Koplik  in  a  valuable  essay,^  in 
the  pus  of  simple  vaginitis  there  are  found  rods,  cocci,  and  diplococci 
in  the  leucocytes,  and  besides  a  pseudo-gonococcus,  somewhat  similar  to 
the  gonococcus,  seated  on  epithelial  cells.  The  Avhole  microscopic 
picture  is  so  difi"erent  from  that  presented  by  true  gonorrhoeal  pus  that 
even  with  a  limited  experience  the  surgeon  will  readily  recognize  its 
simple  nature.  It  is  true  also,  as  claimed  by  Berggriin,^  that  in  these 
mild  cases  we  find  staphylococci  and  streptococci. 

On  the  other  hand,  in  severe  cases  of  vulvo-vaginitis  the  microscopic 
picture  of  the  secretion  is  strikingly  similar  to  that  of  gonorrhoea  of  the 
adult  male  or  female.  Thus  it  would  seem  to  be  very  easy  to  determine 
the  character  of  a  uro-genital  discharge  of  a  young  child,  but,  really, 
such  is  not  very  often  the  case.  Thus  we  frequently  see  a  child  with 
a  profuse  purulent  discharge  from  very  much  inflamed  genitals  which 
under  the  microscope  presents  a  micro-organism  answering  in  every  Avay 
to  the  description  of  the  gonococcus.  Yet  an  exhaustive  and  critical 
study  of  the  case  and  its  environments  may  show  that  there  is  no  basis 
whatever  upon  which  to  fix  a  diagnosis  of  gonorrhoea.  Even  so  eminent 
a  bacteriologist  as  Frankel  had  his  misgivings  as  to  the  nature  of  the 
micro-organisms  he  found  in  the  pus  of  the  Hamburg  epidemic.  It 
seemed  to  him  to  be  the  gonococcus,  but  the  histories  of  his  cases  would 
not  warrant  an  unequivocal  diagnosis  of  gonorrhoea.  I  have  seen  cases 
in  which  no  history  of  gonorrhoea  could  be  obtained,  yet  the  microscopical 
picture  of  the  secretion  seemed  that  of  gonorrhoea. 

This  being  the  state  of  affairs,  we  certainly  cannot  from  microscopic 
findings  alone  unequivocally  pronounce  a  case  to  be  of  gonorrhoeal  nature 
unless  its  history  in  all  its  details  is  in  accord  with  that  view.  This, 
to  my  mind,  clearly  shows  that  from  a  medico-legal  standpoint  the  mere 
finding  of  the  gonococcus  or  the  supposed  gonococcus  in  the  uro-genital 
secretion  of  a  child  only  proves  that  the  disease  possibly  originated  in 
gonorrhoea. 

Succinctly  stated,  the  truth  of  this  question  of  etiology  is  this :  In 
many  cases  the  clinical  history  and  microscopic  picture  establish  a  diag- 
nosis of  simple  catarrhal  vulvo-vaginitis ;  in  other  cases  the  clinical  and 
microscopical  evidence  points  clearly  to  gonorrhoea ;  but  in  still  other 
cases,  though  the  symptom-complex  is  complete  and  the  microscopical 
picture  points  to  gonorrhoea,  absolutely  no  evidence  can  be  obtained  to 

^  "Uro-genital  Blennorrhcea  in  Children,"  Journal  of  Cutaneous  and  Oen.-urin.  Diseases, 
1893,  pp.  219  and  263  et  seq. 

^ "  Bakteriolngische   Untersuchungen    bei    der   Vulvo-vaginitis    Kleinen   Miidchen," 
Archivfiir  Kinder heilkunde,  1893,  vol.  xv.  pp.  321  et  seq. 
21 


322  GONORRHCEA  AND  ITS  COMPLICATIONS. 

prove  that  the  disease  has  had  a  venereal  origin  or  has  originated  in 
gonorrhoea!  pus.  On  the  other  hand,  all  facts  point  to  the  suppuration 
having  begun  in  a  simple  catarrhal  form,  and  by  reason  of  dirt  and 
uncleanliness  has  assumed  all  the  features  of  a  severe  gonorrhoeal 
inflammation.  I  am  clearlj  of  the  opinion  that  in  many  cases  which 
have  been  regarded  as  undoubtedly  of  gonorrhoeal  nature  the  morbid  pro- 
cess originated  de  novo  in  a  simple  catarrhal  process. 

There  can  be  no  doubt  that  onanism,  eruptive  fevers,  seat-worms, 
pediculi,  eczema,  and  perhaps  impetigo  and  herpes,  act  simply  as  con- 
tributory causes.  They  establish  a  low  form  of  irritative  process,  and 
thus  render  the  tissues  susceptible  to  microbic  invasion  and  inflamma- 
tion, while  dirt,  the  exposed  condition  of  the  parts,  unremoved  dis- 
charges, and  general  uncleanliness  and  want  of  care  combined  contribute 
to  the  production  of  a  very  formidable  suppurative  process. 

Treatment. — The  first  duty  of  the  surgeon  in  all  cases  of  vulvo- 
vaginitis is  to  insist  upon  the  observance  of  absolute  cleanliness  of  the 
infant,  of  its  clothes,  and  of  its  surroundings.  The  next  is  the  enforce- 
ment of  prophylaxis  for  the  children  and  adults  of  the  family.  These 
facts  must  be  vividly  impressed  upon  the  mother  or  nurse  or  upon  any 
one  who  may  temporarily  care  for  the  child. 

In  hospitals  and  nurseries  a  child  should  be  isolated  immediately  that 
it  is  discovered  that  it  is  infected,  and  if  possible  it  should  be  cared  for 
by  nurses  who  wait  on  it  alone.  A  nurse  having  charge  of  a  child  thus 
affected  should  not  be  allowed  to  care  for  other,  non-infected,  children. 
In  the  event  of  necessity,  when  a  special  nurse  cannot  be  detailed  to  the 
case,  she  should  be  thoroughly  instructed  as  to  how  not  to  carry  infec- 
tion or  allow  it  to  occur  in  uninfected  children.  By  rigid  discipline  the 
spread  of  the  disease  (which  in  some  epidemics  is  like  wild-fire)  may  be 
limited  to  the  original  case  or  cases. 

In  newly-born  children  whose  mothers  have  been  known  to  suffer 
with  a  vaginal  discharge  it  is  well,  as  suggested  by  Epstein,  to  apply  to 
the  vulva  the  prophylactic  measure  recommended  by  Crede  for  the  eyes 
— namely,  the  careful  washing  of  the  part  and  the'^application  of  a  few 
drops  of  a  2  per  cent,  solution  of  nitrate  of  silver. 

The  desquamative  catarrhal  condition  of  the  genitals  of  new-born 
girls  may  be  treated  by  cleanliness,  by  free  injections  into  the  vagina  of 
warm  solutions  of  boric  acid  or  diluted  Goulard's  water,  followed  by 
cleanliness  and  dryness  of  the  parts,  obtained  by  means  of  some  dusting 
powder.  "Whenever  it  is  possible  in  these  cases  a  pledget  of  absorbent 
cotton  should  be  placed  in  the  vulva  and  it  should  be  frequently  renewed. 

Currier  speaks  well  of  subnitrate  of  bismuth  in  this  affection  gener- 
ally, and  Comby  states  that  he  has  seen  benefit  in  vulvar  cases  by  dust- 
ing the  surface  with  powdered  salol  and  then  applying  cotton.  '  When 
the  vagina  also  is  affected  this  author  advises  the  insertion  into  that 
tube  of  salol  bougies  (10  centigrammes  of  salol  to  1  gramme  of  cocoa- 
butter). 

For  severe  cases  of  the  simple  and  so-called  gonorrhoeal  type  a  care- 
fully conducted,  methodical  treatment  is  necessary.  Very  thorough 
irrigation  of  the  parts  with  a  warm  bichloride  solution  (1  :  6000  or 
1 :  10,000)  may  be  used  several  times  daily.  After  this  cleansing  pro- 
cess the  vagina  should  be  expanded  by  means  of  a  double-bladed  male 


STRICTURE  OF  THE   URETHRA.  323 

urethral  speculum  or  by  my  own  urethral  speculum,  and  the  parts  made 
dry  by  absorbent  cotton  on  an  applicator.  Then  a  10  per  cent,  nitrate- 
of-silver  solution  is  carefully  applied  to  the  whole  inflamed  surface.  This 
treatment  is  mainly  that  recommended  by  Koplik,  and  is  usually  pro- 
ductive of  good  results.  The  applications  should  be  made  by  the  sur- 
geon or  by  an  intelligent  nurse,  and  they  should  be  thorough.  As 
Koplik  says,  infants  struggle  and  resist  when  any  mode  of  treatment 
is  used,  so  it  is  necessary  to  have  a  convenient  table,  good  light,  and  all 
suitable  instruments  and  appliances  ready  at  hand.  This  author  states 
that  he  has  refrained  from  treating  the  urethra,  since  the  parts  are  so 
small,  and  the  pain  resulting  from  interference  with  this  canal  by  our 
present  methods  do  not  justify  persistence  in  efforts  of  treatment. 
Alkaline  mixtures  containing  tincture  of  hyoscyamus  may  be  given  with 
benefit  to  relieve  the  burning  on  urination. 

Thallin  and  iodoform  in  bougies  may  be  used,  but  there  is  no  cer- 
tainty of  good  resulting  from  them. 

Under  the  application  of  the  solution  of  nitrate  of  silver  benefit  will 
be  noticed  in  the  change  in  the  color  of  the  discharge  from  a  greenish 
to  a  grayish  milky  hue,  and  the  gonococci  (if  found  in  the  course  of  the 
case)  will  become  much  less  numerous  in  the  specimens  examined.  In 
this  event  the  treatment  may  be  continued  by  means  of  warm  irrigations 
of  nitrate  of  silver  (1  or  2  :  2000),  given  once  or  twice  a  day.  In  almost 
every  case  the  cure  Avill  be  slow  and  exacerbations  may  be  expected, 
and  the  patience  of  the  surgeon  and  fortitude  of  the  mother  may  be 
sorely  taxed.  Still,  in  any  event,  care  must  not  be  relaxed  nor  should 
the  treatment  be  suspended. 


CHAPTER    XXXII. 

STRICTURE  OF  THE  URETHRA. 

A  FULL  knowledge  of  chronic  anterior  and  posterior  urethritis  and  of 
their  pathological  anatomy  is  absolutely  essential  to  the  clear  comprehen- 
sion of  the  nature  and  course  of  stricture  of  the  urethra.  While  true 
gonorrhoeal  stricture  of  the  urethra  is  only  found  in  the  anterior  part  of 
the  canal,  it  is  very  essential  that  the  inflammatory  condition  of  the  pos- 
terior part  which  frequently  coexists  should  be  well  understood.  It  is 
necessary  to  emphasize  this  point,  since  nearly  all  authors  concern  them-' 
selves  solely  with  the  morbid  changes  which  take  place  in  the  anterior 
urethra. 

It  has  already  been  shown  (see  page  78)  that  in  chronic  anterior  ure- 
thritis the  essential  lesion  is  a  more  or  less  extensive  small-cell  infiltra- 
tion into  the  submucous  connective-tissue  layer  and  a  chronic  catarrhal 
condition  of  the  mucous  membrane  itself.  These  pathological  conditions 
may  disappear,  perhaps  spontaneously  in  some  cases,  but  generally  as  the 
result  of  treatment.     On  the  other  hand,  when  this  localized  inflammatory 


324  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

process  persists  for  a  very  long  time,  it  leads  to  certain  permanent  cell- 
changes  which  materially  lessen  the  calibre  and  impair  the  dilatability 
of  the  urethra  and  interfere  with  its  function. 

In  previous  years,  when  our  knowledge  of  urethral  pathology  was  quite 
limited  and  far  from  clear,  stricture  of  the  urethra  was  defined  in  the 
following  terms :  Any  loss  of  dilatability  of  the  urethra ;  all  encroach- 
ments on  the  average  normal  urethral  calibre;  any  abnormal  lessening 
of  the  calibre  and  dilatability  of  the  canal.  To  one  familiar  with  the 
subject  all  of  these  definitions  will  appear  to  be  unsatisfactory  and  incor- 
rect. Thus,  in  primary  acute  gonorrhoea  the  dilatability  of  the  urethra 
is  more  or  less  impaired,  yet  there  is  no  stricture.  A  papillomatous 
growth  or  an  inflamed  follicle  may  encroach  on  the  urethral  calibre,  yet 
neither  one  constitutes  what  we  know  as  stricture.  In  chronic  anterior 
urethritis  the  calibre  of  the  canal  may  be  narrowed  by  submucous  exuda- 
tion and  epithelial  hyperplasia  in  patches  and  areas,  both  of  which  impair 
its  dilatability,  yet  it  would  be  rash  to  say  that  a  man  thus  afi"ected  had 
stricture  of  the  urethra  until  the  morbid  process  had  become  so  chronic 
and  inveterate  that  true  structural  constringing  change  had  taken  place 
in  the  urethral  walls.  With  these  exclusions  and  in  the  light  of  our 
present  knowledge  we  may  define  stricture  of  the  urethra  to  be  a  condi- 
tion of  the  canal  attended  by  decidedly  well-marked  contraction  or  ste- 
nosis, and  an  utter  loss  of  normal  dilatability  caused  by  an  inflammatory 
process  which  produces  a  sclerosis  of  greater  or  less  density  and  contract- 
ile power. 

In  most  cases  of  chronic  anterior  urethritis  the  submucous  exudation 
remains  in  the  small  round  cellular  condition  for  varying  periods,  in  some 
cases  short,  and  in  others  long.  There  is  present  in  all  such  cases  the 
leaven  of  stricture  of  the  urethra.  When  this  infiltration  is  quite  dense 
it  constitutes  what  is  known  as  soft  stricture.  When  these  round-cells 
begin  to  change  into  fusiform  cells  and  to  form  fibrous  or  cicatricial  tissue, 
a  true  incipient  stricture  begins  to  form  which  may  then  be  called  semi- 
fibrous  stricture.  As  we  shall  see  later  on,  we  have  means  at  our  com- 
mand to  determine  quite  accurately  the  stage  and  character  of  a  urethral 
infiltration  and  whether  it  constitutes  a  soft  or  a  semi-fibrous  stricture. 

There  is  great  diversity  in  the  extent  and  depth  of  stricture-formation, 
which  should  be  clearly  understood.  In  some  cases  the  sclerosis  is  soft 
and  yielding,  and  in  others  it  has  more  density  and  resistance.  In  some 
patients  the  cell-changes  incident  to  the  production  of  a  true  sclerotic 
condition  take  place  very  slowly,  and  in  others  more  rapidly,  while  in 
some  exceptional  cases  the  development  is  very  rapid  indeed.  In  very 
many  cases  the  morbid  process  is  sharply  limited  to  the  submucous  con- 
nective-tissue coat,  which  may  be  involved  to  a  greater  or  less  extent. 
Thus  there  may  be  a  simple  narrow  band  of  stricture-tissue,  which  may 
occupy  only  a  small  part  of  the  circumference  of  the  tube,  or  it  may  be 
more  extensive,  even  to  the  formation  of  a  ring.  (See  Fig.  118.)  Per- 
haps an  inch  or  two  of  the  canal  may  be  the  seat  of  morbid  change,  and, 
again,  a  larger  segment  may  be  involved.  In  the  pendulous  urethra  we 
not  uncommonly  find  three,  four,  and  even  five  inches  of  the  canal  the 
seat  of  true  stricture-formation.  Then  in  the  subpubic  curve  a  part  of 
the  canal  may  be  found  stenosed,  and  in  somewhat  rare  and  old  cases  the 
bulbous  part"  in  its  totality  is  involved.     These  sharply-limited  submucous 


STRICTURE  OF  THE   URETHRA.  325 

strictures  therefore  may  be  simply  thread-like,  and  may  form  incomplete 
or  complete  rings.  They  may  involve  less  than  an  inch  or  more  of  the 
canal,  or  they  may  convert  a  large  portion  of  it  into  a  distinct  pathological 
tube.  As  to  density,  these  strictures  may  remain  tolerably  soft  for  long 
periods.  Then,  again,  as  they  grow  older,  they  become  more  or  less  firm, 
and  later  on  even  fibrous.  Clinical  history  and  pathological  anatomy  show 
that  the  morbid  process  may  remain  limited  for  years  in  the  submucous 
coat. 

In  the  cases  just  considered,  therefore,  the  morbid  process  has  not 
extended  beyond  the  submucous  layer,  the  corpus  spongiosum  remaining 
intact.  In  a  severe  class  of  cases,  however,  there  is  a  greater  or  less 
invasion  of  the  corpus  spongiosum.  The  lesion  in  these  cases  is  the  same 
small  round-cell  infiltration  which  is  exuded  into  the  superficial  meshes 
of  the  erectile  tissue.  This  condition  may  be  properly  termed  "  peri- 
urethritis." The  infiltration  into  the  spongy  tissue  may  not  only  be 
scant  and  superficial,  but  it  may  also  be  copious,  dense,  and  more  deeply 
penetrating,  even  to  the  localized  or  extended  involvement  of  the  whole 
thickness  of  the  spongy  body.  In  some  cases  the  corpus  spongiosum 
becomes  aifected  by  means  of  the  crypts  and  follicles  imbedded  in  it. 
These  structures  become  the  seat  of  an  infiltration  which  may  become 
perifollicular,  in  which  case  a  nodule  is  produced,  and  from  this  focus 
more  or  less  of  the  spongy  tissue  may  be  invaded.  These  little  nodular 
masses  may  not  uncommonly  be  felt  in  the  pendulous  urethra. 

In  the  great  majority  of  cases,  particularly  in  men  up  to  forty-five 
years  of  age,  the  corpus  spongiosum  of  the  pendulous  urethra  is  only  super- 
ficially infiltrated,  and  its  distensibility  and  extensibility  are  not  much, 
if  at  all,  impaired.  When  such  a  urethra,  involved  for  several  inches, 
is  carefully  palpated,  it  will  be  found  that  the  canal  is  distinctly  round,, 
tense,  and  dense  in  structure.  If  three  or  more  inches  are  affected,  it 
can  be  ascertained  that  the  normal  extensibility  is  somewhat  impaired. 
Yet  in  these  cases,  though  there  may  be  more  or  less  impediment  to  mic- 
turition, there  is  usually  not  much  impairment  of  the  parts  when  the  penis 
becomes  erect.  It  is  quite  rare  to  find  extensive,  deep,  and  total  infiltra- 
tion of  this  tissue  in  these  parts. 

In  the  subpubic  curve,  particularly  in  the  bulbous  portion  of  the 
urethra,  there  seems  to  be  a  marked  tendency  to  extensive,  and  often 
total,  involvement  of  the  spongy  tissue.  This  deep-seated  infiltration 
may  be  found  as  far  forward  as  the  peno-scrotal  angle.  The  cell-infiltra- 
tion, however,  shows  a  tendency  to  become  more  extensive  as  it  passes 
down  the  canal  and  reaches  the  height  of  its  development  in  the  bulbous 
urethra  at  its  junction  with  the  membranous  segment.  Total  infiltration 
of  the  corpus  spongiosum,  or  cavernitis,  is  not  very  infrequently  met  with 
in  the  form  of  a  hard,  round,  cord-like  mass  at  the  peno-scrotal  angle 
and  extending  for  an  inch  or  more  down  the  canal. 

At  the  bulbous  portion  of  the  urethra,  with  the  expanded  and  much 
thicker  spongy  body  encircling  it,  the  round-cell  infiltration  becomes 
more  exuberant  than  elsewhere.  Here  the  tissues  are  soft  and  succulent, 
and  the  blood-supply  is  copious.  Here  also  there  is  no  firm,  fibrous  cap- 
sule around  the  bulb ;  therefore  there  is  not  that  hindrance  to  profuse 
hypersemia  and  inflammation  that  there  would  be  if  the  parts  were  quite 
firmly  invested  in  dense  tissue.     For  these  reasons  the  post-gonorrhoeal 


326  GONORBHCEA  AND  ITS  COMPLICATIONS. 

inflammatory  process  is  severe  and  long-lasting,  and  its  resulting  cell- 
infiltration  exuberant  and  extensive.  In  the  bulb,  therefore,  the  infiltra- 
tion is  at  first  inextricably  mixed  with  muscular  and  elastic  fibres  and 
vessels,  and  the  condition  called  soft  stricture  then  exists.  The  morbid 
condition  then  consists  of  round-cell  infiltration  with  a  tendency  to  the 
development  of  fibrous  tissue.  When  this  fibrous  tissue  is  tolerably 
copious  and  intermixed  with  the  round-cell  infiltration,  the  resulting  con- 
traction is  of  semi-fibrous  structure.  Then,  as  time  goes  on  and  the  mor- 
bid process  increases  very  decidedly  in  extent  and  depth,  the  newly- 
formed  fibrous  tissue  takes  the  place  of  the  erectile  and  vascular  tissues, 
the  areolae  are  obliterated,  and  the  normal  structure  of  the  parts  becomes 
wholly  lost  and  replaced  by  a  uniform  sclerotic  and  atrophic  fibrous 
tissue,  white,  firm,  and  homogeneous  in  structure,  which  constitutes  what 
is  called  inodular  stricture. 

This  division  of  strictures  into  soft,  semi-fibrous,  and  inodular  and 
densely  fibrous  strictures  is  based  on  well-attested  pathological  facts,  and 
is  worthy  of  acceptance,  since  it  conforms  accurately  to  the  clinical  history 
of  these  coarctations. 

In  the  early  stage  of  the  stricture-formation  the  mucous  membrane 
rests  on  the  infiltrated  submucous  connective-tissue  layer,  but  when  the 
process  reaches  the  inodular  stage,  either  in  the  pendulous  or  the  bulbous 
urethra,  the  mucous  layer  then  rests  directly  on  the  fibrous  tissue. 

Recent  pathological  and  clinical  studies  have  thrown  a  flood  of  light 
upon  the  course  and  development  of  urethral  strictures.  In  olden  times 
it  was  thought  that  strictures  always  began  in  a  ring  of  infiltration, 
and  that,  if  there  were  several  of  them,  they  were  each  a  separate  morbid 
entity.  This  idea,  in  the  main,  is  incorrect.  In  somewhat  exceptional 
cases  in  the  pendulous  urethra  we  may  find  what  may  seem  like  a  large 
number  of  distinct  tight  bands,  six  to  fifteen  perhaps  in  number,  yet 
these  are  not  true  strictures.  They  are  simply  folds  of  mucous  membrane 
more  densely  infiltrated  than  the  tissue  on  either  side  of  them.  They 
result  from  the  stenosis  of  more  or  less  of  the  pendulous  urethra.  Not 
infrequently,  true  stricture  begins  in  a  little  thickened  patch  or  area  of 
the  pendulous  urethra,  seated  perhaps  on  one  side  or  on  the  upper  or 
lower  wall  of  the  canal.  If  not  dissipated  this  focus  of  infiltration  be- 
comes larger  as  time  elapses,  and  it  may  lead  to  a  true  annular  stricture. 
It  may  be  remarked  that  almost  all  old  strictures  are  annular.  Baraban  ^ 
has  clearly  shown  that  the  morbid  process  may  be  far  from  uniform  in 
development,  and  that  patches  and  small  foci  of  infiltration  may  be  joined 
together  among  tissues  less  affected.  Wassermann  and  Halle  ^  in  their 
studies  found  the  sclerosis  of  the  urethra  to  be  present  in  various  degrees 
of  development  and  severity.  In  old  men  the  subjects  of  strictures  for 
many  years  they  saw  evidences  of  a  progressive  increase  and  invasion 
of  the  infiltrating  process.  Fully-formed  stricture-tissue  usually  increases 
in  thickness,  particularly  near  and  in  the  bulb  ;  and  from  such  a  stricture 
the  infiltration  may  extend  anteriorly  to  other  parts  of  the  canal.     I  have 

^  "  Sur  les  Modifications  ^pitheliales  de  I'Ur^tlire  apres  Blennorrhagie  chez  I'Homme," 
Bevue  mkl.  de  I'lJsL,  vol.  xxii.  June  15,  1890,  pp.  3()1  et  seq.,  and  Oct.,  1890. 

^  "  Op.  cit.  Brissaud  and  Segond  ("Etude  sur  I'Anatomie  patholngique  des  Eetr^- 
cissements  de  I'Uretlire,"  Gaz.  Hchdnm.  de  Med.  et  de  Chir.,  No  39,  1881,  pp.  fi2.5  et  seq.) 
in  two  cases  found  the  upper  wall  of  the  spongy  urethrn  the  seat  of  soft  inflammation, 
while  the  lower  wall  was  the  seat  of  true  sclerotic  change. 


STRICTURE  OF  THE   URETHRA.  327 

observed  many  conspicuous  instances  of  this  progressive  invasion  of  the 
urethra,  such  as  is  well  shown  in  the  following  personal  case :  A  gentle- 
man at  the  age  of  twenty-one  had  gonorrhoea,  and  at  thirty  complained 
of  symptoms  of  stricture.  His  urethra  (calibre  30  French)  was  quite 
firmly  contracted  at  the  depth  of  five  and  a  half  inches  to  No.  7  French. 
Gradual  dilatation  during  five  months  restored  the  canal  at  the  affected 
part  to  a  calibre  of  27  French.  He  then  remained  without  any  discharge 
and  without  any  instrumentation  whatever  for  seven  years.  Then  exam- 
ination of  the  canal  showed  that  from  three  and  a  half  inches  down  to  the 
bulb  it  was  quite  uniformly  and  firmly  contracted  to  No.  8  French,  the 
bulb  causing  some  slight  bleeding  as  it  passed  over  several  soft-feeling 
bands.  In  this  case,  therefore,  the  exudative  process  in  seven  years  crept 
up  the  urethra  toward  the  meatus,  a  distance  of  two  inches.  In  many 
cases,  however,  the  process  remains  limited  for  years,  but  even  when  it 
has  thus  remained  dormant  it  may  later  on  become  active  and  involve 
more  tissue.  This  is  the  underlying  cause  of  the  extensive  and  deeply 
invading  strictures  which  are  not  uncommonly  found  in  old  men. 

In  some  very  exceptional  cases  a  peculiar  form  of  stricture  is  found  in 
the  pendulous,  and  also  in  the  bulbous,  urethra.  The  cell-infiltration  is 
quite  copious  and  compact,  and  it  converts  the  urethra,  for  a  distance  of 
several  lines  to  perhaps  more  than  an  inch,  into  a  firm  fibrous  tube  lined 
with  granulations  or  rugosities.  In  these  cases  the  submucous  tissue 
alone,  or  perhaps  a  little  of  the  corpus  spongiosum,  is  involved.  The 
calibre  of  the  canal  may  be  reduced  to  20  F.,  and  there  it  will  remain 
year  after  year  with  no  tendency  whatever  to  contract,  and  causing  no 
symptoms  other  than  slight  dribbling  at  the  end  of  urination.  These 
cases  prove  obstinate  to  dilatation  and  all  treatment,  and  in  general  they 
get  along  best  when  they  are  let  alone. 

It  is  important  that  clear  ideas  should  be  entertained  as  to  the  condi- 
tion of  the  membranous  urethra.  There  is  a  vagueness,  almost  amount- 
ing to  ignorance,  displayed  by  many  writers,  who  speak  of  stricture  of 
the  membranous  urethra  and  of  "  strictures  six  and  a  half  inches  down 
the  canal  in  the  membranous  urethra."  As  a  result  of  the  study  of  270 
museum  preparations,  Sir  Henry  Thompson  ^  concludes  that  stricture 
never  exists  beyond  the  bulbo-membranous  junction,  except  as  a  result 
of  traumatism.  In  an  oral  communication  Dr.  Gouley  informed  me  that 
he  sought  for  evidence  of  stricture  of  the  membranous  urethra  in  more 
than  500  dead-house  specimens  of  urethral  stricture,  and  had  not  found  it 
in  a  single  instance.  I  have  carefully  looked  for  this  form  of  stricture 
in  the  living  and  in  the  dead,  and  have  never  found  it.  The  studies  of 
Wassermann  and  Hall^,  however,  show  that  synchronously  with  stricture 
in  the  pendulous  urethra  the  membranous  segment  undergoes  a  number 
of  changes.  The  most  common  change  is  dilatation  of  this  part  of  the 
canal,  and  perhaps  also  of  the  prostatic  urethra,  in  cases  of  chronic  tight 
anterior  stricture.  The  submucous  connective  tissue  is  sometimes  the 
seat  of  a  mild  small-cell  infiltration,  but  it  never  goes  on  to  the  produc- 
tion of  stricture.  Epithelial  thickening  is  not  uncommon,  and  little 
papillomatous  tufts  and  masses  are  prone  to  form  in  this  situation.  These 
consist  of  enlarged  vessels,  embryonic  tissue,  and  epithelial  hyperplasia. 

'  The  Pathology  and  Treatment  of  Stricture  of  the  Urethra,  etc.,  4th  ed.,  London,  1S85, 
p.  50. 


328  OONOBBHCEA  AND  ITS  COMPLICATIONS. 

Cystic  degeneration  of  crypts  and  follicles  may  also  be  found  in  this 
region. 

When  the  normal  urethra  is  cut  across  at  right  angles  to  the  axis  of 
the  penis,  it  presents  a  sta.r-shaped  appearance  or  it  may  be  likened  to  a 
festooned  slit.  It  is  elastic  and  very  compressible,  and  surrounded  by 
the  loose  erectile  tissue  of  the  corpus  spongiosum.  When  the  seat  of 
stricture,  the  urethra  presents  a  variety  of  appearances  when  cut  trans- 
versely to  its  long  axis.  Its  tissue  is  whitish,  hard,  and  inelastic.  In 
the  pendulous  urethra  the  canal  has  a  round  or  oval  shape ;  it  sometimes 
looks  like  a  straight,  transverse,  or  bow-shaped  slit.  In  the  region  of 
the  bulb  it  has  an  elliptical,  triangular,  and  even  quadrangular  shape. 
All  these  distortions  are  due  to  the  submucous  cellular  changes. 

Gonorrhoeal  stricture  of  the  prostatic  urethra  has  never  been  found. 

While  the  whole  anterior  urethra  may  be  the  seat  of  stricture,  there 
are  certain  parts  where  it  occurs  more  frequently.  For  convenience  of 
description,  Sir  Henry  Thompson  divides  the  urethra  into  three  parts,  called 
the  subpubic  curvature,  the  centre  of  the  spongy  portion,  and  the  distal 
portion.  The  first  division  includes  the  membranous  urethra,  which  is 
never  the  seat  of  stricture.  It  is  this  inclusion  of  the  membranous  ure- 
thra in  the  stricture  field  that  leads  readers  into  error.  Consequently,  I 
will  modify  Thompson's  division  as  follows : 

Region  No.  1,  which  begins  at  the  bulbo-membranous  junction,  and 
includes  one  inch  and  a  half  of  the  canal  up  to  the  peno-scrotal  angle, 
and  which  constitutes  the  greater  part  of  the  subpubic  curve. 

Region  No.  2  begins  at  the  anterior  limit  of  the  preceding,  includes 
three  inches  of  the  canal,  and  ends  within  two  and  a  half  inches  of  the 
meatus. 

Region  No.  3  begins  at  the  external  orifice,  and  includes  a  distance  of 
two  and  a  half  inches  beyond  it.     (See  Figs.  2  and  11.) 

If  this  division  be  followed,  we  should  hear  no  more  of  these  putative 
strictures  of  the  membranous  urethra. 

As  to  the  frequency  of  occurrence  of  stricture  in  these  three  regions, 
the  analysis  of  the  findings  of  Sir  Henry  Thompson  in  the  270  museum 
specimens  is  very  important.  In  these  270  specimens  310  distinct 
strictures  were  found,  and  were  seated  as  follows : 

In  Region  No.  1,  215,  or  67  per  cent,  of  the  entire  number. 
"         "         "     2,    51,  or  16       "  "      "         "  " 

"         "         "     3,    54,  or  17        "  "      "        "  " 

These  statistics  of  post-mortem  examinations  are  in  accord  with  my  own 
statistics  in  250  personal  hospital  and  clinic  cases  very  carefully  examined 
and  recorded : 

In  155  cases,  or  62  per  cent.,  the  stricture  was  found  in  Region  No.  1. 

"     50      "       "   20       "  "  "  "■         "      "  "         "    2. 

«       ^5         u  tt     jg  il  i(  «  (1  «         «  ii,  ((      g 

Total,  "250      " 

In  most  cases  only  one  region  (No.  1)  was  involved ;  in  some  cases 
Regions  1  and  2,  and  exceptionally  Regions  1  and  3,  Avere  the  seat  of 
coincident  strictures.  The  records  show  that  in  the  great  majority  of 
cases  there  was  but  one  stricture,  and  that  less  commonly  two,  three,  and 
four  were  found. 

Under  the  influence  of  the  old  conception  of  a  stricture  we  understood 


STRICTURE  OF  THE   URETHRA.  329 

and  spoke  of  a  band,  a  ring,  or  a  callous  mass  tunnelled  by  a  small  chan- 
nel. In  the  light  of  recent  pathological  studies  we  know  that  gonorrhoeal 
stricture  of  the  urethra  really  means  a  stenosis  of  greater  or  less  length  of 
the  canal,  and  that  the  infiltrating  process  is  not  uniformly  developed,  it 
being  more  advanced  in  some  parts  than  in  others.  The  urethral  mucous 
membrane  in  the  quiescent  state  of  the  penis  and  in  the  intervals  of 
urination,  besides  being  folded  longitudinally,  is  also  thrown  in  smaller 
transverse  folds.  Now,  it  seems  that  these  transverse  folds  become  infil- 
trated, and  are  thus  rendered  prominent  and  impinge  on  the  calibre  of 
the  canal,  and  they  constitute  what  we  know  as  stricture  bands  or  rings. 
Therefore,  when  we  speak  of  these  bands  or  rings  we  simply  specify  those 
portions  of  the  urethral  sclerosis  which  jut  toward  the  axis  of  the  canal 
most  prominently.  These  bands  and  rings,  however,  are  usually  the 
surface  indications  of  the  underlying  cellular  infiltration,  which  is  really 
the  essential  lesion.  In  some  cases  of  nearly  total  invasion  of  the  pen- 
dulous urethra,  when  the  bougie  a  houle  is  gently  pushed  down  to  the 
bulb  and  withdrawn  a  jumping  or  bumping  sensation  is  conveyed  to  the 
hand  as  the  head  of  the  instrument  passes  over  thickened  ridges.  I  have 
encountered  as  many  as  fifteen  of  these  ridges  or  rings  in  a  space  of  three 
or  four  inches.  Patients  presenting  this  condition  cannot,  correctly,  be 
said  to  have  fifteen  strictures,  since,  in  truth,  they  have  a  decidedly 
stenosed  urethra  with  fifteen  transverse  thickened  folds.  The  same  re- 
marks apply  to  cases  in  which  we  find  several  bands  near  the  meatus  or 
at  any  part  down  the  canal.  In  somewhat  exceptional  cases  Regions 
Nos.  1  and  3  are  synchronously  affected  with  stenosis,  while  Region  No. 
2  is  intact.  In  such  cases  there  may  be  separate  strictures.  To  sum  the 
matter  up,  therefore,  we  may  say  that  exceptionally  in  gonorrhoeal  steno- 
sis of  the  urethra  the  lesion  consists  of  a  firm,  strongly-marked  ring-like 
band,  but  that,  as  a  general  rule,  a  greater  or  less  segment  of  the  canal 
is  involved,  in  which  case  there  may  be  several  constricting  bands  felt 
when  sought  for  by  means  of  instruments. 

There  is  an  erroneous  impression  entertained  by  many  that  gonorrhoea 
promptly  causes  stricture,  and  many  young  men  are  said  to  be  thus 
affected  who  are  then  only  suff"ering  from  chronic  urethritis.  As  a  broad 
general  rule  it  may  be  stated  that  unless  gonorrhoea  is  acquired  in  early 
youth  true  stricture  is  not  common  in  persons  under  twenty-five,  and  even 
twenty-eight,  years.  In  the  following  table  of  the  250  cases  already 
spoken  of,  the  dates  at  which  patients  presented  themselves  for  relief  of 
true  strictures  are  given,  as  well  as  the  number  of  patients : 


From  10  to  15  years 

of 

a.e;e 

in 

1 

case. 

(1 

15  " 

20     " 

" 

11 

4 

cases. 

(( 

20  " 

25     " 

(1 

" 

25 

(1 

« 

25  " 

30     " 

li 

u 

35 

II 

a 

30  " 

35     " 

a 

(I 

49 

u 

(f 

35  " 

40     " 

u 

" 

46 

li 

(( 

40  " 

45     " 

" 

" 

31 

tl 

(> 

45  " 

50     " 

(( 

(1 

26 

<l 

(( 

50  " 

55     " 

(1 

a 

13 

« 

li 

55  " 

60     " 

(( 

ii 

8 

a 

a 

60  " 

65     " 

« 

" 

8 

(1 

a 

65  " 

76     " 

" 

It 

3 

ii 

<i 

76  " 

89     " 

a 

u 

1 

case. 

Total,  ; 

250 

cases. 

330  GOXOBBHCEA  AND  ITS  COMPLICATIONS. 

It  will  be  seen  that  up  to  twenty-five  years  of  age  stricture  is  not,  com- 
paratively speaking,  common ;  that  between  twenty-five  and  forty  years 
of  age  the  greatest  number,  nearly  one-half,  is  recorded ;  and  that  a 
goodly  number  occurred  between  forty  and  fifty  years.  After  the  fiftieth 
year  they  grow  progressively  less  numerous. 

It  is  significant  of  the  usual  slowly-developing  character  of  stricture 
that  the  greatest  number  of  patients  felt  the  necessity  of  relief  between 
the  twenty-fifth  and  fiftieth  years. 

Varieties  of  Stricture. — A  number  of  terms  are  used  in  the  descrip- 
tion of  the  various  forms  of  stricture.  The  thread-like  form  consists  of 
one  or  more  thin  bands,  usually  seated  just  under  the  mucous  membrane 
and  not  involving  the  submucosa  deeply.  This  is  also  called  the  linear 
stricture.  The  diaphragmatic  stricture  consists  of  a  thickened  fold  of 
mucous  membrane  with  a  centrally-  or  laterally-placed  iris-like  opening, 
small  or  large.  The  crescentic  or  bridle  stricture  is  that  form  in  which 
the  mucous  fold  juts  from  about  one-half  of  the  lumen  of  the  canal,  either 
laterally  or  on  the  upper  or  lower  wall.  By  the  term  annular  stricture 
a  more  or  less  complete  ring,  narrow  or  broad,  of  the  stenosed  urethral 
canal  is  understood.  When  the  resulting  narrowed  tube  to  the  extent  of 
one  or  more  inches  is  irregular  in  its  course,  the  case  is  called  one  of  tor- 
tuous stricture. 

The  term  fibrous  stricture  is  applicable  to  some  cases  of  ring-like  con- 
tractions due  to  gonorrhoeal  inflammation.  It  is,  however,  usually  applied 
to  contractions  which  result  from  traumatisms,  so  that  the  terms  fibrous 
and  traumatic  strictures  are  generally  accepted  as  synonymous.  "When 
the  urethra  is  converted  into  an  irregular  mass  of  fibrous  tissue  with  much- 
contracted  lumen,  the  condition,  as  it  has  already  been  described,  is  called 
inodular  stricture. 

The  terms  hard  and  soft  stricture  are  frequently  used,  with  much  sig- 
nificance, in  describing  the  degree  of  density  of  the  urethral  infiltration 
present. 

An  inflamed  or  hypersemic  condition  of  the  mucous  membrane,  usually 
of  short  duration,  sometimes  occurs  at  the  affected  part  in  stricture  of  the 
urethra.  In  such  cases  the  patients  are  said  to  have  inflammatory  stric- 
tures. They  simply  have  strictures  of  greater  or  less  calibre  which,  owing 
to  various  causes,  such  as  alcoholic  and  sexual  excesses,  cold,  horseback 
and  bicycle  riding,  laborious  work,  and  bodily  strain,  have  for  a  time 
become  impermeable  by  reason  of  the  swelling  of  the  mucous  membrane. 
Such  accidental  conditions  should  not  be  dignified  by  such  a  formidable 
name  as  inflammatory  stricture. 

In  some  cases  of  stricture,  particularly  when  seated  in  the  subpubic 
curve,  as  a  result  of  the  causes  just  mentioned,  and  sometimes  from  the 
intemperate  use  of  exploratory  instruments,,  the  compressor  urethn-e 
muscle,  with  perhaps  the  external  vesical  sphincter,  becomes  the  seat  of 
spasm  and  renders  the  urethra  for  a  time  impermeable.  This  condition  is 
paraded  at  great  length  by  some  writers  under  the  title  of  spasmodic  stric- 
ture. It  is  simply  an  ephemeral  complication,  and  is  in  no  sense  whatever 
a  morbid  entity.     It  is  more  common  in  some  patients  than  in  others. 

While  performing  catheterization  upon  irritable  subjects  it  has  occa- 
sionally been  observed  by  nearly  every  surgeon  that  the  instrument  is 
grasped  and  temporarily  held  by  the  urethral  walls,  even  when  the  canal 


STRICTURE  OF  THE   URETHRA.  331 

is  free  from  permanent  obstruction.  In  this  case  the  sound  or  catheter 
acts  as  a  foreign  body,  and  the  irritation  which  it  produces  is  followed  by 
contraction  in  accordance  with  the  familiar  laws  of  reflex  action. 

In  other  cases  the  eccentric  irritation  is  caused  by  laceration,  abrasion, 
or  a  wound  of  the  lining  membrane,  such  as  may  ensue  from  the  rough 
use  of  a  catheter  or  other  surgical  instrument.  This,  of  itself,  may  excite 
spasm,  or  the  same  may  be  induced  by  contact  of  urine  with  the  raw 
surface. 

Striking  examples  of  urethral  spasm  are  also  met  with  as  the  result  of 
irritation  about  the  rectum  excited  by  the  presence  of  a  tape-worm,  ascar- 
ides,  hemorrhoids,  fissure  of  the  anus,  fecal  accumulation,  or  by  operations 
upon  this  part,  especially  the  ligature  of  piles.  Sir  Benjamin  Brodie  met 
with  a  case  of  spasmodic  stricture  in  which  the  spasm  was  intermittent, 
recurring  every  twenty-four  or  forty-eight  hours,  and  Avhich  was  finally 
cured  by  quinine  after  the  failure  of  other  means. 

Among  other  causes  of  spasm  are  the  presence  of  a  stone  in  the  bladder 
or  urethra  ;  organic  stricture  of  this  canal ;  long  retention  of  the  urine  ; 
digestive  derangements  ;  exposure  to  sudden  changes  of  temperature  ;  and 
mental  emotion. 

It  is  very  important  that  we  should  clearly  understand  the  scope  and 
the  limitation  of  the  term  "stricture  of  the  urethra."  To  my  mind,  a 
canal  may  be  said  to  be  the  seat  of  stricture  when  its  calibre  is  reduced 
below  that  which  Nature  requires  it  to  be  in  the  performance  of  its 
functions.  The  oesophagus  is  an  accommodating  tube  which  will  allow 
the  easy  passage  of  goodly-sized  boluses  of  food,  yet  it  can  hardly  be  said 
to  be  the  seat  of  stricture  if  it  contracts  on  a  walnut  or  an  egg.  The 
urethra  also  is  a  tube  of  much  dilatability,  but  if,  under  extreme  instru- 
mentation, its  lumen  may  be  very  greatly  increased,  it  does  not  follow 
that  the  calibre  thus  registered  is  the  normal  one,  any  more  than  a  blad- 
der reaching  up  to  the  umbilicus  from  retained  urine  can  be  said  to  then 
present  its  normal  capacity.  We  estimate  the  capacity  of  this  viscus  by 
the  quantity  of  urine  which  it  will  hold  without  inconvenience  or  discom- 
fort in  health.  In  like  manner  we  should  estimate  the  calibre  of  the 
urethra.  The  question  therefore  arises.  To  what  extent  is  the  urethral 
canal  dilated  in  urination  ?  as  this  is  the  main  function  of  the  tube.^ 
Upon  this  point  I  have  made  many  investigations  which  can  be  stated  in 
approximative  terms.  The  plan  of  procedure  is  to  make  as  sharp  an  esti- 
mate of  the  distention  of  the  urethra  as  possible  by  means  of  the  fingers 
while  a  patient  is  urinating,  and  after  that  distending  the  canal  by  a  soft 
olivary  bougie,  and  then  forming  estimates.  In  this  way  it  can  be  deter- 
mined that  when  the  bladder  is  only  about  half  filled  the  urethra  is  only 
distended  to  from  18  to  20  or  to  22  French,  and  if  there  is  very  little 
urine  present  the  distention  is  much  less  than  20  F.  But  when  the  viscus 
is  very  full  the  canal  may  be  distended  from  24  to  28  French.  Now, 
when  this  distention  is  made  greater  by  compressing  the  meatus  and  dam- 
ming back  the  stream,  the  urethra  bulges  out  considerably,  and  the  patient 
immediately  complains  of  uneasiness  and  pain.     If,  therefore,  the  function 

^  Repeated  examinations  on  many  subjects  will  show  that  there  is  much  variation  in 
the  compactness,  density,  and  elasticity  of  the  corpus  s[)ongiosum.  Consequently,  con- 
clusions can  only  be  drawn  from  the  study  of  cases  in  which  this  structure  is  soft,  supple, 
and  very  extensible. 


332  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

is  normally  performed  when  the  stream  of  urine  dilates  the  urethra  to  24 
or  28  French,  it  seems  warrantable  to  assume  that,  on  an  average,  the 
canal  naturally  has  a  calibre  of  about  28  or  30  F.  Exceptionally  we  find 
instances  where  the  calibre  is  a  little  above  30  F.  It  is  a  safe  rule,  there- 
fore, to  take  30  French  as  the  average  normal  calibre  of  the  urethra,  with 
the  understanding  that  there  are  exceptional  cases,  some  of  which  are 
under  and  some  over  that  average.  My  experience  and  studies  upon  this 
subject,  which  extend  over  more  than  twenty-seven  years,  have  taught 
me  that  those  patients  do  the  best  and  enjoy  the  greatest  immunity  from 
remote  troubles  whose  urethral  strictures  have  been  treated  on  the  basis 
of  a  30  F.  calibre.  And  as  antithesis  I  may  add  that  I  have  seen,  exam- 
ined, and  treated  very  many  patients  who  have  been  (to  my  mind  unwisely) 
subjected  to  over-distention  and  incision  beyond  30  French,  even  to  40, 
who  have  been  great  sufferers  in  various  ways,  and  who  are  constantly 
seeking  relief  from  the  surgeon.  We  cannot  too  prominently  keep  in  mind 
Sir  Henry  Thompson's  impressive  admonition,  "that  the  urethra  is  a  very 
delicate  and  sensitive  passage,  never  to  be  stretched  beyond  certain  limits 
without  incurring  risks  which  are  sometimes  very  grave." 

Development  and  Course  of  Stricture. — The  opinion  is  very  generally 
held  by  surgeons  that  the  development  and- course  of  stricture  of  the  ure- 
thra are,  as  a  rule,  quite  rapid.  Many  of  the  laity  also  partake  of  this 
view,  and,  as  a  result,  the  surgeon  is  frequently  asked  or  importuned  by 
men  recovering  from  gonorrhoea  to  pass  a  sound  in  order  to  prevent 
stricture.  Unfortunately,  the  surgeon  often  yields,  and  commonly  to  the 
sorrow  of  the  patient. 

It  has  occurred  to  me,  seeing  that  we  have  little  if  any  statistical 
details  concerning  the  course  and  evolution  of  stricture  of  the  urethra,  to 
present  here  a  table  of  34  very  carefully  observed  cases  in  which  the 
duration  of  gonorrhoea  is  given,  together  with  accurate  measurements  of 
the  urethral  canal.  In  none  of  these  cases  had  instrumentation  of  any 
kind  been  adopted  with  a  view  of  curing  or  relieving  the  urethral  trouble : 

TaMe  sJioiving  Evolution  and  Course  of  Stricture  of  the  Urethra. 

Duration  of  gonorrhoea,  6  months,  1  case,  urethra  reduced  at  affected  part  to  15  French  scale. 

20 

12  and  14  Fr.  scale. 
"  "         21  French  scale. 

"  "         o  and  20  Fr.  scale. 

.1  ti  (  7  and  20  French,  and 

(^     filiform  in  2  cases. 
„  „  flO   and    18    French 

(.     and  filiform. 
"  "  18  F.  and  filiform  in  2. 

"  "  1.5  F.  and  filiform. 

'•  "         8  and  13  French  scale. 

20  F.  and  filiform. 
fSand  lOF.  and2  fll- 
1     iform. 

21  F.  and  filiform. 
7,  9,  and  10  F. 

"  "         23  and  filiform. 

Thus  we  see  that  in  4  cases  in  from  six  to  thirteen  months  the  urethra 
has  lost  from  rather  less  than  a  half  to  one-third  of  its  normal  calibre. 
These  cases  illustrate  the  rapid  development  of  stricture-tissue.     From 


1 

year, 

1 

" 

13 

months 

2 

cases. 

2 

years. 

1 

case,        "            '■ 

-3 

2 

cases,      " 

4 

4 

" 

5 

3 

.. 

6 

3 

.. 

7 

2 

"           "            " 

to  9 

2 

"           "            " 

10 

2 

"           "            " 

11 

4 

" 

15 

2 

.. 

20 

3 

"           "            " 

25 

Total, 

2 

" 

34 

cases. 

STRICTURE  OF  THE   URETHRA.  333 

the  second  to  the  tenth  year  it  will  be  seen  that  the  development  of 
stricture  is  somewhat  rapid  in  some  cases  and  quite  slow  in  others,  there 
being  no  uniformity  of  course  whatever.  Taking,  for  instance,  the  three 
cases  in  the  fifth  year,  the  figures  are  10  and  18  French  and  filiform, 
while  in  the  tenth  year  two  cases  are  respectively  20  F.  and  filiform. 
Very  much  the  same  conditions  exist  up  to  the  twentieth  year,  while  in 
the  two  cases  of  twenty-five  years  we  find  the  astonishing  combination  of 
23  F.  and  filiform.  We  are  warranted,  therefore,  in  concluding  that  in 
its  development  stricture-formation  may  be  quite  rapid,  but  that,  as  a 
rule,  it  is  moderately  slow,  and  that  in  a  goodly  proportion  of  cases  ten 
to  twenty  years  may  elapse,  and  yet  the  normal  urethral  calibre  will  only 
be  reduced  about  one-third  or  even  less.  In  the  latter  category  belong 
the  very  slow  cases. 

Symptoms  of  Stricture. — In  many  cases  patients  suffering  from  chronic 
posterior  urethritis,  urethro-cystitis,  prostatitis,  and  seminal  vesiculitis 
reach  the  conclusion  that  they  have  stricture  of  the  urethra,  and  I  have 
known  many  cases  in  which  physicians  have  concurred  in  this  wrong 
diagnosis.  In  cases  of  stricture  the  affections  above  mentioned  may  co- 
exist, and  may  urgently  require  treatment.  Consequently,  the  surgeon 
should  be  thoroughly  familiar  with  all  these  morbid  conditions,  and  should 
take  them  into  consideration  when  treating  the  patient  for  stricture. 

One  of  the  earliest  symptoms  of  stricture  is  a  slight  muco-purulent  dis- 
charge, which  may  be  observed  only  in  the  morning,  as  already  described 
(see  Chronic  Anterior  Urethritis),  or  it  may,  in  exceptional  cases,  be 
noticed  at  intervals  during  the  day.  Usually  the  quantity  of  secretion 
is  very  scant,  but  exceptionally  a  good-sized  drop  may  be  expressed  from 
the  meatus  once  or  twice  a  day,  and  perhaps  oftener.  A  gleety  discharge 
is  an  exceptional  rather  than  a  constant  symptom  of  stricture.  Jamin 
examined  in  Guyon's  ^  service  61  cases  of  stricture,  and  found  an  appre- 
ciable discharge  in  only  4  cases.  According  to  my  experience,  this 
proportion  is  too  small,  but  the  presence  of  a  discharge  in  10  per  cent, 
of  all  cases  would  be  a  quite  large  average.  There  is,  however,  greater 
or  less  pus-formation  in  all  cases  of  stricture,  but  it  usually  can  only  be 
seen  by  examining  the  urine.  When  stricture  is  uncomplicated  with 
bladder  inflammation,  the  urine  is  usually  clear,  but  contains  more  or  less 
threads  and  lumpy  masses.  (See  p.  75.)  In  some  quite  old  cases  there 
may  be  some  pus  and  much  flat  epithelium  in  a  state  of  fatty  degener- 
ation. 

Some  patients  quite  early  or  at  more  remote  periods  after  gonorrhoea 
complain  of  various  subjective  symptoms,  such  as  slight  uneasiness,  a 
mild  smarting,  or  a  decidedly  burning  pain  during  micturition.  In  some 
cases  increased  frequency  of  urination,  with  pain  at  the  beginning  or  end 
of  the  act,  is  experienced,  due  to  coexistent  chronic  posterior  urethritis. 
In  other  cases  there  is  concomitant  urethro-cystitis  even  quite  early  in 
the  development  of  the  stricture. 

As  a  rule,  I  think  that  strictures  in  the  pendulous  urethra  are  some- 
times attended  with  uneasy  smarting  and  mildly  burning  sensations 
in  the  canal  and  at  the  end  of  the  penis,  while  those  in  the  subpubic 
canal  are  sometimes  complicated  with  decidedly  burning,  even  scalding, 
pains,  particularly  when  the  posterior  urethra  and  bladder  are  also  involved. 

1  Op.  cit.,  p.  416. 


334  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

Another  striking  symptom  may  be  complained  of  quite  early — namely, 
a  more  frequent  desire  to  make  Avater.  Great  variation  in  this  symptom 
is  observed  in  the  general  run  of  cases.  In  some  patients  the  intervals 
between  urination  may  be  three  hours,  and  in  others  they  may  be  much 
shorter,  the  desire  coming  every  hour  or  even  more  frequently.  This 
great  frequency,  however,  is  commonly  seen  in  old  cases  complicated  with 
cystitis.  At  first  the  desire  is  experienced  during  the  day,  but  as  the 
morbid  condition  increases  the  sufferer  finds  that  he  has  to  empty  his 
bladder  (or  try  to)  several  times  during  the  night. 

As  the  stenosis  of  the  urethra  increases  the  expulsive  power  of  the 
bladder  is  materially  impaired.  Some  patients  state  that  the  first  inti- 
mation of  a  stricture  known  to  them  was  the  necessity  for  greater  than 
usual  force  in  voiding  their  urine.  This  symptom  may  in  some  cases  be 
noticed  quite  early,  but,  as  a  general  rule,  the  stricture  is  well  advanced 
and  the  urethral  lumen  quite  small  before  it  is  experienced.  In  general, 
the  bladder  gradually  accommodates  itself  to  the  extra  strain  put  upon  it 
by  means  of  the  hypertrophy  of  its  muscular  fibres.  Owing  to  this  fact, 
a  patient,  particularly  an  obtuse  or  an  insensitive  or  careless  one,  may 
not  for  several  years  appreciate  the  fact  that  there  is  an  impediment  to 
his  stream,  and  that  he  uses  more  than  ordinary  expulsive  power.  In 
cases  where  the  stricture  forms  rapidly  this  symptom  may  quite  promptly 
be  appreciated. 

Synchronously  with  the  diminished  expulsive  power  of  the  bladder 
changes  in  the  shape  of  the  stream  of  urine  may  occur,  and  they  usually 
make  an  impression  on  the  patient's  mind.  In  very  many  cases,  though 
other  symptoms  have  existed,  this  is  the  first  one  to  attract  the  patient's 
attention.  The  shape  of  the  stream  depends  largely  on  the  conformation 
of  the  meatus.  If  this  slit  is  wide,  the  urine  may  escape  in  two  small 
streams — one  with  an  upward  tendency,  while  the  lower  one  curves  over 
and  falls  barely  beyond  the  patient's  toes.  Then,  again,  in  cases  of  large 
meatus  a  sputtering,  broken,  and  short,  or  a  flat,  fan-like,  stream  may  be 
observed.  When  the  meatus  is  normal  or  quite  small  the  stream  may 
be  thin  and  wiry,  and  perhaps  a  little  twisted.  Then,  again,  it  may  be 
very  much  twisted,  forked,  and  corkscrew-like.  In  some  cases  the 
stream,  though  small,  is  quite  strong  and  is  well  projected,  while  in  others 
it  is  weak,  hesitating,  intermittent,  and  falls  within  a  few  inches  of  the 
patient's  body,  often  wetting  his  clothes.  In  almost  all  well-advanced 
cases  there  is  more  or  less  dribbling  of  urine  after  micturition,  owinor  to 
the  inelasticity  of  the  urethral  walls  and  imperfect  closure  of  the  canal, 
and  the  diminished  contractile  power  of  the  accelerator  urinas  muscle  and 
of  the  involuntary  fibres  of  the  corpus  spongiosum.  This  symptom  may 
be  well  marked  in  cases  of  stricture  in  the  deep  urethra,  and  it  is  usually 
very  pronounced  when  the  pendulous  urethra  is  involved. 

In  more  advanced  cases  patients  may  experience  more  or  less  difiiculty 
in  starting  the  stream  of  urine.  They  frequently  make  several  attempts 
during  one  or  more  minutes  before  the  urine  appears,  and  then  it  fre- 
quently stops,  and  requires  renewed  efforts  to  start  it  again.  As  the  ste- 
nosis grows  more  compact  and  the  urethral  canal  is  more  and  more  con- 
tracted all  these  disturbances  in  urination  may  become  more  severe  and  con- 
stant. The  patient  experiences  a  constant  desire  to  make  water,  and  the 
act  is  attended  with  much  pain.     There  is  often  pain  in  the  bladder  and 


STRICTURE  OF  THE   URETHRA.  335 

above  the  pubis,  in  the  perineum,  testes,  vas  deferens,  and  groins.  In 
some  cases  patients  complain  of  a  constant  dull  aching  or  spasmodic  pain 
in  the  glans  penis,  which  may  lead  the  surgeon  to  suspect  stone  in  the 
bladder.  The  inflammation  behind  the  stricture  often  aifects  the  ejacula- 
tory  ducts,  the  verumontanum,  and  the  seminal  vesicles,  and  disturbs 
their  function.  As  a  result,  there  may  be  sexual  inability  or  frequent 
emissions,  pain  on  coitus,  and  ejaculation  may  be  attended  by  a  severe 
stabbing  pain.  In  some  cases  the  semen  passes  backward,  and  is  later  on 
discharged  with  the  urine.  In  such  instances  the  power  of  fecundation 
is  lost. 

In  advanced  cases,  where  great  straining  is  necessary  for  the  expul- 
sion of  the  urine,  prolapse  of  the  rectum,  hemorrhoids,  and  uneasy  and 
painful  sensations  in  the  rectum,  perhaps  with  spasm  of  its  muscles,  may 
result.  In  some  cases  the  contents  of  the  rectum  are  expelled  with  every 
attempt  at  urination.  In  these  cases  we  frequently  see  that  the  penis  is 
more  or  less  congested,  the  blood  remaining,  occasionally  from  mild  ex- 
travasation, in  the  areolae  of  the  corpora  cavernosa  and  corpus  spongiosum, 
and  giving  them  an  unusually  firm  consistence.  Then,  again,  painful 
erections,  like  chordee,  may  occur,  and  as  a  result  there  may  be  mild 
hsematuria. 

Epididymitis  and  epididymo-orchitis  of  a  low  form  and  with  slow  and 
not  painful  invasion  may  sometimes  occur  rather  late  in  the  course  of 
stricture.  In  somewhat  exceptional  cases  these  complications  come  on 
rapidly,  with  much  pain. 

In  old  men  with  firm  stricture  hernia  may  be  produced  by  the  great 
efforts  in  straining.  In  these  old  cases  it  is  not  uncommon  to  observe  a 
more  or  less  profuse  muco-purulent  discharge,  either  transparent  or  opaque. 

Retention  of  urine  is  a  quite  common  complication  of  stricture  of  the 
urethra,  particularly  in  cases  in  which  the  stenosis  is  in  Region  No.  1. 
It  is  observed  less  frequently  when  Regions  Nos.  2  and  3  are  the  seat  of 
contraction.  In  some  cases  this  complication  is  the  first  warning  indica- 
tion of  the  presence  of  stricture. 

Some  patients  seem  particularly  susceptible  to  retention  of  urine, 
which  seizes  them  at  shorter  or  longer  intervals  for  years.  Others,  again, 
in  spite  of  many  and  varied  hygienic  and  sexual  transgressions,  seem  to 
be  free  from  this  accident.  In  still  other  cases  during  a  period  of  twenty- 
five  or  more  years  retention  may  occur  but  once  or  twice,  even  though 
the  patient  leads  a  free-and-easy  life.  Retention  is,  as  has  been  stated, 
due  to  hyper?emia  of  the  mucous  membrane  and  spasm  of  the  compressor 
urethrge  muscle. 

In  some  old  cases  of  very  tight  stricture  the  urine  constantly  dribbles 
from  the  meatus,  and  patients  thus  aflflicted  are  said  to  suffer  from  incon- 
tinence. In  this  condition  there  is  a  constantly  distended  bladder,  and 
the  external  sphincter  vesicee  and  compressor  urethrse  muscle,  having  lost 
much  of  their  tonicity,  possess  but  feeble  contractile  power,  and  as  a 
result  the  urine  dribbles  away.  In  such  cases  the  genitals  and  thighs 
may  become  much  excoriated,  the  under-linen  and  trousers  are  constantly 
soaked,  and  the  patient  carries  with  him  an  offensive  odor  of  decomposed 
urine.  In  this  condition  there  is  usually  sufficient  overflow  to  relieve 
the  patient  of  the  imperative  desire  to  urinate  which  is  so  constant  in 
retention. 


336  O0N0RRH(EA   AND  ITS  COMPLICATIONS. 

Pathological  Complications  in  the  Course  of  Stricture. — As  a  result  of 
advanced  stricture  the  urethra  posterior  to  it  becomes  more  or  less  dilated, 
and  its  walls  attenuated  in  spots  or  patches  by  the  retarded  stream  of 
urine  forced  forward  by  bladder-contraction.  This  dilatation  involves  the 
membranous  and  prostatic  urethra,  and  it  may  be  so  extensive  that  the 
fore  finger  may  be  readily  admitted  into  the  canal.  In  some  cases  a 
decided  pouch  is  produced.  The  mucosa  and  its  underlying  connective- 
tissue  layer  are  much  thickened,  the  prostatic  and  ejaculatory  ducts  are 
dilated,  and  the  floor  of  the  urethra  is  traversed  with  longitudinal  and 
irregular  septa,  between  which  are  little  pouches  of  dilatation.  A  notable 
instance  of  extreme  dilatation  of  the  urethra  behind  a  stricture  is  pre- 
sented in  a  case  reported  by  Sir  B.  Brodie,  in  which,  on  urination,  a 
fluctuating  tumor  as  large  as  an  orange  was  felt  in  the  perineum. 

Superficial  and  deep  ulcerations  very  frequently  occur  behind  old  stric- 
tures. In  some  cases  large  and  ragged  excavations  are  produced.  Concre- 
tions are  not  infrequently  found  imbedded  in  the  urethral  mucous  membrane. 

Abscesses  and  fistulas  sometimes  develop  in  the  neighborhood  of 
strictures.  They  may  begin  in  inflamed  follicles  or  in  small  ulcerated 
spots  which  allow  the  escape  of  a  few  drops  of  urine  into  the  surrounding 
connective  tissue.  They  then  burrow  in  various  directions,  and  form 
hard,  circumscribed  masses  on  the  external  surface,  which  soften  and  give 
rise  to  fistulse,  of  Avhich  many  may  open  on  the  perineum,  the  scrotum, 
the  nates  and  thighs,  and  upon  the  abdomen  as  high  up  as  the  umbilicus. 
These  fistulse  usually  have  but  one  opening  into  the  urethra.  As  they 
grow  older  their  walls  become  covered  with  a  layer  of  pavement  epithe- 
lium, which  in  many  cases  must  be  curetted  away  before  healing  can  be 
brought  about.      Calcareous  matter  may  be  deposited  in  these  fistulae. 

Abscess  of  the  prostate  occurs  in  some  cases  of  very  old  stricture,  par- 
ticularly those  which  have  been  subjected  to  much  instrumentation.  (See 
Fig.  119.)  It  discharges  into  the  urethra,  the  perineum,  or  the  rectum. 
The  muscular  layers  of  the  bladder  become  much  hypertrophied,  and  at 
the  same  time  there  is  great  increase  in  its  connective  tissue.  As  a 
result,  the  walls  of  the  bladder  are  increased  to  five  or  six  times  their 
normal  thickness,  measuring  in  some  cases  a  full  inch.  (See  Fig.  119.) 
The  mucous  membrane  then  presents  prominent  ridges  which  resemble 
the  columnse  carneae  of  the  heart's  cavities.  Between  these  ridges,  owing 
to  the  violent  expulsive  efforts  of  the  bladder,  thinned  spaces  or  sacculi 
sometimes  form,  which,  when  the  bladder  is  full,  jut  out  like  pouches 
which  sometimes  become  of  very  large  size,  even  larger  than  the  bladder 
itself,  and  frequently  calculi  form  in  them. 

In  some  cases  the  sac  or  pouch  becomes  thinned,  perhaps  from  ulcera- 
tion, and  the  bladder  being  over-distended  Avith  urine,  it  gives  way  at  this 
part.  The  urine  escapes  into  the  peritoneal  cavity  or  into  the  pelvic 
connective  tissue  behind  the  triangular  ligament.  When  this  occurs  the 
bladder-tumor  previously  felt,  extending  toward  the  umbilicus,  ceases  to 
be  salient.  In  these  cases  patients  usually  die  from  shock,  particularly 
when  the  rupture  has  been  into  the  peritoneal  cavity. 

Rupture  of  the  bladder  resulting  from  stricture  of  the  urethra  is  of 
very  rare  occurrence.  In  a  series  of  67  cases  collected  from  various 
sources  by  Dr.  Stephen  Smith, ^  in  only  4  was  stricture  of  the  urethra 

1  N.  Y.  Journal  of  Medicine,  March,  1851. 


STRICTURE  OF  THE   URETHRA.  337 

noted  as  the  cause.  To  these  Gouley  ^  adds  the  details  of  4  cases,  2  of 
which  were  personal. 

As  the  bladder  becomes  more  affected  certain  changes  take  place  in 
the  urine.  At  first  it  is  of  acid  reaction  and  slightly  cloudy  from  the 
presence  of  pus.  Then,  owing  to  its  partial  retention  in  the  bladder,  it 
becomes  more  turbid,  and  finally,  from  decomposition,  it  becomes  am- 
moniacal  and  emits  a  penetrating  fetid  odor.  It  then  has  a  very  cloudy 
appearance  and  contains  much  ropy  mucus.  Under  these  circumstances 
blood,  usually  in  small  quantities,  may  escape  from  the  urethral  walls, 
and,  mingling  wath  the  urine,  will  give  it  a  dirty-brown  color. 

The  morbid  changes  which  are  seen  in  the  urethra  and  bladder  extend 
to  the  ureters  and  kidneys.  The  ureters  become  much  dilated,  so  that 
the  fore  finger  or  thumb  may  be  passed  into  them,  and  ever  greater  dila- 
tation than  this  has  been  observed.  The  pelves,  infundibula,  and  calices 
of  the  kidney  may  be  distended  and  the  seat  of  chronic  inflammation. 
With  the  advent  of  advanced  bladder  symptoms,  particularly  when  the 
ureters  and  kidneys  are  affected,  a  marked  condition  of  ill-health  super- 
venes. These  patients  become  sallow,  have  much  digestive  disturbance, 
and  rapidly  lose  weight.  They  become  chronic  invalids,  complain  con- 
stantly, are  anxious  and  careworn,  and  suffer  from  pain  in  the  back  and 
loins.  They  not  infrequently  have  symptoms  similar  to  fever  and  ague. 
In  an  advanced  case  every  few  minutes  the  patient  has  a  desire  to  pass 
his  urine.  He  then  strains  violently,  writhes  with  intense  pain  and  agony, 
and  breaks  out  in  a  cold  sweat,  and,  as  a  result,  he  is  perhaps  able  to 
expel  only  a  few  drops  of  putrid,  scalding  urine.  These  sufferings,  which 
make  the  patient  a  pitiable  object,  have  much  to  do  with  hastening  death. 
In  some  cases  mild  or  severe  urethral  fever  follows  every  attempt,  no 
matter  how  gentle,  at  instrumentation  of  the  urethra. 

Pains  at  such  remote  parts  as  the  heel  and  the  sole  of  the  foot  have 
been  complained  of,  as  well  as  neuralgic  affections  of  the  testes,  abdomen, 
and  thighs. 

In  some  very  bad  cases  the  patient  continually  loses  ground,  and  finally 
dies  of  exhaustion.  In  other  cases  a  low  grade  of  urinary  fever,  with 
marked  evidences  of  malnutrition,  tortures  the  patient  until  death  relieves 
him. 

Extravasation  of  Urine. — As  a  result  of  violent  straining  efforts 
in  some  cases  of  very  tight  stricture  the  urethral  walls  give  way  and  the 
urine  then  gushes  into  the  surrounding  or  nearby  connective  tissue. 

Rupture  of  the  urethra  may  occur  (1)  in  the  course  of  the  penis  as  far 
back  as  the  peno-scrotal  angle.  It  may  occur  (2)  in  the  bulbous  part  of 
the  urethra  between  the  angle  and  the  triangular  ligament.  It  may  rup- 
ture (3)  in  its  membranous  portion,  between  the  layers  of  the  triangular 
ligament,  and  (4)  behind  the  triangular  ligament,  either  at  the  junction 
of  the  membranous  and  prostatic  urethra  or  in  the  prostatic  urethra  itself. 
The  direction  of  the  extravasation  varies  according  to  the  part  of  the 
urethra  which  is  the  seat  of  rupture. 

Rupture  of  the  pendulous  urethra  which  is  rather  rare,  causes  much 
swelling  of  the  organ.  The  fibrous  covering  which  invests  the  corpus 
spongiosum,  which  consists  of  fascia  derived  from  the  suspensory  ligament 
of  the  penis  and  from  the  deep  perineal  fascia,  may  remain  intact,  and 

'  Diseases  of  the  Urinary  Oryans,  New  York,  1873,  p.  251. 


338  GONORBHCEA  AND  ITS  COMPLICATIONS. 

then  the  swelling  pushes  down  to  the  root  of  the  penis  and  the  scrotum; 
or  this  fibrous  investment  may  be  ruptured,  in  which  case  there  is  much 
extravasation  into  the  connective  tissue  of  the  penis  itself,  and  also  into 
the  scrotal  tissues. 

When  rupture  takes  place  anterior  to  the  triangular  ligament  the  urine 
is  prevented  by  the  dense  stricture  from  escaping  into  the  pelvic  cavity. 
It  cannot  diffuse  itself  down  the  thighs,  because  the  deep  perineal  fascia 
is  firmly  adherent  to  the  ischio-pubic  line ;  consequently,  it  takes  the  easy 
course  and  ascends  up  the  hypogastrium  between  the  pubic  spine  and  the 
symphysis.  The  extravasation  may  in  severe  cases  reach  as  far  up  as  the 
umbilicus.  When  the  rupture  takes  place  in  the  membranous  urethra  the 
Tirine  is  confined  between  the  two  layers  of  the  triangular  ligament.  In 
these  cases  suppuration  and  sloughing  are  prone  to  occur,  and  then  the 
urine  will  escape  in  the  direction  which  the  newly-formed  sinus  follows, 
generally  backward  into  the  pelvis,  and  rarely  forward  toward  the  peri- 
neum and  scrotum. 

If  the  extravasation  occurs  behind  the  posterior  layer  of  the  triangular 
ligament,  the  urine  may  gush  or  leak  out  down  the  recto- vesical  space  and 
point  in  the  perineum  anterior  to  or  at  the  sides  of  the  anus ;  or  it  may 
ascend  through  the  pelvic  fascia  near  the  pubo-prostatic  ligament,  and 
then  diffuse  itself  through  the  pelvic  connective  tissue. 

The  symptoms  of  extravasation  of  urine  are  generally  well  marked. 
Extravasations  anterior  to  the  triangular  ligament  usually  present  such 
marked  features  that  they  are  promptly  recognized.  Extravasations 
behind  the  triangular  ligament  may  be  attended  by  marked  symptoms 
when  the  gush  of  urine  is  prompt  and  copious.  In  some  cases,  however, 
the  extravasation  takes  place  quite  slowly,  and  then  the  symptoms  may 
not  be  well  marked  and  appreciated  for  a  day  or  more. 

Usually  a  patient  suffering  from  extravasation  states  that  he  felt  some- 
thing give  way,  and  experienced  a  sensation  of  relief,  but  he  Avonders  why 
his  urine  does  not  flow  away  normally.  Very  soon  systemic  symptoms  set 
in.  The  patient  complains  of  great  weakness  and  depression,  nausea, 
fever,  and  perhaps  chills.  Then  it  is  noticed  that  the  scrotum  is  more  or 
less,  even  enormously,  distended,  and  that  the  swelling  extends  up  the 
hypogastrium,  perhaps  to  the  umbilical  region  or  laterally  in  the  iliac 
region.  The  skin  then  becomes  tense  and  erysipelatous,  and  to  the  fin- 
ger-tips gives  the  sensation  of  emphysematous  crackling.  The  bright-red 
hue  rapidly  becomes  dusky,  purplish,  and  even  gangrenous.  Sloughs  of 
skin  may  come  away,  and  in  some  cases  the  whole  scrotum  is  destroyed, 
leaving  the  testicles  completely  bare. 

When  the  extravasation  has  been  anterior  to  the  peno-scrotal  angle,  it 
may  occur  into  the  meshes  of  the  corpus  spongiosum,  and  then  push  for- 
ward to  the  glans  penis,  where  it  forms  a  black  gangrenous  spot.  This 
is  a  symptom  of  very  bad  omen,  since  cases  presenting  it  usually  die. 

The  symptoms  of  rupture  into  the  membranous  urethra  may  at  first  be 
mild,  but  they  grow  worse  as  the  urine  tunnels  for  itself  a  passage  and 
allows  of  copious  extravasation.  In  cases  of  rupture  behind  the  triangu- 
lar ligament  the  systemic  symptoms  come  on  more  or  less  promptly,  and 
are  correspondingly  grave. 

Unless  relieved  by  operation,  patients  suffering  from  extravasation  go 
on  from  bad  to  worse.     Nausea,  vomiting,  total  anorexia,  mild  delirium, 


STRICTURE  OF  THE   URETHRA.  339 

high  fever,  and  a  small  wiry  pulse  are  the  chief  symptoms.  The  patient 
becomes  more  feeble,  and  has  a  dry,  parched  tongue,  his  muttering  delir- 
ium increases,  and  he  perishes  in  coma  from  uraemia  and  septicaemia. 

It  is  very  probable  that  the  condition  of  the  urine  has  much  to  do  with 
the  course  and  gravity  of  extravasation.  If  this  fluid  is  in  an  aseptic 
condition,  it  is  much  less  destructive  (and  it  is  claimed  by  some  not  at  all 
destructive)  to  the  tissues.  Consequently,  necrosis  and  its  concomitant, 
septicaemia,  may  not  occur,  particularly  if  prompt  relief  is  given  by  the 
knife.  Unfortunately,  in  the  majority  of  cases  in  Avhich  the  urethra  is 
the  seat  of  tight  stricture  its  Avails  behind  it  are  much  damaged  and  the 
bladder  is  deeply  affected.  The  urine  as  a  result  is  largely  mixed  with 
pus  and  is  poisonous  to  tissues  with  which  it  may  come  in  contact. 

Causes  of  Stricture. — In  the  vast  majority  of  cases  gonorrhoea  is  the 
cause  of  urethral  stricture.  It  may  also  result  from  the  healing  of  chan- 
cres and  chancroids  and  of  phagedena  at  the  meatus.  In  some  cases 
injury  to  the  urethra  causes  strictures  which  are  called  traumatic. 

Masturbation  has  been  claimed  to  cause  stricture.  This  habit  causes 
congestion  and  moderate  submucous  cell-infiltration  in  the  prostatic  ure- 
thra, in  which  strictures  other  than  traumatic  are  never  found.  It  is 
perhaps  possible  that  this  inflammation  of  the  prostatic  urethra  may  ex- 
tend forward  and  involve  the  bulb,  and  thus  produce  stricture,  but  we 
have  no  scientific  evidence  whatever  upon  the  subject.  It  sometimes 
happens,  strange  to  say,  that  men  who  are  suff"ering  with  stricture  will 
absolutely  deny  that  they  ever  had  gonorrhoea.  In  these  cases  the 
habit  of  masturbation  can  usually  be  ascertained,  and  then  the  neophyte 
may  hit  upon  that  as  the  cause  of  the  urethral  coarctation. 

Cono-enital  stricture  is  not  common,  and  is  found  at  and  near  the 
meatus. 

I  saw  many  years  ago  a  case  of  stricture  of  the  urethra  due  to  a  pecu- 
liar condition  of  the  mucous  membrane  of  the  glans  and  involving  the 
mucous  membrane  of  the  fossa  navicularis.  The  membrane  was  trans- 
formed into  a  pearly-white,  shining,  intensely  dense  tissue,  which  began 
above  the  corona  glandis,  covered  the  glans  like  a  tightly-fitting  cap, 
and  extended  into  the  urethra,  uniformly  narrowing  its  lumen  to  No.  6 
French  for  the  distance  of  an  inch.  I  have  since  seen  that  J.  Greig 
Smith  ^  has  reported  two  such  cases.  The  first  was  that  of  a  man,  thirty- 
four  years  old,  who  had  never  suff"ered  from  any  venereal  lesion  or  injury 
of  the  penis.  At  the  end  of  the  penis  a  semi-cartilaginous  tissue  so  oc- 
cluded the  urethra  that  the  urine  could  only  be  expelled  drop  by  drop. 
The  second  case  was  that  of  a  boy,  aged  eighteen,  also  without  any  history 
of  venereal  disease  or  local  injury.  There  was  the  same  pale,  hard,  con- 
tracted condition  of  the  mucous  membrane  of  the  glans  and  fossa  navicu- 
laris, which  presented  the  appearance  of  a  true  sclerosis.  Smith  thinks 
this  condition  is  allied  to  scleroderma  of  the  skin. 

In  this  connection  it  is  interesting  to  note  that  Minges  and  McCarthy  ^ 
have  reported  a  case  of  stricture  at  the  meatus  three-quarters  of  an  inch 
long  to  12  F.,  caused  by  the  development  of  keloid.     Incision,  electrol- 

^  "  An  Undescribed  Form  of  Stricture  at  the  Orifice  of  the  Male  Urethra,"  Bristol 
Med.-Chir.  Journal,  Sept.,  1884,  pp.  154  et  seq. 

^  "  A  Case  of  Keloid  of  the  Male  Urethra,"  Medical  and  Surgical  Reporter,  Aug.  27, 
1892. 


340  GONORRHCEA  AND  ITS  COMPLICATIONS. 

ysis,  and  the  passage  of  sounds  seemed  to  aggravate  the  morbid  process, 
so  that  a  mass  of  dense  tissue  was  formed  around  the  urethra  so  deeply 
that  it  was  necessary  to  extirpate  two  and  a  half  inches  of  the  canal  with 
some  of  the  surrounding  healthy  tissue.  This  radical  procedure  failed  to 
stop  the  progress  of  the  infiltration,  and  it  became  necessary  to  amputate 
the  whole  penis.  The  microscope  showed  clearly  that  the  morbid  tissue 
consisted  of  true  keloid. 

Thus  we  have  two  very  rare  forms  of  stricture  of  the  urethra  which 
are  not  very,  if  at  all,  amenable  to  treatment — the  one  a  sclerosis  resem- 
bling scleroderma,  and  the  other  keloid  of  the  male  urethra.  My  expe- 
rience with  my  own  case  showed  me  very  clearly  that  fairly  good  results 
followed  gentle  dilatation,  which  just  kept  the  urethra  patulous,  and  that 
active  and  aggressive  dilatation  caused  pain  and  a  further  increase  of  the 
trouble. 

The  long  continuance  of  gonorrhoea  is  the  essential  cause  of  stricture 
rather  than  the  severity  of  the  attack. 

In  somewhat  rare  cases  we  learn  from  a  patient  having  a  tight  stricture 
that  he  had  but  one  attack  of  gonorrhoea,  or  perhaps  two,  and  that  the 
disease  did  not  persist  very  long.  In  the  majority  of  cases  of  stricture 
there  is  a  history  of  repeated  recrudescences  of  an  original  gonorrhoea  or  a 
greater  or  less  number  of  new  infections.  As  a  result,  the  small  cell-infil- 
tration goes  on  increasing,  and  from  it  fibrous  tissue  is  developed  which 
forms  the  stricture.  In  old  times  breaking  the  cord  when  the  seat  of 
chordee,  which  means  rupture  of  the  urethra,  was,  it  seems,  a  somewhat 
frequent  cause  of  stricture,  but  to-day  such  cases  are  of  the  greatest 
rarity. 

In  the  minds  of  the  laity  injections  play  an  important  part  in  the  pro- 
duction of  urethral  stricture.  This  view  has  no. foundation  in  fact,  since 
mild  injections  are  productive  of  some  good,  and  strong  and  severe  ones 
are  so  painful  in  their  effects  that  they  are  soon  given  up. 

Exploration  of  the  Urethra. — For  the  diagnosis  of  stricture  we  employ, 
in  the  main,  bougies  of  various  kinds  which  are  flexible,  and  sounds  which 
are  made  of  solid  metal. 

For  simplicity  and  precision  in  use  these  instruments  are  made  in  sizes 
which  increase  from  small  to  quite  large  ones,  and  are  graduated  according 
to  their  diameters,  Avhich  are  clearly  portrayed  by  certain  scales  used  for 
measurement.  The  most  extensively-used  scale  for  urethral  instruments 
is  the  French  one,  called  the  filiere  Charri^re.  The  English  scale  is  also 
used  by  many  surgeons,  but  it  has  its  drawbacks.  Besides  these  scales 
there  are  others  which,  since  they  do  not  possess  any  marked  advantages 
in  their  favor,  and  have  some  disadvantages,  need  not  be  considered  here. 
The  French  scale  progresses  by  steps  of  one-third  of  a  millimetre  in 
diameter ;  thus,  No.  1  represents  an  instrument  one-third  of  a  millimetre 
in  diameter.  No.  2,  two-thirds,  and  No.  3,  three-thirds  or  one  millimetre. 
In  this  manner  the  scale  progresses  up  to  No.  30,  Avhich  has  a  diameter 
of  ten  millimetres,  there  being  a  bougie  for  each  number.  Thus  it  will 
be  seen  that  a  bougie  No.  6  French  scale  has  a  diameter  of  two  millime- 
tres. No.  9  of  three  millimetres.  No.  12  of  four,  No.  18  of  six,  No.  24  of 
eight,  and  No.  30  often  millimetres.  The  sizes  of  intermediate  numbers 
can  thus  be  readily  computed. 

In  Fig.  92  both  French  and  English  scales  are  given,  and  by  study- 


STRICTURE  OF  THE   URETHRA. 


341 


ing  them  a  clear  idea  of  the  greater  or  less  progressive  uniformity  in  size 
may  be  obtained : 

Fig.  92. 


O  O  O  O  O  o  o  00,0  o  o 


^,.-T)SMfl-MN-Sfi.  NY; 


French  and  English  scales. 

Sounds. — These  instruments  are  made  of  nickel-plated  steel,  and  their 
surface  should  be  so  smooth  that  they  will  readily  glide  over  the  urethral 
walls.  The  best  all-round  instruments  are  those  having  what  is  known 
as  Thompson's  short  curve  at  their  distal  portion.  They  should  be  conical 
at  their  point,  which,  while  being  very  round  and  smooth,  is  three  sizes 
smaller  than  the  shaft  of  the  instrument.  It  is  very  desirable  that  the 
handle  of  the  sound  should  be  rather  thin,  tolerably  light,  and  somewhat 
wedge-shaped.     Fig.  93  gives  a  very  clear  idea  of  an  exceedingly  grace- 

FiG.  93. 


Conical  steel  sound. 

ful  and  useful  sound,  which  can  be  used  with  much  delicacy  of  touch. 
Sounds  with  heavy,  clumsy  handles,  insufficiently  nickel-plated,  dull  of 
surface,  and  not  very  smooth  should  be  avoided. 

There  is  a  tendency  among  some  to-day  to  carry  the  antiseptic  care  of 
sounds  to  an  extreme  degree  of  refinement.  It  is  unnecessary  to  immerse 
these  instruments  in  strong  antiseptic  solutions,  which  will  tarnish  them 
and  render  their  introduction  rather  more  difficult  than  usual.  They 
should  be  well  washed  with  soap  and  Avater  and  carefully  dried  with  a 
clean  towel  before  and  after  each  introduction.  With  this  ordinary  care 
one  need  never  fear  carrying  an  extraneous  infective  material  into  the 
urethra. 

A  full  set  of  sounds  according  to  the  English  scale  begins  at  No.  6, 
which  corresponds  to  No.  12  French,  and  ends  at  No.  18,  which  is  the 
equivalent  of  30  F.  Though  sounds  are  found  in  the  market  as  large  as 
40  French,  it  will  be  very  seldom  necessary  for  the  conservative  surgeon 
to  employ  these  instruments  of  a  larger  size,  at  the  very  utmost,  than 
34  F. 


342 


OONORRHCEA  AND  ITS  COMPLICATIONS. 


As  a  rule,  steel  sounds  are  used  in  practice  in  numbers  between  11 
and  12  English,  corresponding  to  20  and  21  French,  and  18  English  or 
30  French.  When  an  instrument  is  needed  smaller  than  20  F.,  it  is  well 
to  use  the  olivary  bougies.  On  the  other  hand,  when  an  instrument  larger 
than  20  or  21  F.  or  11  or  12  English  is  needed,  it  is  better,  in  general, 
to  use  the  steel  sound. 

There  has  been  a  tendency  developed  of  late  years  to  shorten  the 
length  of  the  curve  of  sounds — first,  by  those  who  taught  that  nearly  all 
urethral  troubles  were  seated  in  the  anterior  urethra,  and,  second,  by 
those  who  are  possessed  of  a  deeply-rooted  dread  of  producing  infection 
and  inflammation  in  the  posterior  urethra.  Without  now  discussing  this 
subject  fully,  it  may  briefly  be  stated  that  the  opinions  of  the  persons  in 
the  first  category  were  based  entirely  upon  false  views  of  pathology,  and 
that  the  fears  of  the  second  class  were  undoubtedly  caused  by  the  results 
of  the  careless  and  indiscriminate  passage  of  sounds. 

A  very  useful  and  desirable  sound  is  that  known  as  Benequ^'s.  It  has 
a  long  double  curve,  corresponding  nearly  to  the  two  curves  of  the  urethra 
when  the  penis  is  not  elevated  against  the  abdomen.  It  is  really  of  the 
same  shape  that  a  flexible  bougie  assumes  when  introduced  into  the  blad- 
der and  left  to  itself.  Within  certain  restrictions  and  limitations,  to  be 
detailed  a  little  later  on,  this  sound  will  be  found  of  much  service  in  a 

Fig.  94. 


Benequ6's  sound. 


number  of  cases.  It  is  only  necessary  to  have  six  of  Beneque's  sounds, 
beginning  with  No.  14  E.  or  23  F.,  and  ending  with  20  E.  or  34  F. 

Straight  steel  sounds,  of  the  sizes  from  20  to  30  F.,  are  sometimes 
very  useful  in  cases  of  stricture  in  the  pendulous  urethra.  (See  p.  176, 
Fig.  66.) 

Olivary  Bougies. — These  bougies  are  so  useful  that  the  surgeon  should 
always  have  a  goodly  supply  at  hand.  Formerly  French  bougies  were 
the  best  in  use,  but  of  late  years  excellent  ones  have  been  manufactured 
in  this  country.^  The  olivary  bougie  is  the  one  best  fitted  for  general 
purposes,  and  the  blunt  ones  are  seldom  used.     In  Fig.  95  is  Avell  shown 

Fig.  95. 


Flexible  olivary  bougie. 

an  ideal  olivary  bougie.     The  surgeon  should  exercise  great  care  in  the 

selection  of  these  instruments,  and  should  reject  those  that  are  in  any  way 

^  By  the  J.  E.  Lee  Co.,  Consholiocken,  Pa. 


STRICTURE  OF  THE   URETHRA.  343 

faulty.  The  following  are  the  particular  points  of  excellence  necessary 
in  these  bougies :  The  whole  instrument  should  have  a  smooth,  shining 
surface,  either  black  or  yellow,  and  there  should  be  no  cracks  whatever 
on  it.  The  olivary  point  should  be  rounded  and  smooth,  and  should 
taper  oif  gracefully  into  the  neck,  which  should  very  gradually  increase 
in  size  until  the  shaft  is  reached,  as  is  well  shown  in  Fig.  95.  The  neck 
should  be  very  supple,  and  the  whole  instrument  should  be  so  flexible 
that  on  introduction  it  will  easily  and  almost  imperceptibly  follow  the 
course  of  the  urethra  without  any  discomfort  to  the  patient.  As  a  rule, 
the  olivary  end  should  be  about  seven  sizes  smaller  than  the  shaft  of  the 
bougie,  and  the  neck  at  the  base  of  the  olive  point  should  have  a  diam- 
eter of  about  one-half  of  that  of  the  olivary  expansion.  When  these 
requirements  are  fulfilled  the  instrument  is  quite  gradually  tapering, 
and  will  produce  much  benefit  in  the  process  of  dilatation  of  the  ure- 
thra. All  bougies  with  imperfect  olivary  ends  should  be  rejected.  These 
seemingly  minor  points  are  worthy  of  much  attention. 

The  surgeon  should  provide  himself  liberally  with  these  instruments, 
having  three  or  four  at  least  of  each  size.  The  most  useful  sizes  begin 
at  No.  6  F.  and  end  about  No.  22  or  24  F.  It  will  be  found,  as  a  rule, 
that  bougies  of  sizes  above  No.  22  or  24  French  are  liable,  even  when 
great  care  is  used  in  their  introduction,  owing  to  their  quite  large  calibre 
and  their  comparatively  thin  and  compressible  walls,  to  become  cracked 
or  more  or  less  broken  from  two  to  four  inches  from  their  distal  portion. 
As  a  rule,  therefore,  these  instruments  may  be  used  for  dilatation  or 
exploration  in  sizes  as  high  as  20  to  24  French.  Beyond  these  limits 
much  better  results  will  be  obtained  from  the  use  of  steel  sounds. 

These  bougies  should  be  kept  (few  in  number)  in  compartments  in 
which,  in  hot  Aveather,  powdered  French  chalk  may  be  placed  to  prevent 
the  gumming  of  opposing  surfaces.  Before  and  after  use,  like  sounds, 
olivary  bougies  should  be  carefully  washed  and  dried.  Immersion  in 
strong  antiseptic  solutions  causes  the  varnished  surface  of  these  instru- 
ments to  tarnish  and  crack,  in  which  condition  they  are  wholly  unfit  for 
use. 

Filiform  Bougies. — Very  attenuated,  delicate  bougies,  called  filiforms, 
are  of  great  service  in  the  diagnosis  and  treatment  of  tight  strictures. 
The  two  principal  forms  are  those  of  French  manufacture  and  the  whale- 
bone bougies.  French  filiform  bougies  are  very  soft  and  flexible,  and 
are  of  much  use  in  cases  w^here  the  stricture  does  not  hug  tightly.  In 
examining  tight  strictures  they  soon  become  twisted  and  cracked,  and 
then  it  is  necessary  to  discard  them. 

For  general  use  Gouley's  whalebone  filifoi'm  bougies  are  most  service- 
able. These  little  exploratory  instruments  have,  as  a  rule,  a  diameter  of 
two-thirds  of  one  millimetre,  but  some  of  them  are  of  larger  calibre.  Of 
whalebone  filiform  bougies  there  are  two  kinds,  the  short  and  the  long. 
The  short  bougies  are  about  twelve  inches  long,  while  the  long  ones  are 
twenty  to  twenty-five  inches  long.  The  short  instruments  are  employed 
for  purposes  of  diagnosis,  while  the  long  ones  are  used  as  conductors  for 
sounds  or  catheters  throuo;h  strictured  tissues. 

The  shafts  of  these  instruments  should  be  perfectl}''  smooth,  and  they 
should  never  be  used  until  they  have  been  carefulh^  examined,  for  they, 
by  use,  are  apt  to  chip  and  crack  or  become  frayed.     Their  points  are 


344 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


usually  tapering,  and  they  end  in  a  minute  bulb.  These  bougies  may  be 
straight  or  they  may  have  eccentric  and  twisted  points.  By  soaking 
them  in  hot  water  they  can  be  twisted  into  any  desired  shape,  spiral,  zig- 


FiG.  96. 


X^ 


Gouley's  whalebone  flliform  bougies. 

zag,  and  bent  at  any  angle.     After  soaking  in  hot  water  and  bending 
them  the  shape  may  be  made  stable  by  plunging  them  into  cold  water. 

Whalebone  filiform  bougies  should  be  kept  in  tin  cases  to  ensure  them 
from  the  attacks  of  certain  grubs  or  worms  which  destroy  them.  As  they 
grow  old  they  may  become  brittle,  consequently  it  is  well  to  oil  them 
occasionally. 

Whalebone  bougies  with  tapering  filiform  ends,  increasing  quite  ab- 
ruptly up  to  goodly-sized  10  to  13  F.  shafts,  are  sometimes  of  very  great 
service  in  preparing  the  w^ay  for  gradual  dilatation,  for  a  small  retention 
catheter,  or  for  the  introduction  of  a  staff  for  internal  or  external  ure- 
throtomy. These  bougies  are  known  as  Banks's  whalebone  bougies.  (See 
Fig.  97.) 

Fig.  97. 


Banks's  whalebone  bougies. 

What  are  known  as  Harrison's  dilators  or  whips  are  often  very  useful 
for  quite  rapid  dilatation  at  one  seance.  These  bougies  are  twenty-four 
inches  long,  and  are  straight  for  thirteen  or  fourteen  inches,  then  they 
taper  down  gradually  to  the  tip.  They  range  in  sizes  between  10  and 
20  French,  and  are  very  soft  and  supple.  Six  of  them  form  a  set,  the 
smallest  of  which  is  filiform  at  its  tip. 

The  French  and  English  filiform  boudes  are  ^enerallv  armed  with 
screw  tips,  which- permit  of  their  adjustment  to  catheters  and  to  the  staffs 
of  urethrotomes,  to  which  they  serve  as  guides  to  the  bladder.  These 
bougies  with  screw  tips  are  particularly  frail  at  their  point  of  junction, 
and  as  a  result  can  scarcely  ever  be  used  more  than  once  or  twice.  The 
English  bouo;ies  are  rather  more  brittle  than  the  French  ones,  but  when 
used  carefully,  owing  to  their  stability,  they  traverse  strictures  with  more 
uniform  success  than  the  French  ones  do. 

Bougies  a  Boule. — The  acorn-pointed  bougies,  or  bougies  a  boule,  have 


STRICTURE  OF  THE  URETHRA.  345 

already  been  spoken  of.  (See  p.  175,  Fig.  75.)  These  instruments  are 
indispensable  for  the  diagnosis  of  stricture,  since  they  allow  us  to  clearly 
detect  and  define  hyperplastic  and  inflamed  points  and  strictures  in  the 
anterior  urethra.  They  are  rarely  used  in  the  posterior  urethra.  The 
soft,  flexible  bougies  a  houle  should  be  the  instruments  of  choice.  These 
bougies  are  also  made  of  nickel-plated  copper,  but  they  are  stiff"  and 
unwieldy,  and  their  use  is  liable  to  cause  pain  and  uneasiness  to  the 
patient.      I  have  never  seen  the  necessity  of  using  these  bougies. 

The  Urethrameter. — Since  the  meatus  is  usually  the  smallest  part  of 
the  urethra  and  varies  very  much  in  its  calibre,  it  may  not  allow  the  intro- 
duction of  any  of  the  instruments  thus  far  mentioned  of  sufficient  size  to 
thoroughly  explore  the  canal  and  especially  to  detect  contractions.  An 
instrument  which  could  be  inserted  through  a  narrow  meatus  and  then  be 
dilated  within  the  urethra,  with  an  index  at  its  distal  extremity  showing 
the  amount  of  its  dilatation,  was  therefore  a  desideratum.  This  Avant  has 
been  supplied  by  the  ingeniously  contrived  urethrameter  of  Dr.  Otis  (Fig. 
98),  who  describes  it  as  follows:  "It  consists  of  a  small,  straight  cannula. 

Fig.  98. 


Otis's  urethrameter. 


size  No.  8  French,  terminating  in  a  series  of  short  metallic  arms  hinged 
upon  the  cannula  and  upon  each  other.  At  the  distal  extremity  where 
they  unite  a  fine  rod,  running  through  the  cannula,  is  inserted.  This 
rod  (which  is  worked  by  a  stationary  screw  at  the  handle  of  the  instru- 
ment), when  retracted,  expands  the  arms  into  a  bulb-like  shape,  ten 
millimetres  in  circumference  when  closed,  and  capable  of  expansion  up  to 
40  French  scale.  A  thin  rubber  stall  drawn  over  the  end  of  the  closed 
instrument  protects  the  urethra  from  injury  and  prevents  the  access  of 
the  urethral  secretions  to  the  interior  of  the  instrument.  When  intro- 
duced into  the  urethra  and  expanded  up  to  a  point  which  is  recognized 
by  the  patient  as  filling  it  completely — and  yet  easily  moving  back  and 
forth — the  index  at  the  handle  then  shows  the  normal  circumference  of 
the  urethra  under  examination.  In  withdrawing  the  instrument  contrac- 
tions at  any  point  may  be  exactly  measured,  and  any  want  of  correspond- 
ence between  the  calibre  of  the  canal  and  the  external  orifice  be  readily 
appreciated.  Among  the  advantages  claimed  for  this  instrument  are — 1, 
its  capacity  to  measure  the  size  of  the  urethra  and  to  ascertain  the  locality 
and  size  of  any  strictures  present,  without  reference  to  the  size  of  the 
meatus  ;  2,  it  enables  the  surgeon  to  complete  the  examination  of  several 
strictures  by  a  single  introduction  of  the  instrument." 

For  cases  in  which  the  meatus  is  rather  small  this  instrument  may  be 
of  much  service,  provided  its  bulb  is  not  screwed  up  beyond  30,  or  at  the 
most  32,  F.  Within  these  sharp  limitations  the  instrument  may  be  em- 
ployed. But  beyond  these  limits  it  is  one  of  the  most  mischievous,  and 
even  dangerous,  instruments  in  use.  It  can  be  said  without  fear  of  con- 
tradiction, and  in  the  utmost  spirit  of  fairness  and  truth,  that  there  is  not 


346 


OONOBRHCEA  AND  ITS  COMPLICATIONS. 


a  man  alive  who  cannot  be  convicted  of  having  one  or  more  strictures  of 
the  urethra  of  large  calibre  if  he  is  examined  by  means  of  this  instru- 
ment and  it  is  screwed  up  to  36  or  40  F.  I  have  personally  seen  scores 
of  men  who  have  been  falsely  pronounced  to  have  strictures  of  large 
calibre  based  upon  examinations  made  with  this  instrument.  These  points 
will  be  further  discussed  a  little  later  on. 

Catheters. — Catheters  are  tubular  instruments  used  to  draw  off  urine 
from  the  bladder.  They  are  made  of  soft  rubber,  of  lisle  thread  with 
gum-elastic  coating,  and  of  silver. 

The  soft-rubber  (also  called  Ndlaton's)  catheters  are  instruments  which 
have  a  wide  range  of  usefulness.  They  may  be  found  in  sizes  varying 
from  10  to  30  French,  but,  as  a  rule,  the  intermediate  sizes  are  by  far 
the  most  useful.     Soft-rubber  catheters  should  be  made  of  flexible  and 

Fig.  99. 


Velvet-eye  catheter. 

extensible  material,  and  should  be  soft  and  supple,  and  not  brittle  and 
liable  to  crack  and  break.  It  is  always  well  to  avoid  inferior  grades  of 
soft  catheters. 

The  most  commonly  used  catheter  now  is  Tiemann's  velvet-eye 
catheter,  which  is  soft  and  smooth  and  provided  with  an  eye  which  is  so 
depressed  and  rounded  off  that  it  causes  no  friction  or  uneasiness  when 
introduced. 

Gum-elastic  catheters  have  more  firmness  than  the  soft  ones,  and  con- 
sequently can  be  passed  through  urethrpe  the  seat  of  more  or  less  con- 
traction or  inflammatory  hyperplasia.  These  catheters  may  have  a  uni- 
form calibre  with  blunt  and  rounded  ends,  or  they  may  have  the  shape 
of  olivary  bougies.     They  may  be  straight  or  they  may  be  curved. 


Fig.  100. 


Curved  blunt  gum-elastic  catheter  and  olivary  catheter,  with   curve  for  prostatic  obstruction. 

These  catheters  are  now  made  of  excellent  quality  and  design  in  this 
country. 


STRICTURE  OF  THE   URETHRA.  347 

The  curved  olivary  catheter  shown  in  Fig.  100  is  an  excellent  one  for 
use  in  some  cases  of  old  prostatics. 

What  are  known  as  Mercier's  coude  (or  elbowed)  and  bi-coud^  (or 
double-elbowed)  catheters,  made  of  gum  elastic  and  lisle  thread,  sometimes 

Fig.  101. 


Mercier's  coud6  and  bi-coude  catheters. 

prove  brilliantly  useful  in  relieving  the  full  bladders,  narticularly  of  fat 
old  men,  Avhose  bulb  of  the  urethra  is  flabby  and  dependent.  The  sur- 
geon should  always  have  these  instruments  at  hand.  Many  of  the  coude 
catheters  as  sold  in  the  shops  are  faulty,  for  the  reason  that  the  curved 
portion  is  too  short.  In  Fig.  101  the  correct  angle  and  proper  length  of 
this  curve  of  the  catheter  are  well  shown. 

Of  late  years  silver  catheters  are  quite  seldom  used,  owing  to  the  per- 
fection attained  in  the  manufacture  of  the  soft-rubber  and  gum-elastic 
instruments.  They  may  be  found  in  pocket  cases  in  shapes  suitable  for 
males  and  females,  young  and  old,  but  they  will  commonly  be  used  only 
when  the  surgeon  has  not  the  softer  instruments  at  hand.  A  soft-rubber 
or  a  blunt  gum-elastic  catheter  cut  off  to  a  length  of  five  or  six  inches  is 
equally  as  useful  for  the  female  bladder  as  a  regular  female  catheter.  In 
some  rare  cases  of  prostatic  hypertrophy,  particularly  of  the  lateral  lobes, 
and  also  of  the  median  lobe,  silver  catheters  with  a  very  long  curve  may 
reach  the  bladder  when  the  surgeon  has  failed  with  the  long-curve  gum- 
elastic  catheter  and  with  Mercier's  catheters.  It  is  well,  therefore,  to  be 
provided  with  one  or  two  silver  prostatic  catheters. 

Instruments  for  Incision  and  Iiuj)ture  of  Stricture. — There  are  so 
many  instruments  before  the  profession  for  the  treatment  of  stricture  by 
incision,  by  dilatation  and  incision,  and  by  divulsion  that  an  inexperienced 
person  becomes  bewildered  and  is  incapable  of  making  a  judicious  selec- 
tion. Though  there  are  many  useful  instruments  in  the  market,  there  are 
very  many  which  are  of  limited  use,  others  that  are  decidedly  dangerous, 
and  still  others  that  are  of  no  use  whatever  except  in  the  hands  of  the 
men  who  invented  them.  There  is  one  very  serious  trouble  which  is  inhe- 
rent in  most  stricture  instruments,  which  occurs  in  this  way  :  The  surgeon 
has  a  stricture  case  for  which  he  devises  a  more  or  less  useful  instrument, 
which  in  his  hands  works  well,  and  on  this  basis  he  then  exploits  this 
instrument  for  strictures  in  general.  An  attentive  reading  of  most  of  the 
articles  on  stricture  by  gentlemen  of  an  inventive  turn  of  mind  will  very 
clearly  show  that,  having  invented  his  urethral  instrument,  he  proceeds 
to  indiscriminately  treat  all  cases  by  it,  and  reports  them  by  the  score, 
and  always  claims  conspicuously  brilliant  results  and  cures.     The  trouble 


348  GONORRHCEA  AND  ITS  COMPLICATIONS. 

is  that  cases  in  general  are  made  to  fit  certain  instruments,  and  not  the 
instruments  to  fit  the  cases. 

The  young  surgeon  should  always  begin  cautiously  by  the  purchase  of 
only  a  few  instruments,  and  then  he  may  increase  his  armamentarium  in 
accord  with  his  growing  experience.  This  much  certainly  may  be  said : 
that  surgeons  who  have  large  hospital  services  can  do  good  and  efi"ect- 
ive  work  with  a  few  suitable  instruments  which  have  a  considerable  field 
of  usefulness. 

For  strictures  near  the  meatus  Civiale's  concealed  bistoury  (bistouri 
cache)  may  be  used  if  the  surgeon  has  one  handy.  In  general,  however, 
the  ordinary  straight  blunt-pointed  bistoury  will  answer  every  purpose  to 
the  surgeon's  satisfaction. 

Fig.  102. 


Civiale's  concealed  bistoury. 

One  of  the  most  useful  and  simple  instruments  for  tight  strictures  in 
the  pendulous  urethra  is  Dr.  Fluhrer's  modification  of  Maisonneuve's  ure- 
throtome. This  consists  of  a  stafi"  or  conductor  nine  and  a  half  inches 
long  of  a  calibre  of  12  F.,  grooved  on  its  upper  surface  and  slightly 
curved  at  its  distal  end,  Avhich  is  tunnelled  for  one-eighth  of  an  inch. 
The  triangular  blade  Avith  a  blunt  apex  is  seated  at  the  end  of  the  stylet 
and  is  provided  with  a  handle.  The  whalebone  guide  having  been  passed 
down  the  urethra  and  into  the  bladder  if  possible,  the  grooved  staff  is 
slid  over  it  as  far  as  the  peno-scrotal  angle,  and  then  the  knife  is  slowly 
and  firmly  pushed  down,  the  penis  being  held  straight  and  tense.  By 
this  urethrotome  the  urethra  may  be  incised  to  18  or  24  F. 

For  stricture  of  the  urethra  which  will  allow  the  passage  of  a  bougie 
15  F.  the  aseptic  urethrotome  of  Dr.  Gerster  is  often  very  useful.  "  This 
instrument  is  composed  of  five  detachable  parts — three  steel  rods  and  two 
screws.  One  of  the  rods  is  provided  with  a  laterally-grooved  bulb  of 
small  size  (1),  acting  on  a  Avedge,  Avhich  by  the  aid  of  a  stout  thumb- 
screw serves  to  spring  apart  a  pair  of  congruent  steel  blades  (2).  The 
amount  of  separation  of  the  steel  blades  (somewhat  resembling  a  pair 
of  old-fashioned  draper's  shears),  reduced  to  millimetres  corresponding  to 
the  urethral  calibre,  is  indicated  by  a  dial  placed  above  the  ring  that 
serves  for  the  fixation  of  the  instrument.  The  correct  adjustment  of  the 
thumbscreAv  is  secured  by  a  small  checkscrcAV  which  represents  the  proxi- 
mal end  of  the  urethrotome.  The  third  rod,  a  small  knife  hidden  in  the 
slightly-curved  beak  of  the  instrument,  can  be  AvithdraAvn  so  as  to  cor- 
respond to  the  place  of  Avidest  separation  of  the  shear-blades." 

The  mode  of  operation  is  as  folloAvs  :  The  closed  instrument,  lubricated 
with  glycerin,  is  passed  Avell  beyond  the  strictures,  and  then  the  shear- 
blades  are  separated  by  means  of  the  thumbscrew  to  the  desired  calibre. 
The  instrument  is  then  draAvn  forAvard  until  resistance  is  felt  from  the 
stricture.  The  hidden  knife  is  then  draAvn  into  position,  and  the  whole 
instrument,  being  firmly  grasped,  is  steadily  pulled  forAA^ard.     Thus  the 


STRICTURE  OF  THE   URETHRA. 


349 


stricture  is  gradually  dilated  so  as  to  oiFer  a  favorable  degree  of  tension 
for  the  action  of  the  knife.  This  instrument  should  not  be  used  for  verj 
tight  and  dense  strictures. 

For  the  moderate  or  limited  incision  of  bands  or  broader  coarctations 
of  the  pendulous  urethra,  which  will  admit  of  instruments  as  large  as  16 


Fig.  103. 


Fig.  104. 


Maisonneuve-Fluhrer 
urethrotome. 


Gerster's  aseptic  urethrotome. 


or  17  F.,  Civiale's  urethrotome  will  sometimes  prove  very  useful.  This 
instrument  has  a  terminal  bulb  in  which  the  blade  is  concealed,  but  which 
can  be  readily  drawn  out  by  pressing  on  a  spring  near  the  handle.  A 
glance  at  Fig.  105  will  reveal  its  construction. 

When  used  with  great  caution  in  a  restricted  number  of  very  carefully 
selected  cases,  Otis's  dilating  urethrotome  may  be  of  service,  particularly 
when  there  is  a  bona-fide  stricture  of  a  calibre  of  from  16  to  20  F.  in  the 
pendulous  urethra. 


350 


GONOBRHCEA   AND  ITS  COMPLICATIONS. 


This  instrument  consists  of  a  pair  of  steel  shafts  connected  together  by 
short  pivoted  bars,  on  the  plan  of  an  ordinary  parallel  ruler.  They  are 
separated  by  means  of  a  screw  at  the  handle,  near  which  is  a  dial  indi- 
cating the  extent  of  their  divergence.  The  upper  bar  of  the  instrument 
is  traversed  by  a  urethrotome,  terminating  in  a  thin,  narrow  spring  blade, 


Fig.  107. 


Fig.  106. 


Fig.  lOo. 


ill 


Civiale's  urethrotome.       Otis's  dilating  urethrotome. 


Maisonneuve's  uretlirotome. 


which,  when  at  the  extremity  of  the  groove  in  which  it  runs,  is  concealed 
in  a  slot.  The  instrument,  with  its  contained  urethrotome,  having  been 
passed  down  beyond  the  site  of  the  stricture  and  dilated  until  the  stricture 
is  made  tense,  the  handle  of  the  urethrotome  is  withdrawn,  causing  the 
blade  to  rise  from  the  depression  in  Avhich  it  was  concealed,  and  the 
stricture  is  divided  upon  its  upper  wall  from  behind  forward.  The  ad- 
vantages claimed  by  its  inventor  for  this  instrument  are — that  it  attacks 


STRICTURE  OF  THE   URETHRA.  351 

a  tense  instead  of  a  flaccid  stricture ;  that  its  incisions  are  made  at  a  pre- 
determined point,  depth,  and  extent ;  that  it  is  especially  adapted  to 
strictures  of  large  calibre ;  and  that  it  combines  great  strength  with  ease 
of  manipulation. 

For  certain  cases  of  tight  stricture  in  the  urethra  at  the  peno-scrotal 
angle,  and  as  far  back  as  the  bulbo-membranous  junction,  Maisonneuve's 
urethrotome  is  sometimes  very  serviceable.  This  instrument  is  far  supe- 
rior to  all  other  curved  urethrotomes.  Its  use,  however,  is  restricted  to  a 
certain  class  of  cases. 

Maisonneuve's  urethrotome  consists  simply  of  a  grooved  staif,  which 
need  not  exceed  No.  7  of  the  French  catheter  scale  (three  and  one-third 
millimetres  in  diameter),  provided  at  its  extremity  with  a  screw-point  to 
which  is  attached  a  filiform  bougie.  The  blades,  intended  to  slide  in  the 
groove  and  to  divide  the  stricture,  are  triangular  in  shape,  sharpened 
before  and  behind,  but  blunt  at  the  apex,  so  that  they  may  pass  over  the 
sound  urethral  mucous  membrane  without  Avounding  it.  The  staff  has  a 
short  curve  (see  Fig.  107),  and  the  groove  extends  only  through  the 
straight  portion,  which  is  quite  sufficient,  since  wherever  the  point  has 
made  to  pass  the  stricture  the  shaft  in  its  groove  will  readily  follow. 
The  groove  should  always  be  on  the  upper  concave  side  of  the  shaft, 
never  on  the  lower.  The  manner  of  using  this  instrument  is  very  simple. 
In  most  cases  the  filiform  flexible  conductor  is  first  introduced  as  a  guide, 
and  the  shaft  of  the  instrument  is  then  screAved  upon  it  and  made  to  fol- 
low it  into  the  bladder.  In  many  instances  it  is  possible  to  introduce  the 
shaft  alone,  armed  with  the  blunt  point  which  is  always  provided,  when 
it  is  impossible  to  pass  the  conducting  bougie.  In  either  case,  when  the 
bladder  is  fairly  entered,  as  may  be  recognized  by  the  finger  in  the  rec- 
tum, the  penis  is  to  be  put  upon  the  stretch,  and  the  blade  is  carefully 
and  gently,  but  firmly,  thrust  down  to  the  extremity  of  the  groove,  divid- 
ing every  obstruction  before  it.  It  is  important  to  take  care  in  with- 
drawing the  blade  lest  it  should  cut  healthy  tissue.  To  this  end  the  penis 
must  be  held  tense,  just  as  it  was  when  the  knife  Avas  pushed  down  (and 
the  transverse  folds  were  effaced).  Then  the  instrument  should  be  slowly 
drawn  out,  care  being  taken  to  keep  exactly  in  the  median  line,  Avhich 
was  traversed  in  the  urethrotomy. 

Rupture  or  Divulsion. — With  perhaps  few  exceptions,  surgeons  in 
New  York  have  ceased  to  treat  strictures  of  the  urethra  by  rupture  or 
divulsion,  and  they  agree  with  Stein, ^  "  that  it  is  dangerous,  rude,  inex- 
act, and  a  purely  mechanical  means  that  does  not  exact  and  is  exempt 
from  surgical  skill."  This  view  is  not  entertained  by  a  number  of  very 
able  and  conservative  surgeons  attached  to  the  Massachusetts  General 
Hospital,  who  employ  Bigelow's  divulsor,  which  they  claim  is  free  from 
the  objections  which  apply  to  Holt's,  Voillemier's,  and  Dittel's  instru- 
ments. Using  all  antiseptic  care,  Bigelow's  instrument  is  used  in  "  soft 
strictures  Avhich  are  firm  enough  to  cause  retention  of  urine  and  Avhich 
yield  to  little  force."  It  is  further  claimed  for  this  method  that  it  is  "at 
once  accurate,  easy,  ready,  safe,  and  almost  bloodless."^ 

1  Medical  Record,  May  25,  1889. 

^  The  reader  is  referred  to  a  very  comprehensive  article  by  Dr.  C.  L.  Scudder,  entitled 
"  A  Study  of  Four  Hundred  and  Four  Cases  of  Divulsion  of  Urethral  Stricture ;  the 
results  in  Twenty-eight  Cases,"  Journal  Cutaneous  and  Gen.-urinary  Diseases,  vol.  xi.,  Oct., 
1893,  pp.  383  et  seq. 


352 


GONORRHCEA  AND  ITS  COMPLICATIONS. 


"  The  instrument  consists  of  a  slender  staff  (1),  curved  as  is  a  steel 
sound  at  2  for  greater  ease  of  introduction.  The  bladder  end  of  the 
staif  has  a  removable  tip  (3)  for  the  attachment  of  a  filiform  guide  (4). 
The  divulsor  proper  (5)  is  a  shaft  expanded  in  a  long,  oval  shape  at  the 
bladder  end  to  act  as  a  wedge,  but  is  otherwise  straight,  and  is  grooved 
with  a  slot  throughout  its  whole  length  (5)  that  it  may  fit  the  stafi"  (1)  as 
in  6.     At  the  distal  end  of  the  stafi"  is  a  shield  for  the  glans  penis, 


Bigelow's  divulsor. 

which  is  placed  at  a  measured  distance  from  the  bladder  end  of  the  in- 
strument, so  that  when  the  urethra  is  held  on  the  stretch  ready  for  divul- 
sion  with  the  instrument  in  situ  there  is  absolutely  no  possibility  of 
perforation  of  the  bladder-wall.  The  left  hand  of  the  operator  grasps  the 
penis  and  staff",  and  holds  the  penis  stretched  toward  the  shield.  The 
right  hand  of  the  operator  pushes  the  divulsor  through  the  stricture — 
i.  e.  the  two  hands  approximate  each  other.     Thus  in  the  very  act  of 


Gouley's  divulsor. 

divulsion  there  is  a  constant  tendency  away  from  the  posterior  bladder- 
wall. 

"The  operation  is  performed  in  this  manner:  The  filiform  guide  is 
introduced  to  the  bladder  through  the  stricture.  To  the  tip  of  the  fili- 
form is  screwed  the  slender  staff".  This  is  then  advanced  into  the  bladder, 
following  the  guide.  When  the  staff"  is  well  introduced  and  slightly  de- 
pressed between  the  thighs,  the  several  divulsors  proper,  beginning  with 
the  smallest  size  and  running  up  to  the  largest,  are  introduced  into  the 
urethra  on  the  staff"  and  pushed  through  the  stricture  with  an  even,  steady 


STRICTURE  OF  THE   URETHRA.  35S 

force  without  violence.  The  divulsor  as  originally  made  was  of  three 
sizes,  measuring  respectively  23,  27,  and  32  of  the  French  scale.  Larger 
sizes  may  be  added." 

As  an  accessory  agent  only  in  some  very  tight  strictures  near  the  peno- 
scrotal angle  and  in  the  bulbous  part  of  the  urethra,  and  in  some  large 
and  deep  resilient  strictures.  Dr.  Gouley's  modification  of  Thompson's 
divulsor  will  occasionally  prove  very  useful.  The  construction  of  this 
instrument  is  shown  in  Fig.  109.  By  means  of  a  single  lever  the  two 
parallel  rods  are  made  to  "  separate  so  as  to  form  a  long  oval  or  spindle- 
shaped  figure,"  the  greater  diameter  of  which  will  be  equal  in  circumference 
to  No.  18  of  the  English  catheter  scale,  or  even  more.  Gouley  has  re- 
duced Thompson's  instrument  in  size,  and  modified  it  so  that  it  can  be 
used  with  a  whalebone  guide.  The  dimensions  of  the  instrument  (Fig. 
109)  are  tAvo  millimetres  at  the  extremity  and  three  and  one-half  at  the 
part  susceptible  of  greatest  expansion.  Another  important  modification 
is  in  the  blades,  Avhich,  instead  of  being  flat  or  guttered  on  their  inner 
surface  for  the  first  two  inches  from  the  point,  are  cylindrical,  so  that  the 
urethral  mucous  membrane  cannot  be  pinched  and  torn  in  withdrawing 
the  divulsor,  as  it  so  frequently  was  when  Thompson's  instrument  was  used. 

Preliminary  Considerations  in  the  Examination  of  Cases  of  Strictures. 
— Every  case  of  stricture  of  the  urethra  presents  features  peculiar  to  itself, 
consequently  each  case  should  be  carefully  studied  in  all  its  details. 

The  first  consideration  is  the  age  of  the  patient.  If  he  is  young  and 
under  thirty  years  of  age,  in  the  majority  of  cases  the  stricture  will  be 
found  to  be  of  the  soft  or  semi-fibrous  variety.  In  some  cases — rare, 
however,  particularly  when  gonorrhoeal  infection  has  occurred  long  before 
puberty — the  subject  may  suffer  from  true  inodular  stricture  in  early 
manhood.  Beyond  the  age  of  twenty  we  find  that  strictures  become  more 
condensed  and  fibrous,  while  after  forty,  and  particularly  about  the  fiftieth 
year,  the  inodular  or  hard,  fibrous  stricture  is  quite  common.  Severe 
inodular  stricture  may  be  found  in  patients  even  as  early  as  the  thirtieth 
or  thirty-fifth  year. 

The  second  point  for  consideration  is  the  date  of  gonorrhoeal  infection. 
We  must  ascertain  the  age  at  which  the  disease  was  acquired  and  the 
facts  as  to  the  severity  and  length  of  the  attack.  Then  the  matter  of 
relapses  and  later  infections  should  be  taken  up,  and  the  facts  concerning 
them  brought  out.  The  inquiry  is  still  incomplete  until  all  facts  as  to 
the  condition  of  the  posterior  urethra,  the  prostate,  and  the  seminal  vesi- 
cles are  ascertained,  together  with  full  particulars  as  to  the  condition  of 
the  bladder  and  its  functions. 

As  a  rule,  we  do  not  find  secondary  kidney  complications  in  cases  of 
stricture  until  after  the  fortieth  year.  These  complications  are  preceded 
by  cystitis  of  varying  grades,  which  may  exist  several  or  many  years 
before  the  infective  inflammatory  process  invades  and  creeps  up  the 
ureters  and  involves  the  pelvis  and  parenchyma  of  the  kidneys.  In  all 
cases,  and  particularly  in  subjects  over  forty  or  fifty  years  of  age,  the 
condition  of  the  bladder  and  kidneys  is  a  very  vital  question  in  the 
matter  of  treatment  of  stricture  of  the  urethra. 

It  is  further  necessary  to  take  into  consideration  the  general  health 
of  the  patient,  his  habits,  his  temperament,  his  occupation,  and  his  mode 
of  life. 

23 


364  GONORRHCEA  AND  ITS  COMPLICATIONS. 

Coming  down,  now,  to  a  consideration  of  the  stricture  itself,  it  is  neces- 
sary to  inform  ourselves  as  to  its  symptoms,  and  particularly  as  to  how 
much  it  interferes  with  urination.  Then  the  frequency  of  the  urinary 
act  is  to  be  considered.  If  there  are  any  complications,  such  as  fistulse 
or  rectal  disorders,  these  must  be  borne  in  mind  in  forming  an  estimate 
of  the  case.  As  to  the  stricture  itself,  it  is  necessary  to  determine  its 
location  and  its  degree  of  contraction,  together  Avith  the  amount  in  length 
of  the  urethral  canal  which  is  damaged. 

If  the  patient  had  at  an  earlier  date  been  operated  upon  for  stricture, 
all  the  facts  relating  to  this  operation  and  its  results  should  be  gathered,  and 
due  weio-ht  should  be  attached  to  them.  Further  than  this,  the  length  of 
time  in  Avhich  the  stricture  undei'went  recontraction  is  an  important  point. 

3IetJiods  of  Instrumental  Examination. — It  is  a  good  rule  to  have  the 
patient  pass  his  water  in  the  presence  of  the  surgeon  before  he  submits 
to  examination.  In  the  examination  of  the  urethra  for  stricture  it  is 
always  best,  at  first,  to  use  an  olivary  bougie  of  about  20  or  22  F.,  which, 
after  lubrication  with  pure  white  vaseline,  should  be  slowly  introduced 
into  the  canal  and  passed  downward  until  an  obstruction  is  met.  To  my 
mind,  this  instrument,  thus  introduced,  gives  a  better  idea  of  the  state  of 
the  canal  as  far  as  the  stricture  than  any  other,  and  this  is  the  first  condi- 
tion to  ascertain.  When  the  stricture  is  not  very  tight,  the  olive  point 
of  the  bougie  may  enter  it  as  far  as  its  expansion.  Then  on  its  with- 
drawal a  small  bougie  a  boule,  9  to  10  French  or  larger  if  indicated,  may 
be  carefully  introduced,  and  if  it  traverses  the  stricture  without  impedi- 
ment, on  its  return  the  shoulder  of  the  bulb  will  give  very  important  in- 
formation as  to  the  amount  of  urethra  which  is  the  seat  of  coarctation,  and 
to  the  condition  as  to  firmness  or  succulence  of  the  stricture-tissue.  In 
practice,  the  bougie  a  boule,  as  a  general  rule,  will  give  no  precise  infor- 
mation and  will  not  adapt  itself  to  ready  use  in  sizes  under  9  or  lO  F. 
It  may  be  difficult  in  many  instances  to  introduce  these  small  sizes. 
When  strictures  will  admit  larger  sizes  of  this  form  of  bougie  than  from 
12  French  upward,  their  use  is  generally  productive  of  much  important 
information. 

When  it  is  necessary  to  use  large  bulbous  bougies,  the  meatus  may 
sometimes  be  too  small  to  admit  them.  If  expedient  in  these  cases,  the 
meatus  should  be  properly  incised,  but  if  for  any  reason  meatotomy  is  at 
the  time  inadvisable,  the  urethrameter  may  be  employed.  With  this 
instrument  it  is.  only  necessary  to  determine  the  lessened  calibre  of  the 
canal  at  the  stricture,  taking  30  or  32  F.  as  the  standard  and  the  maxi- 
mum. There  is  no  need  of  making  measurements  of  the  canal  up  to  35 
or  40  F.,  since  that  amount  of  distention  is  utterly  unnatural,  and  ope- 
rations based  on  that  assumed  calibre  are,  as  a  general  rule,  productive 
of  infinite  harm  to  the  patient.  By  means,  therefore,  of  the  olivary 
bougie,  the  bougie  a  boule,  and  exceptionally  of  the  urethrameter,  we  can 
generally  obtain  scientific  knowledge  of  the  nature  and  extent  of  strictures 
of  the  urethra  from  9  to  10  French  upward. 

Much  useful  information  may  be  gained  by  careful  palpation  of  the 
pendulous  urethra,  and  even  of  the  canal  nearly  up  to  the  bulb,  by  means 
of  the  finger-tips.  This  procedure  will  reveal  little  masses  or  rings  of 
indurated  tissue,  and  also  localized  spots  where  there  is  less  than  normal 
elasticity  if  they  are  present. 


STRICTURE  OF  THE   URETHRA.  355 

When  the  stenosis  has  reduced  the  canal  to  a  calibre  under  9  French, 
exploration  should  be  made  by  means  of  correspondingly  small  olivary 
bougies  or  of  filiform  bougies. 

Urethral  examinations  for  stricture  should  be  conducted  with  the 
utmost  care,  deliberation,  gentleness,  and  good  judgment.  Our  aim 
should  be  to  cause  the  patient  a  minimum  of  uneasiness  or  pain,  and  not 
to  distend  the  tissues  any  more  than  is  absolutely  necessary. 

It  is  always  an  excellent  rule  to  begin  examinations  with  instruments 
of  goodly  size,  and  to  use  smaller  and  smaller  ones  as  the  condition  of 
affairs  indicates. 

In  strictures  of  calibre  above  12  or  15  French  there  is  usually  no 
difficulty  experienced  in  their  exploration,  and  no  preparatory  treatment 
is,  as  a  rule,  necessary.  In  cases  of  tighter  strictures  more  or  less  dif- 
ficulty may  be  encountered. 

In  passing  delicate  olivary  bougies  and  filiforms  into  the  urethra  much 
care  and  patience  is  required.  The  instrument  should  be  Avell  oiled,  and 
then  held  between  the  finger  and  thumb  in  a  delicate,  easy  manner.  I 
have  seen  surgeons  grasp  these  instruments  in  a  clumsy  and  inflexible 
manner,  and  push  and  poke  rather  than  skilfully  manipulate.  Steady- 
ing the  penis  with  the  left  hand  and  everting  the  lips  of  the  meatus  with 
the  thumb  and  forefinger  of  the  same  hand,  the  operator  passes  the 
bougie,  held  with  the  right  hand,  gently  into  the  urethra.  As  the 
mucous  crypts  and  follicles  are  seated  mostly  on  the  upper  wall,  the  in- 
strument is  pushed  gently  forward  on  the  lower  wall,  and  if  it  catches  in 
a  follicle  it  should  be  withdrawn  slightly  and  then  pushed  or  coaxed 
along  again.  In  this  way  we,  as  a  rule,  avoid  the  lacuna  magna  and 
other  valve-like  pockets  and  the  orifices  of  ducts  of  glands.  When  the 
instrument  is  down  on  the  face  of  the  stricture,  the  penis  should  be  mildly 
put  on  the  stretch  and  held  at  right  angles  to  the  body.  Then  the  very 
slight  forward  and  backward  movement  of  the  bougie  may  be  begun, 
with  the  idea  of  getting  into  the  mouth  of  the  stricture.  Sometimes  when 
the  penis  is  held  in  the  horizontal  position  in  conformity  with  the  thighs, 
the  bougie  will  slip  in  easily,  whereas  before  that  it  did  not  pass. 

In  many  cases  the  prompt  introduction  of  a  small  olivary  bougie  or  a 
filiform  may  be  brought  about  by  injecting  into  the  urethra  and  there 
retaining  about  two  drachms  of  pure  olive  oil  or  liquid  vaseline.  This 
injection  distends  and  lubricates  the  canal,  and  often  allows  a  filiform 
bougie  to  slip  through  the  obstruction,  which  before  seemed  impassable. 

It  is  always  necessary  to  bear  in  mind  the  fact  that  the  mouth  of  the 
stricture  may  be  eccentric  rather  than,  as  the  rule,  centric.  Therefore, 
it  is  well,  after  having  failed  with  the  ordinary  straight  filiforms,  to  try 
those  which  have  various  twists  and  curves  at  their  ends,  since  by  these 
we  may  most  unexpectedly  succeed  when  we  had  already  perhaps  given 
up  hope  of  passing  the  stricture. 

It  is  always  well  to  have  several  Banks  filiforms  at  hand,  since  they 
often  prove  very  useful  at  unexpected  contingencies.  In  cases  where 
much  difficulty  has  been  experienced,  but  where  the  passage  of  a  filiform 
has  been  accomplished,  this  instrument  may  be  left  in  for  an  hour  or  two, 
and  then  a  Banks  filiform  may  be  introduced,  and  by  means  of  it  such 
temporary  dilatation  may  be  accomplished  that  the  subsequent  treatment 
of  the  case  is  rendered  materially  less  difficult  and  trying. 


356  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

In  some  troublesome  cases  it  is  well  to  pass  several  (as  many  perhaps 
as  six)  filiforms  as  far  down  as  the  stricture,  and  then  to  inject  the  urethra 
with  oil,  after  which  the  surgeon  should  try  to  pass  each  bougie  individ- 
ually. In  this  way  he  may  often  succeed,  whereas  before  adopting  this 
expedient  he  had  failed  utterly.  In  some  very  troublesome  cases  1  have 
succeeded  in  getting  through  a  stricture  by  first  passing  down  to  its  face 
several  filiforms,  and  then  by  means  of  a  hard-rubber  uterine  syringe, 
introduced  as  far  down  as  possible,  injecting  about  two  drachms  of  very 
warm  olive  oil,  and  holding  it  in  the  canal  well  down  by  means  of  com- 
pression by  the  fingers.  In  this  distended  and  lubricated  condition  of 
the  urethral  canal  the  orifice  of  the  stricture  is  often  so  much  dilated  that 
it  will  allow  the  filiform  to  pass  through. 

There  is  another  method  of  procedure  which  should  never  be  forgotten. 
This,  in  the  main,  consists  in  the  employment  of  a  truncated  catheter. 
A  silver  catheter  (20  or  22  F.)  is  cut  off"  at  right  angles  to  its  shaft  at 
the  length  of  six  inches.  The  cut  end  is  then  rendered  round,  smooth, 
and  harmless  by  means  of  a  thin  ring  of  solder,  which  is  evenly  moulded 
around  the  distal  end  of  its  lumen.  This  catheter  then  becomes  a  very 
useful  conductor.  It  is  well  oiled  and  passed  down  to  the  face  of  the 
stricture,  and  there  held  gently  but  quite  firmly  ;  then  through  it  filiforms 
are  passed  and  gently  manipulated.  In  many  cases,  even  when  success 
is  not  hoped  for,  this  procedure  will  result  in  the  passage  of  the  bougie. 

Having  succeeded  in  passing  the  filiform  into  the  bladder,  the  surgeon 
can  moderately  dilate  the  canal  by  sliding  over  it  one  or  more  increasing 
sizes  of  Gouley's  tunnelled  sound.      By  this  procedure  (assuming  that 

Fig.  110. 


Gouley's  tunnelled  sound  (and  guide). 

urethrotomy  is  not  contemplated)  the  surgeon  generally  places  the  urethra 
in  such  a  condition  that  it  will  be  passable  for  a  day  or  two,  at  least,  by 
instruments.  If,  however,  the  operation  of  internal  or  external  urethrot- 
omy is  indicated,  and  the  time  and  conditions  are  favorable  to  its  perform- 
ance, the  surgeon  then  has  a  clear  field. 

If,  after  prolonged  efforts  to  reach  the  bladder,  much  uneasiness  is  pro- 
duced and  much  hemorrhage  occurs,  and  the  instrument  still  does  not  pass, 
it  is  well  to  stop  the  examination  and  wait  for  a  day  or  two. 

In  some  cases,  after  one  or  more  failures  in  introducing  very  small 
instruments  through  a  stricture,  it  may  be  necessary  to  put  the  patient  to 
bed,  to  allow  him  a  very  spare  diet  (bread  and  milk  preferably),  and  to 
purge  him  well,  in  order  to  relieve  the  pelvic  organs  of  congestion.  As 
a  result,  strictures  previously  impassable  will  often  alloAv  the  instrument 


STRICTURE  OF  THE   URETHRA. 


357 


to  glide  into  the  bladder.  In  many  cases  rest,  an  opium  suppository,  and 
a  hot  bath  will  relieve  the  stricture  of  congestion,  so  as  to  allow  the  pas- 
sage of  the  exploratory  instrument. 

For  various  reasons,  more  or  less  urgent,  it  is  often  necessary  to  pass 
sounds  and  catheters  through  the  urethra  into  the  bladder. 

lyitroduction  of  the  Catheter  or  Sound. — A  catheter  or  sound  may  be 
introduced  while  the  patient  is  in  the  standing^  or  sitting  posture,  but  the 

Fig.  111. 


First  step  in  introducing  a  catheter. 

recumbent  position  is  on  many  accounts  the  best,  the  patient  lying  square 
on  the  back,  with  the  shoulders  elevated,  the  knees  drawn  up  and  some- 
what separated,  the  genital  organs  entirely  exposed,  and  the  surgeon 
standing  on  his  left.  The  operator  now  raises  the  penis  to  an  angle  of 
about  sixty  degrees  with  the  body,  thereby  effacing  the  anterior  curve  of 

^  A  method  of  passing  the  sound  known  as  the  tour  de  maitre  is  nuich  preferred  by 
some  surgeons.  It  is  a  very  simple,  easy,  and  expeditious  procedure  in  the  liands  of  men 
of  large  experience,  but  to  the  beginner  it  may  prove  a  stumbling-block  which  will  bring 
mortification  to  him  and  pain  and  discomfort  to  his  patient.  The  surgeon  sits,  and  the 
patient  stands  before  him.  The  sound  is  introduced  with  its  convexity  fjicing  the  pubes 
as  far  down  as  the  bulb;  then  the  shaft  is  quite  rapidly  rotated  toward  the  abdomen, 
when  the  point  readily  slips  into  the  membranous  urethra  and  the  handle  is  depressed 
between  the  thighs.  When  skilfully  done,  this  operation  is  unattended  with  any  un- 
pleasant symptoms  whatever  to  patients,  many  of  whom  prefer  it  on  account  of  its  ease 
and  celerity. 


358 


GONORBHCEA  AND  ITS  COMPLICATIONS. 


the  urethra,  by  means  of  the  ring  and  middle  finger  of  the  left  hand,  its 
palm  looking  upward  ;  the  thumb  and  fore  finger  are  thus  left  free  to  re- 
tract the  prepuce  and  separate  the  lips  of  the  meatus.  The  catheter,  pre- 
viously warmed  and  oiled,  is  held  lightly  between  the  thumb  and  fore  and 
middle  fingers  of  the  right  hand  "like  a  pen,"  its  shaft  corresponding  to 
the  fold  between  the  abdomen  and  the  left  thigh.  The  introduction  of 
the  instrument  should  be  slow  and  with  the  exercise  of  little  force ;  its 
own  weight  is  almost  sufficient  to  effect  its  passage  if  properly  directed ; 
if  any  obstruction  be  met  with,  the  instrument  should  be  Avithdrawn  for  a 
short  distance  and  again  advanced  with  the  direction  of  its  point  slightly 
varied.  While  passing  through  the  first  two  inches  of  the  urethra  the 
point  of  the  instrument  is  inclined  to  the  lower  surface  in  order  to  avoid 
the  lacuna  magna,  and  it  is  well  to  hug  the  lower  wall  until  the  end  of 
the  instrument  has  passed  the  peno-scrotal  angle ;  beyond  this  it  should 
be  directed  rather  to  the  upper  surface  to  escape  the  sinus  of  the  bulb  ; 
when  it  has  penetrated  beneath  the  pubes,  the  shaft  is  brought  round  to 
the  median  line  of  the  body  and  parallel  to  the  surface  of  the  abdomen ; 
the  handle  is  now  to  be  elevated  to  a  perpendicular,  and,  pressure  being 

Fig.  112. 


Second  step  in  introducing  the  catheter. 

made  with  the  disengaged  hand  upon  the  mons  Veneris  and  the  root  of 
the  penis  for  the  purpose  of  stretching  the  suspensory  ligament,  be  gently 
depressed  between  the  thighs,  not  forgetting  meanwhile  to  maintain  a  cer- 
tain amount  of  progressive  motion  in  the  instrument,  when  the  point  Avill 
usually  glide  into  the  bladder.  If  any  difficulty  is  met  with  at  this  stage 
of  the  proceeding,  it  is  probably  because  the  point  has  caught  in  the  ex- 
tensible tissue  of  the  bulb,  and  the  instrument  should  be  a2;ain  raised  to 
a  perpendicular  and  slightly  withdrawn,  and  the  penis  elongated  by  trac- 
tion before  the  manoeuvre  is  repeated.  Further  assistance  may  be  ob- 
tained, if  necessary,  during  the  latter  part  of  the  introduction  by  gently 
pressing  against  the  convexity  of  the  instrument  just  back  of  the  scrotum 
or  by  introducing  a  finger  into  the  rectum,  ascertaining  the  exact  position 
of  the  point,  and  guiding  it  forward  and  upward  against  the  posterior 
surface  of  the  symphysis ;    the  passage  of  the  extremity  over  the  uvula 


STRICTURE   OF  THE   URETHRA.  359 

vesicae  is  often  indicated  by  nausea  or  a  slight  tremor  on  the  part  of  the 
patient,  and  its  entrance  into  the  bladder  by  a  flow  of  urine. 

When  dexterously  and  gently  performed,  the  introduction  of  the 
sound  or  catheter  is  accomplished  without  a  hitch  or  halt  in  most  cases. 
By  want  of  gentleness  and  by  bungling  procedures  spasmodic  contraction 
of  the  involuntary  muscle-fibres  of  the  pendulous  urethra  may  be  induced, 
and  also  spasm  of  the  compressor  urethrge  muscle.  In  this  event  it  is 
well  to  desist  or  to  press  the  tip  of  the  instrument  gently  and  continuously 
against  the  obstruction  until  spasm  ceases,  and  then  it  will  slowly  glide 
onward. 

To  recapitulate  :  In  this  operation  it  will  be  seen  that  the  first  possible 
obstacle  is  the  lacuna  magna,  which  is  avoided  by  keeping  the  point  of 
the  instrument  on  the  lower  wall  for  the  first  three  inches  of  the  canal. 
Then  by  holding  the  instrument  along  the  fold  of  the  groin  there  is  no 
fear  that  its  point  Avill  impinge  against  the  symphysis  pubis,  which  it 
might  do  if  the  abdomen  was  distended  and  the  instrument  held  in  the 
median  line.  When  the  instrument  is  five  or  six  inches  down  the  canal, 
during  the  passage  of  which  its  tip  glides  over  the  under  wall  of  the  ure- 
thra and  its  point  is  under  the  symphysis,  this  part  is  then  to  be  slightly, 
and  sometimes  decidedly,  elevated,  and  then  it  enters  the  membranous 
urethra.  At  this  time  the  shaft  of  the  instrument  is  to  be  elevated  and 
brought  exactly  in  the  median  line.  As  the  tissues  of  the  bulb  are  rather 
loose  and  very  extensible,  it  is  necessary  here  to  make  sufficient  traction 
on  the  penis  to  render  the  whole  spongy  urethra  tense,  smooth,  and  free 
from  folds.  Then,  when  the  tip  of  the  instrument  is  in  the  orifice  of  the 
membranous  urethra  and  directed  slightly  upward,  its  handle,  held  very 
gently  between  the  right  thumb  and  fore  finger,  makes  a  circular  turn, 
and  as  it  does  so  the  whole  subpubic  curvature  is  traversed  by  the  curve 
of  the  instrument,  and  its  end  then  protrudes  into  the  bladder. 

Catheterization  in  the  Pouchy  Condition  of  the  Bulbous  Urethra  and 
in  Eyilargement  of  the  Prostate. — In  the  directions  just  given  for  the 
passage  of  curved  sounds  and  catheters  it  is  assumed  that  the  urethral 
canal  is  in  a  normal  or  nearly  normal  condition.  In  elderly  persons 
there  are  two  segments  of  the  urethral  canal  which  may  offer  resistance 
to  the  passage  of  curved  and  also  straight  instruments  in  the  classical 
manner.  These  are,  first,  the  bulbous  and  bulbo-membranous  portions, 
and,  second,  the  prostatic  portion. 

In  many  old  men  the  bulb  of  the  urethra  becomes  redundant,  pouchy, 
and  its  relaxed  membrane  is  very  much  thrown  into  folds.  As  a  result 
of  this  flabby  condition,  when  the  end  of  the  instrument  reaches  the  sinus 
of  the  bulb  the  tonicity  of  the  tissues  is  so  lost  that  there  is  nothing  left 
of  a  firm  character  to  guide  its  onward  progress.  As  a  result,  the  end 
may  impinge  on  the  sagging  lower  part  of  the  bulb,  and  there  be  held  as 
in  a  true  cul-de-sac.  Then,  again,  it  may  press  against  the  upper  wall 
of  the  bulb,  and  its  further  progress  is  impeded  by  it  and  the  anterior 
layer  of  the  triangular  ligament.  In  general,  the  end  of  the  instrument 
catches  in  the  lower,  pouch-like  part  of  the  bulb,  and  it  is  here  that  false 
passages  are  usually  made,  in  Avhich  case  the  instrument  either  pierces  the 
triangular  ligament  or  glides  under  it  and  makes  a  pathological  channel 
in  the  soft  tissues  beneath  the  membranous  urethra  and  the  prostate. 
False  passages  may  also  be  made  on  either  side  of  the  lower  part  of  the 


360  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

bulb.  When  a  false  passage  is  made  in  the  upper  wall  of  the  bulbous 
urethra,  the  end  of  the  instrument,  after  passing  through  that  structure, 
continues  on  through  Henle's  deep  transverse  ligament  of  the  pelvis  until 
it  juts  into  the  prevesical  spaces.     (See  pages  39  and  44.) 

This  abnormal  anatomical  condition  of  the  bulbous  urethra  has  to  be 
met  with  appropriate  instruments.  What  is  needed  under  these  condi- 
tions is  an  instrument  of  sufficient  firmness  of  structure  to  make  its  way 
through  the  canal,  whose  end  points  slightly  upward,  and  which  at  its 
curve  shall  have  such  a  shoulder  that  if  it  sinks  down  to  the  lower  wall 
of  the  pouchy  bulb  its  tip  Avill  then  point  upward  and  strike  the  orifice  of 
the  bulbo-membranous  junction.  The  instruments  which  best  fulfil  these 
requirements  are  the  Mercier  coud^  and  bi-coude  catheters.  (See  Fig. 
101.)  Whether  these  instruments  are  used  by  the  surgeon  or  by  the 
patient,  it  is  always  very  necessary  that  there  shall  be  some  reliable  guide 
which  shall  point  to  the  side  of  the  instrument  which  corresponds  to  its 
convexity.  As  a  rule,  little  reliance  can  be  placed  on  the  surface  mark- 
ing of  the  catheter ;  therefore  it  is  well  to  cut  ofi"  obliquely  by  knife  or 
scissors  the  distal  end  of  the  instrument,  so  that  its  long  wall  will  corre- 
spond to  the  convex  surface  of  the  catheter.  In  this  way  the  oblique  end 
of  the  catheter  will  look  toward  the  abdomen  of  the  patient,  and  it  will  be 
equally  certain  that  its  point  also  is  directed  forward.  This  little  matter 
should  never  be  forgotten. 

Many  of  the  coude  catheters  on  sale  are  faulty  by  reason  of  the  short- 
ness of  their  curved  portion,  which,  as  before  stated,  should  be  fully  one 
inch  long,  and  in  accordance  with  the  curve  depicted  in  Fig.  101.  A 
coude  catheter  will  commonly  traverse  canals  whose  bulbs  are  distorted  by 
age.  It  should  be  well  oiled,  and  slowly  and  carefully  passed  down  the 
urethra,  and  as  it  traverses  the  bulbous  urethra  it  is  well  to  gently  guide 
its  course  by  steadying,  not  pressing,  the  parts  just  back  of  the  scrotum. 
By  this  manoeuvre  the  point  is  made  to  enter  the  membranous  urethra, 
and  the  patient  may  be  relieved. 

In  some  very  marked  instances  of  the  pouchy  state  of  the  bulbous  ure- 
thra the  bi-coud6  catheter  will  prove  very  serviceable.  The  rationale  of 
its  use  depends  upon  its  conformation,  by  which  its  much-curved  portion 
rests  on  the  floor  of  the  relaxed  bulb  and  its  end  points  upward  tOAvard 
the  hole  in  the  triangular  ligament.  In  some  cases  there  is  difficulty 
experienced  in  passing  these  catheters,  and  then  it  is  necessary  to  be 
patient  and  try  to  follow  the  natural  route.  In  several  trying  cases  I  first 
injected  into  the  bulb  four  drachms  of  warmed  olive  oil,  which  so  distended 
it  that  the  instrument  readily  passed  through  the  membranous  urethra. 

In  enlargement  of  the  prostate,  in  the  main,  three  abnormal  conditions 
are  encountered  in  catheterization.  In  the  first  place,  the  urethral  canal 
may  be  much  elongated  by  the  progressive  growth  of  the  gland  tOAvard 
and  in  the  bladder.  In  the  second  place,  by  its  concentric  growth  this 
organ  so  contracts  the  urethral  lumen  or  distorts  its  normal  straightness 
of  direction  and  renders  it  sinuous  that  much  impediment  to  urination  is 
produced.  In  the  third  place,  the  uvula  vesicae  or  the  urethral  and  blad- 
der tissues  just  at  the  commencement  of  the  urethra,  on  its  lower  wall, 
become  so  hypertrophied  that  a  true  valve  obtrudes  itself  in  the  vesical 
orifice,  or  this  opening  is  more  or  less  obliterated  by  the  presence  of  a 
firm  bar  of  tissue  which  extends  across  the  lower  part  of  the  canal.     Now, 


STRICTURE  OF  THE   URETHRA.  361 

these  pathological  conditions  also  have  to  be  overcome  by  means  of  appro- 
priate catheters. 

In  the  majority  of  cases  of  elongation  of  the  urethra,  with  a  corre- 
sponding greater  curve  of  the  canal,  the  bladder  can  readily  be  reached 
by  means  of  the  extra-curved  olivary  catheters  (see  Fig.  100)  called  pros- 
tatic catheters.  These  instruments,  when  used  in  sizes  of  20  to  24  French, 
are  much  more  serviceable,  as  a  rule,  than  the  smaller  and  larger  ones 
are.  They  are  much  to  be  preferred  to  the  old-time  silver  prostatic  cathe- 
ter, which  by  its  density  and  inflexibility  often  caused  pain  and  uneasiness. 
The  long  curve  of  these  prostatic  catheters  is  often  of  material  aid  in 
traversing  a  pouchy  bulbous  urethra. 

In  some  cases  soft  India-rubber  catheters  or  straight,  blunt-pointed, 
lisle-thread  catheters  will  readily  traverse  the  urethral  canal  which  is 
lengthened  or  distorted  by  prostatic  hypertrophy. 

It  may  be  necessary,  when  the  calibre  of  the  prostatic  urethra  is  much 
reduced  or  its  straightness  much  distorted,  to  use  these  catheters  with  the 
long  curve  or  the  straight  ones  in  sizes  smaller  than  20  F. 

When  the  catheters  already  spoken  of  cannot  be  obtained,  the  old- 
style  brick-red  English  catheter  may  be  used  if  at  hand.  It  is  well,  if  it 
is  a  straight  instrument,  to  soak  it  in  hot  water,  then  give  it  the  necessary 
curve,  Avhich  may  be  rendered  sufficiently  permanent  by  immediate  immer- 
sion in  very  cold  or  iced  water. 

In  cases  of  valvular  obstruction  or  of  a  bar  at  the  vesical  orifice  much 
difficulty  may  be  met  in  reaching  the  bladder-cavity.  Sometimes  the  tip 
of  the  Mercier  catheter,  pai-ticularly  when  smaller  than  20  F.,  will  glide 
over  the  obstruction  in  a  surprisingly  prompt  manner.  Then,  again,  it 
may  strike  against  it,   and  no  manoeuvre  will   cause  it  to  traverse  it. 

In  many  cases  the  gum-elastic  prostatic  catheter  will,  by  the  forward 
tilting  or  bending  of  its  tips  or  forward  pressure,  glide  past  the  obstruc- 
tion upward  into  the  bladder. 

In  these  obstinate  cases  it  may  be  necessary  to  use  Otis's  prostatic 

Fig.  113. 


Otis's  prostatic  guide. 


guide,  which  will  steady  and  direct  a  soft-rubber  catheter.  Or  the  ordi- 
nary wire  which  is  found  in  English  catheters,  or  a  piece  of  ordinary 
wire  ten  or  twelve  inches  long,  may  be  curved  in  accordance  with  the 
long  prostatic  urethra.  This  wire  is  introduced  into  a  soft-rubber  cathe- 
ter, and  then  the  combined  instrument  is  passed  until  it  reaches  the  blad- 
der or  comes  to  a  standstill  on  meeting  the  obstruction.  Then  it  is  well 
to  withdraw  the  wire  for  about  half  an  inch,  and  again  push  forward, 
when  the  flexible  end  may  clear  the  obstruction.  If  this  procedure  fails, 
the  surgeon  should  still  further  pull  out  the  Avire  another  half  an  inch, 
and  then  try  to  pass  the  obstruction.  In  case  of  final  failure  the  condi- 
tion of  the  case  will  determine  in  the  mind  of  the  surgeon  whether  it  is 
necessary  to  aspirate,  to  reach  the  bladder  by  external  urethrotomy  by 
Cock's  operation,  or  to  perform  suprapubic  cystotomy. 

I  have  purposely  avoided  mentioning  the  vertebrated  silver  catheter, 


362  GONOBRHCEA   AND  ITS  COMPLICATIONS. 

for  the  reason  that  it  is  a  very  unreliable  instrument,  which  may,  even  if 
carefully  used,  damage  the  urethral  canal,  and  which  it  is  almost  impos- 
sible to  render  aseptic. 

Treatment  of  Contractions  and  of  Strictures  at  and  just  within  the 
Meatus. — It  has  already  been  stated  that  normally  the  lumen  of  the 
meatus  is  from  21  to  28  French,  as  a  general  average.  (See  page  48.) 
By  a  wise  provision  of  Nature  the  end  of  the  urethral  canal  is  so  much 
narrowed  that  the  stream  of  urine  is  projected  well  in  advance  of  the  body 
and  in  a  solid  jet,  in  accordance  with  hydraulic  principles.  Exception- 
ally cases  are  met  with  in  which  there  is  a  greater  or  less  abnormal  con- 
traction of  the  meatus.  "When  this  is  only  moderate,  there  may  be  no 
disturbance  in  the  function  of  urination.  But  in  some  cases  the  meatus 
is  exceedingly  small,  even  of  a  pinhead  size,  and  then  much  functional 
disturbance  may  result.  The  prominent  symptoms  in  cases  of  very  small 
meatus  are  frequent,  painful,  and  prolonged  micturition  and  deep-seated 
urethral  uneasiness  or  irritation,  together  with  vesical  irritability.  In 
some  seemingly  well-observed  cases  such  symptoms  as  anterior  crural  neur- 
algia and  sciatica  have  been  found.  Many  incorrect  and  exaggerated 
statements  have  been  made  as  to  the  serious  conditions  which  often  accom- 
pany contracted  meatus.  Thus  it  is  stated  that  the  anomaly  gives  rise  to 
pain  in  the  back  and  hypogastrium,  groins,  and  testes,  to  hydrocele,  to 
painful  seminal  emissions,  and  to  paresis  and  softening  of  the  brain.  The 
truth  of  the  matter  is  about  as  follows :  In  men  free  from  gonorrhoea  or 
urethral  irritation  the  urinary  functions  may  be  perfectly  performed  even 
if  the  meatus  is  no  larger  in  calibre  than  10  French,  and  there  may  be 
no  abnormal  symptoms.  When  the  urethra  has  been  the  seat  of  gonor- 
rhoeal  inflammation,  congestion  from  masturbation  and  sexual  excesses, 
and  perhaps  of  tuberculosis,  the  narrowed  meatus  may  cause  conditions 
which  react  upon  and  render  more  intense  these  inflammatory  states, 
which  may  perhaps  depend  upon  mechanical  causes  or  possibly  upon 
reflex  action.  It  is  certain  that  no  positive  statement  can  be  made  as  to 
the  mode  of  causation. 

In  former  years,  when  exaggerated  views  on  the  influence  of  con- 
tracted meatus  were  very  generally  entertained,  this  part  of  the  human 
anatomy  was  extensively  and  vigorously  incised.  The  operation  of  mea- 
totomy  or  porotomy  became  routine  practice,  and  large  numbers  of  men 
were  unnecessarily  cut  up  to  35  or  40  French  in  order  to  cure  more  or  less 
severe  ailments  which  were  said  to  have  their  origin  in  the  urethral  orifice. 
This  epidemic,  happily,  is  on  the  steady  decline,  but  to-day  we  not  infre- 
quently see  men  into  whose  foss?e  naviculares  the  first  joint  of  the  fore 
finger  may  be  readily  introduced,  and  who  on  urination  pass  slow,  heavy, 
and  sputtering  streams  which  hardly  clear  their  knees,  and  Avhich  are  as 
ungraceful  as  the  flow  of  Croton  water  from  the  hydrant. 

The  logical  deductions  warranted  by  the  foregoing  facts  and  considera- 
tions are — 1,  that  when  an  abnormally  small  meatus  causes  a  decided 
impairment  of  the  urinary  function,  it  should  be  cut  in  a  conservative 
manner ;  2,  that  when  the  smallness  of  the  urethral  orifice  is  found  to  be 
the  undoubted  cause  of  the  perpetuation  of  deep  urethral  inflammation  of 
any  kind,  it  should  be  enlarged  ;  and,  3,  that  when  the  meatus  will  not 
admit  of  instruments  sufficiently  large  to  act  upon  deep-seated  urethral 
lesions,  it  should  be  incised  in  keeping  with  the  necessity. 


STRICTURE  OF  THE    URETHRA. 


363 


In  general,  the  contraction  of  the  meatus  is  due  to  the  excessive 
development  of  the  mucous  membrane  at  the  lower  commissure,  and 
exceptionally  a  septum  of  mucous  membrane  stretches  across  the  canal 
from  the  upper  commissure  and  encroaches  more  or  less  on  its  lumen. 
Consequently,  it  is  necessary  to  examine  each  case  by  separating  the  lips 
and  also  introducing  a  curved  probe  in  order  to  determine  -whether  the 
incision  is  to  be  made  upward  or  downward.  The  part  having  been 
rendered  aseptic,  an  incision  should  be  very  carefully  made  exactly  in  the 
middle  line  by  means  of  Civiale's  concealed  bistoury  (see  Fig.  102)  or 
of  the  straight  blunt-ended  bistoury.  It  is  well,  as  a  general  rule,  to  make 
the  incision  large  enough  to  admit  a  32  F.  meatus  sound,  supposing  that 

FfG.  114. 


Meatus  sound. 

the  urethra  will  comfortably  admit  a  No.  30  F.  sound.  If  the  urethral 
lumen  is  less  than  30  F.,  it  is  well  to  cut  the  meatus  in  accordance  with 
its  measurement.  In  the  majority  of  cases  it  will  be  found  that  when  the 
meatus  finally  heals  the  calibre  will  be  about  two  sizes  smaller  than  the 
meatotomy  made  it.  After  incision  of  the  meatus  pressure  will  usually 
stop  bleeding  in  a  short  time.  The  meatus  sound  (there  are  varying  sizes 
of  this  useful  little  instrument)  may  be  introduced  every  two  or  three  days 
for  several  weeks.  It  is  thus  necessary  to  keep  up  the  process  of  dilata- 
tion, since  these  parts  show  a  decided  tendency  to  promptly  contract. 

Cicatricial  strictures  of  the  meatus  are  not  very  common,  and  in  general 
follow  the  initial  lesion  of  syphilis  when  seated  here.     In  many  cases  of 

Fig.  115. 


stricture  of  the  meatus  following  hard  chancre. 


chancre  of  the  meatus  the  urethral  lumen  is  not  at  all  impaired  after  its 
involution  ;  in  others  there  may  be  slight  contraction,  and  exceptionally  a 
dense  fibrous  ring  is  left,  which  may  reduce  the  size  of  the  orifice  to  No. 
2  or  3  French  scale.     This  form  of  stricture  is  well  shown  in  Fig.  115. 


364  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

Chancroidal  ulcers,  and  exceptionally  chronic  relapsing  herpes  pro- 
genitalis,  may  cause  cicatricial  stricture  of  this  orifice.  A  scleroderma- 
tous condition  and  keloid  may  also  cause  abnormal  contraction  of  the 
meatus  and  fossa  navicularis.  In  these  cases  of  stricture  due  to  new 
tissue-formation  the  incision  should  be  made  in  accordance  with  the  seat 
of  the  obstruction.  The  passage  of  a  probe  will  show  whether  (as  is 
generally  the  case)  it  is  necessary  to  make  an  upward  and  also  a  downward 
incision,  and  it  will  indicate  the  necessary  depth  of  the  cuts.  The  sub- 
sequent treatment  consists  in  the  careful  introduction  of  the  meatus  sound. 
This  operation  should  be  repeated  for  a  considerable  time,  sometimes  many 
months,  until  all  tendency  (which  is  great)  to  recontraction  has  ceased. 
If,  as  a  result  of  this  operation,  the  meatus  will  admit  a  No.  30  French 
sound,  it  may  be  pronounced  to  be  satisfactory. 

Treatment  of  Strictures  in  the  Pendulous  Portion  of  the  Urethra. — 
The  urethra  from  the  peno-scrotal  angle  to  the  meatus,  corresponding  to 
Regions  Nos.  2  and  3  of  Thompson's  division,  is  in  many  cases  the  seat 
of  stricture,  but  it  is  rather  less  frequently  aifected  than  the  first  region, 
which  includes  the  bulbous  portion  of  the  canal. 

In  the  pendulous  urethra,  which  extends  to  the  peno-scrotal  angle, 
many  changes  take  place  as  the  result  of  gonorrhoeal  inflammation  which 
should  be  separately  considered. 

For  purposes  of  description  it  is  well  to  study  urethral  contractions, 
inch  by  inch,  down  the  canal,  since  the  surgical  indications  and  require- 
ments vary  very  much  in  diff"erent  portions  of  the  anterior  canal. 

In  chronic  gonorrhoea  the  two  inches  of  the  urethra  just  beyond  the 
meatus  may  be  the  seat  of  soft  infiltration,  which  is  thus  limited  or  which 
may  be  continuous  with  a  morbid  condition  of  the  urethra  beyond.  In 
practice  we  not  uncommonly  find  strictures  of  this  part.  They  may  be 
met  with  in  the  semi-fibrous  or  well-developed  fibrous  form.  Inodular 
stricture  is  rarely  found  here. 

Semi-fibrous  strictures  of  the  segment  of  the  urethra  under  considera- 
tion may  be  much  benefited  by  dilatation  with  the  straight  steel  sound, 
provided  they  are  seen  early  enough.  As  a  rule,  however,  these  cases 
come  to  us  when  the  urethral  canal  is  the  seat  of  fibrous  infiltration, 
which  further  shows  itself  by  the  existence  of  one,  several,  or  many  ring- 
like bands.  The  canal  is  then  the  seat  of  fibrous  stricture,  which  in  this 
region  is  usually  very  dense  and  unyielding.  The  calibre  may  be  15  to 
3  or  4  French  scale,  and  the  bulb  introduced  and  withdrawn  bumps 
roughly  over  a  dense  membrane  with  contractions.  It  may  be  stated  as  a 
general  rule  that  in  these  cases  dilatation  is  not  to  be  used,  since  it  will 
produce  of  itself  little  if  any  effect,  and  will  cause  pain  and  uneasiness. 

These  strictures  require  careful  incision,  for  which  purpose  Gouley's 
probe-pointed  bistoury  and  the  straight  blunt-pointed  bistoury  ai'e  the 
necessary  instruments.  The  parts  having  been  thoroughly  cleansed,  coca- 
ine anaesthesia  may  be  produced  by  the  injection  into  the  urethra  of  a 
10  per  cent,  solution.  If  the  contraction  is  very  small,  the  canal  may  be 
widened  sufficiently  by  a  moderate  dowuAvard  cut  with  the  Gouley  knife, 
and  then  an  upward  and  a  downward  cut  exactly  in  the  median  line 
should  be  made  with  the  blunt  bistoury.  These  parts  never  should  be  cut 
recklessly,  either  into  the  space  between  the  cavernous  bodies  above  or 
into  the  cellular  tissue  below.     If  after  this  simple  form  of  urethrotomy  a 


STRICTURE  OF  THE  URETHRA.  365 

No.  25  to  28  F.  straight  steel  sound  can  be  introduced  readily  and  with- 
out pain  to  the  patient,  the  result  may  be  considered  good.  In  these 
cases  it  is  utterly  impossible  to  fully  restore  the  suppleness  of  the  urethral 
walls,  but  much  can  be  done  by  careful  dilatation  kept  up  long  after  the 
incisions.  Stricture-tissue  in  this  portion  of  the  urethra  is  very  prone  to 
rapid  condensation  and  contraction  ;  hence  there  is  always  a  battle  in 
these  cases  to  keep  the  urethral  canal  of  moderately  large  size.  Though 
some  authors  recommend  over-dilatation  and  a  general  vigorous  treatment 
for  these  distal  strictures,  I  am  firm  in  the  conviction  that  moderate  and 
gradual  dilatation  up  to  25  F.,  and  perhaps  a  little  above,  will  in  the  end 
give  the  patient  the  best  results.  In  cases  of  large  urethra  perhaps  we 
may  establish  a  calibre  of  30  F.  This,  however,  may  be  said,  that  if  five 
years  after  this  little  operation  the  patient  can  pass  a  No.  25  F.  sound,  he 
is  a  lucky  man. 

We  sometimes  meet  cases  in  which  the  contraction  is  from  one  to  two 
inches  down  the  canal,  and  a  15  French  bulb  passes  readily  beyond  it. 
For  these  cases  Civiale's  urethrotome  is  particularly  adapted.  Localizing 
the  fibrous  patch  or  band  by  means  of  the  expanded  portion  of  the  instru- 
ment, the  penis  is  rendered  tense  and  the  tissue  is  cut  on  the  upper  wall 
of  the  urethra  to  about  28  or  30  F.  Then  the  straight  steel  sound  may 
be  passed,  and  while  it  is  in  the  canal  moderate  pressure  may  be  exerted 
on  the  morbid  tissue.  By  this  means  considerable  absorption  may  be 
produced. 

To  recapitulate :  In  the  urethra  contiguous  to  the  meatus  we  usually 
find,  in  practice,  firm  fibrous  strictures,  generally  en  nappe  or  in  tubular 
form,  which  require  simple  incision,  followed  by  gradual  dilatation  for 
long  periods.  If  in  these  cases  we  can  restore  the  urethra  to  a  calibre  of 
25  to  28  F.  and  keep  it,  the  result  may  be  considered  very  excellent. 

The  So-called  Strictures  of  Large  Calibre. 

Some  authors  claim  that  the  normal  urethral  calibre  is  much  greater 
than  that  given  in  this  work.  They  base  their  statements  on  the  fact 
that  the  urethra  may  be  dilated  by  the  urethrameter  up  even  as  high  as 
40  F.  They  further  make  the  claim  that  the  calibre  of  the  urethra  is  or 
should  be  uniform  in  its  whole  course  ;  consequently  if  a  urethrameter  is 
introduced  into  a  canal  and  screwed  up  to,  say,  36  F.,  according  to  these 
views  this  expanded  bulb  should  pass  smoothly  out  when  the  instrument 
is  withdrawn.  If,  however,  the  instrument  hitches  or  halts  or  jumps 
over  moderate  obstructions,  these  narrowed  parts  are  called  strictures, 
and  the  patient  is  told  that  he  has  one  or  more  strictures  of  large  calibre. 
I  am  free  to  say,  as  I  have  said  before,  that  there  is  not  a  man  alive 
whose  urethra  will  stand  this  treatment  of  exploratory  over-dilatation  and 
allow  the  bulb  to  glide  easily  and  unobstructedly  out.  The  trouble  Avith 
this  matter  of  strictures  of  large  calibre  is  that  the  assumptions  regarding 
them  are  based  on  conclusions  drawn  from  the  use  of  the  urethrameter, 
and  on  theories  as  to  the  nature  of  stricture  of  the  urethra.  We  already 
know  the  morbid  process  which  leads  to  stricture.  (See  Chapter  VI.) 
Now  let  us  study  in  more  detail  the  anatomical  structure  of  the  urethra. 
This  subject  has  been  exhaustively  treated  by  Zuckerkandl,^  particularly 

^  Art.  "  Harnrohre,"  Real  Encydop.  der  Gemmmten  Heilkunde,  1887,  vol.  ix.  pp.  50  et  seq. 


366  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

in  his  lectures  and  also  in  a  recent  essay.  Outside  of  the  mucous  layer 
of  the  urethra  are  two  muscular  layers  which  extend  from  the  vesical 
orifice  to  the  meatus,  being  particularly  strong  and  thick  in  the  prostatic 
urethra.  The  outer  muscular  layer  consists  of  fibres  forming  distinct 
rino-s,  while  the  inner  muscular  layer  consists  of  longitudinal  fibres. 
When  the  penis  is  in  a  flaccid  condition  these  muscular  fibres  lie  rather 
near  together,  but  when  it  is  erect,  and  when  the  urethra  is  much  dis- 
tended, they  are  stretched  apart.  The  longitudinal  muscular  fibres  in  the 
torpid  condition  of  the  penis  contract  mildly  and  shorten  the  urethral 
canal,  and  throw  it  into  transverse  folds,  while  the  ringed  fibres  bring 
the  walls  into  such  a  collapsed  condition  that  the  urethra  is  converted 
into  a  long  thin  slit.  Now,  when  the  urethra  is,  in  the  dead  subject, 
injected  with  some  hardening  fluid,  and  the  canal  is  then  dissected  out, 
it  presents  the  appearance  shown  in  Fig.  116.     It  will  be  seen  that  the 

Fig.  116. 


Shows  a  normal  urethra  distended  with  solidifying  injection-material.    The  contractions  corre- 
spond to  the  circular  rings  of  muscular  fibres. 

canal  is  both  elongated  and  much  distended,  and  that  at  quite  regular 
intervals  there  are  certain  depressions  which  show  decided  contractions 
(about  eleven  in  number)  in  its  continuity.  Now,  these  constrictions  are 
caused  by  the  resistance  of  the  muscular  rings,  which  are  forced  widely 
apart  and  put  on  the  stretch.  Between  these  muscular  rings  the  dilated 
portions  consist  of  mucous  membrane  and  its  ambient  fibrous  tissue. 
Now,  when  we  apply  these  anatomical  facts  to  clinical  observation  and 
instrumental  examination,  many  points  which  have  until  now  been  obscure 
are  rendered  clear.  These  muscular  rings  will  allow  of  very  considerable 
stretching  by  the  urethrameter,  but  they  finally  off"er  resistance,  while 
the  tissues  between  them,  being  less  firm  and  more  extensible,  yield,  and 
as  the  bulb  of  the  instrument  is  drawn  out  it  is  held  by  a  muscular  band 
on  its  proximal  end,  and  this  contraction  is  then,  by  many,  pronounced 
to  be  stricture.  Consequently,  I  say  that  surgeons  imbued  with  the 
belief  that  the  normal  calibre  of  the  urethra  is  much  above  30  F.,  and 
that  the  lumen  of  the  canal  in  health  is  unvaryingly  uniform  in  calibre, 
can  find  strictures  in  the  urethra  of  any  man  if  they  will  only  turn  the 
bulb  of  the  instrument  on  strongly  enough.  Dr.  R.  W.  Stewart^  very 
truly  says,  in  speaking  of  the  dilatability  of  the  urethral  canal  and  of 
promiscuous  manipulations  and  manipulators,  "  The  urethrameter  will 
seldom  disappoint  him  in  his  search  for  strictures,  and  it  is  just  in  such 

'  "  Some  Observations  on  Stricture  of  the  Male  Urethra."  New  York  Medical  Journal, 
April  12,  1890. 


STRICTURE  OF  THE   URETHRA.  367 

hands  that  the  urethrameter  is  capable  of  so  much  mischief  that  it  is 
questionable  whether  its  invention  has  been  a  means  of  alleviating  or 
adding  to  the  misery  of  humanity." 

Unfortunately,  nearly  every  recent  graduate  in  medicine  and  young 
doctor  thinks  that  there  is  in  him  the  making  of  a  good  genito-urinary 
surgeon  or  of  an  efficient  gynecologist.  Of  the  results  of  meddlesome  and 
mischievous  gynecology  wrought  by  younger  men  I  will  not  speak,  but 
of  the  results  of  reckless  temerity  of  many  men  in  their  wholesale  on- 
slaughts on  the  urethra  in  treating  imaginary  strictures  of  large  calibre, 
I  reluctantly  say  that  to-day  very  many  patients  carry  around  with  them 
incurable,  disquieting,  and  painful  infirmities. 

I  have  in  my  private  records,  kept  with  all  the  care  and  accuracy 
possible,  the  details  of  several  scores  of  patients,  extending  over  a  period 
of  twenty  years,  who  came  to  me  with  urethral  trouble,  but  with  a  per- 
fectly healthy  condition  of  the  urethra  at  and  anterior  to  the  peno-scrotal 
junction,  who  were  said  by  some  surgeons  to  have  strictures  of  large 
calibre  in  the  anterior  part  of  the  canal.  In  many  of  these  cases  the  day 
for  operation  was  set ;  in  some  instances  the  patients  backed  out,  while  a 
few  were  steadfast  in  their  faith  and  they  went  like  lambs  to  the  slaugh- 
ter. I  here  append  the  salient  points  of  ten  cases  taken  without  selection 
as  recorded ;  they  certainly  will  tell  their  story. ^ 

^  1.  Patient  said  to  have  three  strictures  in  the  pendulous  urethra.  Diagnosis  :  pos- 
terior urethritis  with  occasional  mild  and  ephemeral  attacks  of  ha-maturia.  Examination 
of  anterior  urethra  showed  it  to  be  soft,  supple,  and  free  from  inflammation. 

2.  P.  said  to  have  one  firm  band  in  the  third  region.  Diagnosis :  inflammation  at 
bulb  and  slight  posterior  urethritis.  Examination  showed  anterior  urethra  healthy  as 
far  as  the  peno-scrotal  angle. 

3.  P.  said  to  have  six  quite  tight  strictures,  which  should  be  cut  to  36  or  38  F.  Diag- 
nosis: chronic  anterior  and  posterior  urethritis,  with  soft  hyperplasia,  epithelial  thick- 
ening, and  some  discharge.  Urethral  lesion  began  in  bulb  and  ended  just  anterior  to  the 
peno-scrotal  angle. 

4.  P.  was  said  to  have  one  quite  tight  stricture  three  inches  down,  which  needed  free 
incision  and  over-dilatation.  Diagnosis:  chronic  inflammation  of  one  or  more  follicles, 
with  some  localized  hyperplasia  and  some  discharge. 

5.  P.  said  to  have  two  bad  strictures  with  reflex  phenomena.  Diagnosis:  chronic 
posterior  urethritis,  with  pain  in  cord  and  testes.  Examination  showed  the  anterior  ure- 
thra to  be  normal. 

6.  P.  said  to  have  four  strictures  in  pendulous  urethra.  Diagnosis  :  posterior  ure- 
thritis, with  involvement  of  prostatic  follicles  and  much  discharge  (threads).  Anterior 
urethra  perfectly  healthy. 

7.  P.  said  to  have  three  anterior  strictures  which  caused  impairment  of  sexual  func- 
tion.    Diagnosis:  posterior  urethritis.     Anterior  urethra  normal. 

8.  P.  said  to  have  three  strictures  in  Region  No.  3,  and  spasm  from  reflex  action  in 
Eegion  No.  1.  Diagnosis :  urethra  perfectly  healthy  to  peno-scrotal  angle.  Examina- 
tion showed  soft  stricture  near  bulb,  which  caused  some  dysiiria. 

9.  P.  said  to  have  four  large-calibre  strictures  in  Regions  Nos.  3  and  2,  and  spasm 
deeper  down.  Diagnosis:  a  semi-fibrous  stricture  two-thirds  of  an  inch  long  to  12 
French  just  beyond  the  peno-scrotal  angle.  Urethra  perfectly  normal  until  stenosis  was 
reached. 

10.  P.  said  to  have  several  well-marked  band-strictures  in  Regions  Nos.  3  and  2,  and 
spasm  of  the  deep  urethra  with  reflex  phenomena — pain  in  testes,  thighs,  and  lumbar 
region.  Diagnosis:  diffuse  soft  stricture  of  the  bulbous  urethra  to  14  F.  Anterior  ure- 
thra absolutely  normal. 

As  an  addendum  to  the  foregoing  it  may  not  be  amiss  to  quote  the  words  of  the  late 
Dr.  Sands  on  this  subject : 

"  I  may  remark,  in  passing,  that  if  those  who  are  cutting  and  curing  organic  strictures 
by  the  hundred,  and  who  seldom  see  a  meatus  urinarius  which  they  consider  normal, 
would  pay  a  little  more  attention  to  the  study  of  pathological  anatomy,  they  would  add 
weight  to  their  testimony,  and  obtain  knowledge  which  might  induce  them  to  modify 


368  GONORBHCEA   AND  ITS  COMPLICATIONS. 

Though  the  craze  for  indiscriminate  cutting  and  over-dilating  the 
pendulous  urethra  is  on  the  wane,  it  is  yet  necessary  to  speak  in  strong 
condemnation  of  it.  The  following  synopsis  of  a  reported  case  will  cer- 
tainly teach  an  instructive  lesson  :  The  patient  was  said  to  have  three 
strictures  of  the  calibre  of  24  F.,  and  the  surgeon  felt  called  upon  to  cut 
to  32  F.,  using  Dr.  Otis's  dilating  urethrotome.  After  the  operation  the 
following  symptoms  and  conditions  presented  themselves :  Profuse  and 
alarming  hemorrhage  ;  retention  of  urine  ;  severe  chill  and  fever ;  exten- 
sive urinary  infiltration  into  the  connective  tissue  of  the  penis ;  acute 
urethritis ;  and  finally  curvature  of  the  penis.  This  series  of  calam- 
ities came  to  a  man  whose  urethra,  by  the  confession  of  the  surgeon,  was 
only  reduced  to  24  F. — a  condition  in  all  probability  curable  by  gradual, 
dilatation,  without  an}^  pain,  risk,  or  bad  sequelae.  But  still  worse  calam- 
ities have  been  reported  as  following  this  operation,  which  I  quote  liter- 
ally :  they  are  suppression  of  urine,  severe  urinary  fever,  vesical  inconti- 
nence, frequent  micturition  day  and  night  for  years,  and  in  some  cases 
death. 

There  is  one  point  which  deserves  emphasis  —  namely,  that  many 
authors  who  report  orally  or  in  journals  cases  of  large-calibre  strictures 
of  the  anterior  urethra,  as  a  rule  say  nothing  about  the  posterior  urethra. 
In  like  manner,  their  words  and  their  writings  give  but  a  faint  idea  of  the 
frequency  and  inveteracy  of  curvature  of  the  penis.  When  the  truth  is 
told,  this  is  not  the  simple  and  ephemeral  condition  which  it  is  said  to  be. 
A  few  years  ago  it  was,  I  may  say,  quite  common,  and  was  the  source  of 
great  mental  suffering  to  those  thus  afflicted.  In  some  very  rare  cases 
mild  curvature  may  disappear,  but,  as  a  rule,  when  it  begins  it  comes  to 
stay,  and  leaves  the  penis  in  a  distorted  condition,  and,  in  many  instances, 
its  bearers  are  wholly  incapable  of  intromission. 

Curvature  of  the  penis  results  from  two  causes :  first,  the  deep  incision 
through  the  urethral  wall  and  into  the  connective  tissue  under  and  between 
the  corpora  cavernosa ;  and  secondly,  from  the  great  irritation  caused  by 
synchronous  over-dilatation.  Luckily  for  the  male  portion  of  the  human 
race,  the  knife  of  the  dilating  and  cutting  instrument,  as  a  rule,  does  not 
cut  deeply  or  through  the  mucous  membrane,  and  thus,  the  incision  being 
slight,  the  patient  in  many  cases  escapes  without  curvature. 

The  great  mischief  to  the  urethral  canal  is  done  by  the  dilator  and  by 
the  introduction  of  the  verv  laro-e  sounds  Avhich  until  late  were  so  much 
in  evidence. 

Scores  of  men  have  been  permanently  injured  by  the  method  of  over- 
dilatation  of  the  urethra.  They  present  themselves,  according  to  my 
study  and  observation,  for  relief  (after  having  gone  the  rounds  in  con- 
sulting many  genito-urinary  surgeons)  for  the  following  conditions :  1, 
permanent  frequency  of  micturition  from  urethro-cystitis  ;  2.  incontinence 
in  varying  degrees ;  3,  a  sclerotic  and  deep-red  condition  of  the  urethral 
canal,  giving  forth  a  sticky,  muco-purulent  discharge  due  to  very  dense 

their  opinions.  The  frequency  with  which  urethral  strictures  is  said  to  be  met  with 
now-a-days  calls  to  mind  the  account  of  a  rectal  specialist  who  practised  in  the  western 
part  of  England  in  1844,  and  who  claimed  to  treat  so  extraordinary  a  number  of  cases  of 
stricture  of  the  rectum  as  to  cause  a  layman  to  send  a  communication  to  the  ProvincinL 
Medical  Journal,  stating  that  the  disease  was  endemic  in  the  locality  where  this  practi- 
tioner resided,  and  advising  strangers  to  avoid  the  place,  inasmuch  as  nearly  every  person 
who  went  there  became  attacked." 


STRICTURE   OF  THE   URETHRA. 


369 


(and  generally  non-absorbable)  small-cell  infiltration  around  the  "whole 
or  the  greater  part  of  the  urethra  anterior  to  the  triangular  ligament ;  4, 
loss  of  power  in  expelling  the  urine,  the  stream  being  small  and  there 
being  much  difficulty  in  starting  it ;  5,  Avell-marked  hypergesthesia  of  the 
urethral  canal,  so  that  the  slightest  and  gentlest  instrumentation  causes 
great  pain,  which  may  persist  for  hours  or  a  day  or  two.  In  these  cases 
there  is  usually  submucous  infiltration ;  6,  pain  in  the  bladder,  loins,  and 
over  pubis ;  7,  in  some  cases  impairment  in  the  sexual  function,  absence 
of  erections,  feeble  erections,  premature  ejaculations,  and  even  impotence. 

Any  surgeon  who  is  largely  consulted  for  genito-urinary  troubles  now- 
a-days  sees  only  too  many  of  these  distressing  cases,  many  of  which  can 
only  be  moderately  relieved ;  some  may  be  decid- 
edly benefited,  while  to   others  no  relief  can  be 
offered. 

The  logical  conclusions  warranted  by  the  fore- 
going statement  of  facts  (which  is  dispassionately 
made  and  without  one  particle  of  exaggeration)  is, 
first,  that  before  a  man  shall  be  pronounced  to  be 
suffering  from  stricture  its  presence  must  be  con- 
vincingly demonstrated  by  conservative  methods 
of  examination  {bougie  a  houle,  inspection  of 
urine,  digital  examination  of  the  urethral  canal, 
and  perhaps  endoscopy) ;  second,  if  stricture  is 
really  present,  it  should  be  treated  on  the  basis 
of  the  maximum  calibre  of  the  urethra,  being  30 
or  perhaps  32  F. ;  and  third,  very  deep  incisions 
with  much  distention,  followed  by  over-dilatation, 
should  never  be  practised. 

Let  us  now  consider  the  various  conditions  of 
stricture  in  the  pendulous  urethra  up  to  the  peno- 
scrotal angle,  and  the  necessary  operative  pro- 
cedures. 

Undoubtedly,  as  claimed  by  my  friend  Dr. 
Otis,  some  men  present  strictures  of  large  cal- 
ibre which  impinge  very  little  on  the  urethral 
lumen.  In  the  early  years  of  his  studies  I  had 
the  pleasure  of  seeing  with  him  a  number  of  such 
cases,  and  I  appreciated  the  necessity  for  his  in- 
ventive genius  to  devise  instruments  capable 
of  efficiently  treating  these  incipient  contractions. 
It  certainly  seems  a  pity  that  in  the  hands  of 
enthusiastic  and  even  reckless  men  these  delicate 
instruments  have  been  so  much  misused.  In  Fig. 
117  is  clearly  portrayed  a  thread-like  semi-fibrous 
stricture  which  was  seated  in  the  urethral  wall 
three  inches  down  on  its  lateral  portion,  extending 

nearly  but  not  up  to  the  median  line.  Now,  this  is  a  fair  representation 
of  strictures  of  large  calibre.  This  one  formed  only  the  segment  of  a 
circle,  and  more  extensive  ones  form  more  or  less  perfect  rings.  It  will 
be  seen  that  if  the  surgeon  had  attempted  to  incise  this  stricture  by 
means  of  the  dilating  urethrotome,   it  would   have   escaped   the   cutting 

24 


Thread-like  stricture  invelv- 
ing  only  a  portion  of 
tlic  circumference  of  the 
urethra. 


370 


GONOBBHCEA  AND  ITS  COMPLICATIONS. 


Fig. 118. 


blade,  which  follows  the  median  line  almost  exactly.  This  occurrence, 
therefore,  is  very  significant,  and  points  out  the  necessity  of  thorough 
examination  in  all  cases.  When  the  bulb  of  the  bougie  d  houle  was 
slipped  over  this  contraction,  the  sensation  was  conveyed  as  if  it  was 

held  by  a  distinct  band  or  ring.  The 
same  sensation  is  conveyed  when  only 
a  segment  of  the  urethral  ring  is  thick- 
ened from  hyperplasia ;  and  in  many 
cases,  if  the  diagnosis  is  thus  wholly 
based  on  the  finding  of  the  bougie  a 
boule,  the  conclusion  may  be  reached 
that  an  annular  stricture  is  present, 
when  really  only  a  portion  of  the 
urethral  lumen  is  thickened  and  less 
distensible  than  it  is  normally.  Con- 
sequently, it  is  necessary  to  carefully 
palpate  the  urethra  with  the  finger-tip 
over  the  shaft  of  the  bougie  in  the 
canal  in  order  to  discover  areas  of  new 
tissue,  and  in  some  cases  to  examine 
the  urethra  with  the  endoscope.  Be- 
fore making;  a  diagnosis  of  stricture  of 
large  calibre  the  surgeon  must  convince 
himself  beyond  all  doubt  that  the  con- 
traction is  there,  that  it  is  not  due  to 
localized  inflammatory  deposits  already 
described  (see  page  183),  and  that  by 
his  instrument  he  can  reach  and  in- 
cise it. 

Assuming  that  a  stricture  or  stric- 
tures in  ring  or  band  form  have  been 
found,  the  surgeon  has  at  his  com- 
mand— 1,  Civiale's  urethrotome,  which 
with  practice  becomes  a  very  eflScient 
instrument,  and  by  which  the  constric- 
tion can  be  very  accurately  cut ;  2, 
Otis's  dilating  urethrotome,  which 
when  judiciously  used  will  cut  with 
much  accuracy  and  without  damage 
to  the  urethra  beyond  the  strictured 
part ;    and  3,   Gerster's   urethrotome. 


Showing  firm  fibrous  stricture  in  middle  of    With  these  instruments  he  is  prepared 

pendulous  urethra,  dilatation  of  canal  be-      -  -  _  i       r 

hind  it,  inodular  stricture  at  bulb,  abscess 
of  prostate,  hypertrophy  of  bladder,  and 


dilatation  of  orifices  of  ureters.  (From  the 
Museum  of  the  College  of  Physicians  and 
Surgeons,  New  York.) 


for  any  case.     It  may  be  well  to  men- 
tion that  in  a  recent  interesting  essay 


Albarran  ^  has  advocated  four  mild  in- 


cisions in  cases  of  large-calibre  stric- 
ture— an  upper  and  a  lower,  and  an  incision  in  each  of  the  lateral  por- 
tions of  the  urethral  wall. 

Tight  semi-fibrous  and  fibrous  strictures  are  not  infrequently  found  in 

^  "  Les  Retrecissements  larges  de  I'Urethre,"  Aimales  des  Mai.  des  Org.  Gen.-urin.,  1893, 
pp.  721  et  seq. 


STRICTURE  OF  THE   URETHRA.  371 

the  pendulous  urethra.  In  Fig.  118  is  very  clearly  shown  a  firm  stricture 
about  three  inches  from  the  meatus.  This  figure  is  worthy  of  study,  and 
the  following  points  may  be  noted :  The  urethra  behind  the  stricture  is 
dilated  and  its  wall  thinned ;  at  the  bulb  are  several  bands  and  much 
sclerosis  of  the  mucous  membrane ;  at  the  prostate  there  is  an  abscess, 
and  the  bladder-walls  are  much  thickened.  It  is  not  uncommon  to  find  a 
single  anterior  stricture  like  the  one  here  pictured,  but  I  think  it  is  more 
common  to  find  the  pendulous  urethra  the  seat  of  extensive  (as  to  length) 
coarctation,  in  which  there  may  be  several,  even  many,  bands.  In  these 
cases  the  urethral  canal  anterior  to  the  peno-scrotal  angle  is  densely  infil- 
trated, and  these  bands  are  simply  the  more  prominent  evidences  of  the 
morbid  process. 

In  the  treatment  of  these  strictures  in  the  anterior  urethra  much  judg- 
ment and  skill  must  be  exercised.  It  is  always  well  not  to  do  too  much 
in  these  cases.  When  the  stricture-tissue  is  quite  firm,  we  never  can  re- 
store the  urethra  to  its  normal  condition.  Our  function  in  these  cases  is 
to  tunnel  a  moderately  large  passage,  and  then  to  try  to  keep  it  open. 
For  these  cases  there  is  no  more  useful  instrument  at  hand  than  Fluhrer's 
modification  of  Maisonneuve's  urethrotome,  using  the  blade  Avhich  will 
cut  a  passage  for  a  22  sound  or  bougie.  When  this  operation  is  per- 
formed the  treatment  may  be  said  to  have  just  begun.  Thereafter  the 
sound  must  be  regularly  introduced  about  once  a  week  or  less  frequently. 
If  in  these  cases  the  patient  is  left  with  a  canal  which  will  admit  a  20  or 
23  F.  sound,  and  his  bladder  is  healthy,  the  result  may  be  pronounced 
very  satisfactory.  Some  surgeons  recommend  over-dilatation,  sometimes 
applied  with  much  force,  in  these  cases,  but,  as  a  rule,  such  measures 
only  stimulate  the  process  of  recontraction,  and  they  should  not  be  used. 
With  the  dilatation  treatment  subsequent  to  incision  medication  may  be, 
if  necessary,  applied  to  the  posterior  urethra  and  bladder,  and  indeed  to 
any  complication  which  may  exist. 

In  these  cases  the  bulbous  urethra  may  also  be  involved,  and  it  will 
require  suitable  treatment. 

Treatment  of  Strictures  beyond  the  Peno-scrotal  Angle. — By  far  the 
greater  number  of  strictures  will  be  found  just  beyond  the  peno-scrotal 
angle,  as  far  back  as  the  bulbo-membranous  junction.  In  treating  this 
deeply-seated  region  it  is  a  golden  rule  only  to  use  the  knife  as  a  last 
resort. 

In  the  chapter  on  Chronic  Urethritis  directions  are  given  (see  pp.  172 
et  seq.)  for  the  treatment  of  the  lesions  of  the  anterior  urethra,  which 
need  not  be  repeated. 

Strictures  of  the  bulbous  portion  of  the  urethra  may  be  soft,  semi- 
fibrous,  fibrous,  and  inodular,  all  of  which  require  appropriate  treatment. 

Soft  and  semi-fibrous  strictures  should,  as  a  rule,  never  be  incised  until 
milder  means  have  been  tried  and  have  failed. 

The  diagnosis  having  been  carefully  made,  the  calibre  of  the  stricture 
is  to  be  determined.  Now,  on  this  point  no  rule  can  be  laid  down,  since 
cases  diff'er  so  strikingly.  Thus  in  some  patients  the  canal  may  be  re- 
duced to  20  or  15  F.,  and  yet  these  strictures  are  of  the  soft  variety.  In 
others,  with  similar  calibres,  they  may  be  semi-fibrous  or  fibrous.  Then, 
again,  it  is  not  very  uncommon  to  find  a  urethra  reduced  even  to  6  or  8 
F.  by  an  exudative  hyperplasia  which  we  call  soft  stricture.      These 


372  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

various  and  varying  conditions  have  to  be  ascertained,  and  as  the  surgeon 
grows  in  experience  he  will  become  more  and  more  expert  in  recognizing 
them. 

G-radual  Dilatation. — When  the  stricture  in  the  bulbous  urethra  is 
yet  in  the  soft,  or  even  in  the  semi-fibrous,  stage,  the  aim  should  be  to 
remove  as  far  as  possible  the  cell-infiltration,  and  to  thus,  in  a  manner, 
restore  the  mucous  membrane  to  its  natural  condition.  This  can  be  done 
in  many  cases  by  careful  and  gradual  dilatation. 

Seeino-  that  a  soft  stricture  may  contract  the  urethral  lumen  even  as 
low  as  7  or  8  F.,  and  that  in  many  cases  where  the  calibre  is  15  or  20 
F.  the  infiltration  is  yet  soft  and  succulent,  it  is  always  well  to  make  the 
attempt  to  cure  by  the  introduction  of  the  bougie  or  sound  before  the 
knife  is  resorted  to.  When,  however,  a  fibrous  or  inodular  stricture  of 
small  calibre  is  discovered,  our  chief  thought  is  not  toward  gradual  dila- 
tation. 

I  have  in  so  many  instances  been  able  to  restore  the  urethra,  even 
when  contracted  to  7  or  8,  to  30  F.  that  I  am  always  loth  to  operate 
more  radically. 

In  the  process  of  gradual  dilatation  much  care,  patience,  and  good 
judgment  are  necessary.  The  operation  should  always  be  carefully  and 
slowly  performed  in  a  manner  to  cause  no  pain  or  uneasiness  and  no 
damage  to  the  tissues.  By  the  pressure  and  stimulation  of  the  distending 
instrument  we  hope  to  cause  the  absorption  of  the  exudation  and  to  give 
tone  and  resiliency  to  the  dilated  vessels.  It  will  thus  be  seen  that  we 
are  always  liable  to  cause  inflammation,  and  this  condition  will  either 
delay  the  cure  or  perhaps  thwart  our  efforts.  In  cases  where  the  con- 
traction is  as  great  as  7  or  8  F.,  and  also  Avhere  the  calibre  of  the  stricture 
is  much  larger,  there  may  be  posterior  urethritis  or  even  urethro-cystitis, 
and  these  conditions  should  then  receive  proper  treatment. 

Beginning  with  a  small  olivary  bougie,  the  surgeon  should  gradually 
and  slowly  increase  the  size  of  the  instrument  as  the  progress  of  the  case 
will  indicate  to  him.  In  the  early  part  of  the  treatment  the  bougie  may 
be  introduced  once  a  week,  and  then  in  favorable  conditions  the  interval 
may  be  fixed  at  about  five  days.  It  is  almost  always  well  to  allow  this 
interval  of  time  to  elapse  between  the  seances  of  treatment.  Many  men 
have  failed  in  this  method  of  treating  stricture  by  the  too  frequent  in- 
troduction of  the  instrument,  and  many  patients  have  not  received  the 
benefit  they  would  have  if  there  had  been  less  haste.  In  gradual  dilata- 
tion, particularly  in  the  early  stages,  the  sensations  of  the  patient  should 
be  carefully  considered,  and  the  urine  regularly  and  methodically  exam- 
ined. If  the  operation  causes  uneasiness  and  pain  in  the  perineum  and 
over  the  pubes  and  continued  frequency  in  urination,  and  if  the  parts 
resist  the  gradual  increase  in  the  size  of  the  instrument,  it  will  be  necessary 
to  suspend  the  treatment  temporarily,  and  perhaps  permanently.  In  many 
of  these  cases  local  medication  to  the  anterior  and  posterior  urethra  Avill 
put  the  parts  in  such  a  condition  that  gradual  dilatation  may  again  be 
resumed. 

It  will  be  generally  found,  when  dilatation  is  commenced,  in  the  form 
of  stricture  under  consideration,  with  very  small  olivary  bougies,  that  at 
first  the  sizes  may  be  increased  quite  regularly,  and  no  trouble,  or  per- 
haps very  little,  is  experienced  by  the  surgeon  until  he  gets  up  as  high 


STRICTURE   OF  THE    URETHRA.  373 

as  20  or  22  F.  Then  he  Avill  generally  find  that  the  dilating  process 
will  go  on  much  more  slowly,  and  that  it  may  be  necessary  to  introduce 
sounds  of  one  size  several  times  before  larger  ones  can  be  used. 

The  prompt  and  usually  perceptible  effect  of  the  early  small  bougies 
has  much  bearing  on  the  future  of  the  case.  Patients  watch  the  progress 
made  step  by  step,  and  as  they  see  that  they  are  gaining  in  urethral 
calibre,  and  that  they  have  lost  their  unpleasant  symptoms  (urethral  or 
vesical),  they  become  sanguine  of  an  eventual  cure,  and  present  them- 
selves regularly  for  treatment.  It  is  most  essential  in  these  cases  that 
the  patient  should  have  implicit  confidence  in  the  surgeon,  and  that  he 
should  keep  his  moral  courage  up  in  the  ordeal  through  which  he  is  going. 
Though  these  patients  are  neither  hurt  nor  inconvenienced,  the  irksome- 
ness  of  having  at  stated  intervals  to  go  to  the  surgeon  is  very  trying  to  some. 
Others,  and,  indeed  the  majority,  appreciating  the  infirmities  and  suffer- 
ings which  strictures  almost  inevitably  lead  to,  resolve  to  keep  on  till 
they  are  cured.  The  main,  and  indeed  the  only,  valid  objections  to 
gradual  dilatation  are  that  it  is  a  slow  process  and  occupies  a  quite  long 
stretch  of  time.  But  it  must  always  be  remembered  that  if  it  is  followed 
up  until  the  urethra  is  restored  to  a  calibre  of  30  F.,  in  the  majority  of 
cases  it  will  only  be  necessary  to  have  sounds  introduced  once  or  twice  a 
year  thereafter ;  whereas  it  can  be  said,  without  fear  of  contradiction,  that 
when  a  man's  urethra  has  once  been  cut  he  has  (if  he  would  keep  the 
channel  open)  to  pass  instruments  at  short  intervals  all  his  life.  All 
these  considerations  should  be  presented  by  the  surgeon  to  his  patient  as 
the  treatment  goes  on.  Men  often  get  careless  and  even  indifferent  at 
the  time  when  they  may  be  said  to  be  about  half  cured.  In  these  circum- 
stances the  surgeon  should  use  all  his  influence  against  faltering  and  back- 
sliding. 

When  in  the  course  of  this  treatment  the  urethra  will  admit  an  olivary 
bouo;ie  No.  20  F.,  it  is  well  to  resort  to  the  curved  steel  sounds  and  with 
them  finish  the  cure.  In  many  cases  when  the  coarctation  is  extensive 
and  involves  the  whole  length  of  the  bulbous  urethra,  the  Benequ^  sound 
will  produce  particularly  good  results.  Its  double  curve  seems  to  exert 
a  beneficial  pressure  not  obtainable  by  the  use  of  the  ordinary  curved 
sound. 

The  trend  of  thought  as  regards  the  treatment  of  urethral  stricture  of 
late  years  has  been  so  unswervingly  toward  cutting  operations  that  many 
surgeons  are  wholly  unaware  of  the  beneficent  and  lasting  effects  of  grad- 
ual dilatation.  I  have  many  times  been  pleasantly  chaffed  and  even 
mildly  derided  about  my  conservative  views  as  to  the  treatment  of  the 
male  urethra  when  the  seat  of  contractions  ;  but  after  a  not  inconsiderable 
experience,  stretching  over  a  period  of  twenty-seven  years,  I  am  to-day 
more  than  ever  convinced  that  cutting  operations  should  be  a  last  resort, 
and  that  intemperate  incisions  and  over-stretching  are  very  frequently 
the  cause  of  never-ending  suffering  and  inconveniences. 

It  is  impossible  to  exactly  state  the  period  of  time  necessary  for  grad- 
ual dilatation,  since  it  varies  in  each  case  and  much  depends  on  the  reg- 
ularity and  sedulousness  of  the  patient.  In  some  cases  the  normal  urethral 
lumen  may  be  restored  in  three  months,  and  in  others  in  six,  nine,  and 
twelve  months.  As  a  general  rule,  a  six-months'  treatment  will  be  fol- 
lowed with  better  results  than  a  shorter  course. 


374  GONORBHCEA  AND  ITS  COMPLICATIONS. 

Perhaps  the  details  of  a  few  instances  of  the  beneficial  results  of  grad- 
ual dilatation  may  be  of  interest.  I  have  the  records  of  the  case  of  a  man 
thirty-six  years  old  who  had  gonorrhoea  when  twenty-six.  His  urethra 
had  a  calibre  of  30  F.,  but  just  beyond  the  peno-scrotal  angle  it  was 
reduced  by  a  semi-fibrous  coarctation  to  7  F.  Gradual  dilatation  was 
carried  on  with  some  irregularities  and  halts  for  fifteen  months,  at  which 
time  a  No.  30  F.  sound  was  readily  passed  into  the  bladder.  This  man 
returned  after  an  absence  of  ten  years,  during  which  time  he  had  had  no 
urethral  or  bladder  trouble,  and  had  undergone  no  instrumentation,  and 
the  same  sound  was  easily  passed  again.  Now,  I  do  not  regard  this  as 
an  exceptionally  brilliant  result,  striking  as  it  may  seem,  since  I  have 
seen  very  many  such.  During  the  course  of  a  year  I  see  fully  twoscore 
of  patients  whose  strictured  urethrge  were  years  ago  brought  up  to  a  cal- 
ibre of  30  F.,  or  perhaps  32  in  some  cases,  by  gradual  dilatation  at  my 
hands.  Now,  these  men  never  suffered  any  pain  or  uneasiness  in  the 
treatment,  their  bladder  function  became  perfect,  and  they  thereafter  uri- 
nated normally.  They  come  back  now  once  or  twice  a  year,  pass  a  full 
stream  of  healthy  urine,  say  that  they  feel  perfectly  well,  and  go  away 
happy  after  the  introduction  of  a  30  or  32  F.  sound.  When  such  good 
results  can  be  attained  without  cutting,  without  putting  a  man's  life  in 
jeopard)^,  and  without  pain  or  suffering,  I  say  that  we  should,  if  possible, 
avail  ourselves  of  the  means  which  will  in  all  probability  produce  them, 
even  though  the  treatment  be  rather  protracted. 

There  is  one  point  Avhich  deserves  especial  emphasis,  and  it  is  this : 
To  produce  lasting  and  permanent  results  by  gradual  dilatation  the  ure- 
thral canal  must  be  brought  up  to  the  calibre  of  30  or  perhaps  32  F.,  and 
when  this  is  attained  the  dilating  process  must  be  continued  for  some  time, 
until  these  large  sounds  pass  easily  and  without  any  grasping. 

Continuous  dilatation  is  very  rarely  resorted  to  at  the  present  time. 
In  some  cases  where  a  filiform  has  after  a  long  struggle  been  passed 
through  the  stricture,  it  may  be  retained  there  for  some  hours  or  perhaps 
for  a  day,  in  order  to  render  certain  the  passage  of  a  larger  instrument. 

In  the  majority  of  cases  the  process  of  cure  by  gradual  dilatation  is 
uneventful,  but  in  a  small  minority  certain  complications  may  arise  and 
give  more  or  less  trouble.  These  complications  are — 1,  fever  and  chills; 
2,  urethritis  and  urethro-cystitis ;  3,  a  tendency  to  hemorrhage ;  4,  tem- 
porary retention;  5,  rheumatism;  and  6,  pygemic  abscesses.  It  is  well  to 
state  in  advance  that  since  the  beginning  of  the  era  of  asepsis  and  anti- 
sepsis in  surgery  these  complications  occur  much  less  frequently  than  for- 
merly and  they  are  much  less  severe. 

The  occurrence  of  chills  and  fever  shows  that  there  is  a  low  grade  of 
suppuration  in  the  deep  urethra,  but  it  need  not  cause  the  permanent  dis- 
continuance of  dilatation.  Such  cases  should  be  treated  on  the  lines  laid 
down  for  chronic  anterior  and  posterior  urethritis  and  urethro-cystitis. 
(See  pages  172  et  seq.  and  184  et  seq.) 

When  the  sound  causes  inflammatory  reaction,  its  use  should  be  dis- 
continued until  appropriate  treatment  removes  the  tendency  thereto,  as  it 
will  in  most  cases.  Exceptionally,  however,  it  happens  that  the  resulting 
inflammation  is  so  great  and  so  constant  that  it  is  necessary  to  wholly 
abandon  this  form  of  treatment.  In  many  such  cases  judicious  topical 
urethral  medication  after  a  time  brings  about  such  a  change  that  the 


STRICTURE  OF  THE   URETHRA.  375 

sound  may  be  used  again.  In  some  severe  and  exceptional  cases  the 
expediency  of  external  urethrotomy  will  suggest  itself  to  the  mind  of  the 
surgeon. 

In  like  manner,  the  tendency  to  slight  oozing  of  blood  after  dilatation 
can  generally  be  checked  by  the  instillation  of  a  few  drops  of  a  solution 
of  nitrate  of  silver  (1  :  250). 

When  in  the  course  of  gradual  dilatation  retention  of  urine  occurs  once 
or  at  intervals,  it  is  perfectly  certain  that  one  or  two  causes  are  at  work  ; 
these  are  swelling  of  the  mucous  membrane  in  and  near  the  stricture  and 
temporary  spasm  of  the  compressor  urethrse  muscle.  In  such  cases  there 
is  need  of  topical  urethral  medication,  and  the  intervals  between  the  pas- 
sage of  the  bougies  or  sounds  should  be  materially  lengthened.  When 
carefully  managed  this  complication  can  be  overcome. 

The  occurrence  of  rheumatism  and  of  pysemic  abscesses  indicates  very 
clearly  that,  besides  the  stricture-process,  a  decided  suppuration  of  the 
urethra  also  exists,  which  can  be  cured  by  the  means  described  in  the 
section  on  the  treatment  of  chronic  anterior  and  posterior  urethritis. 

It  will  be  seen,  therefore,  as  I  have  already  pointed  out,  that  in  the 
successful  employment  of  gradual  dilatation  the  surgeon  must  be  thor- 
oughly conversant  Avith  all  forms  of  urethral  inflammation. 

Strictures  at  and  just  beyond  the  peno-scrotal  angle  are  frequently 
formed  of  the  dense  fibrous  variety.  In  cases  presenting  this  form  of 
stricture  gradual  dilatation  alone  is  usually  an  unsatisfactory  treatment. 
In  some  cases  in  which  the  tissue  is  not  very  dense  and  is  of  decidedly 
ringed  form  careful  stretching  by  means  of  Gouley's  divulsor  may  be  of 
decided  benefit,  and  Bigelow's  instrument  may  be  guardedly  used. 
These  strictures  sometimes  become  tolerably  well  dilated,  and  then  they 
recontract  more  or  less  promptly  ;  hence  they  are  called  "  resilient  stric- 
tures." It  is  in  these  cases  only  that  mild  over-dilatation  cautiously 
practised  is  admissible,  if  at  all.  By  gentle  local  dilatation  with  a  di- 
vulsor the  surgeon  may  do  away  with  the  tendency  to  recontract,  and 
then  he  can  go  on  with  the  regular  course  of  dilatation  by  steel  sounds. 
He  should  never  carry  the  procedure  much  if  any  beyond  32  F, 

Internal  urethrotomy  in  the  deep  urethra  may  be  performed  with 
certain  restrictions  in  a  limited  number  of  cases.  This  procedure  may 
be  resorted  to  in  cases  of  tight  fibrous  stricture  just  at  and  about  one 
inch  beyond  the  peno-scrotal  junction,  and  perhaps  at  the  bulbo- 
membranous  junction  if  the  stricture  is  not  a  very  large,  dense, 
and   inodular   one. 

Fig.  119  will  give  a  very  clear  idea  of  a  severe  case  of  tight 
stricture  just  beyond  the  peno-scrotal  angle,  with  involvement  of  the 
greater  portion  of  the  pendulous  urethra.  It  will  be  evident  that 
in  such  a  case  dilatation  by  sounds  would  be  painful  and  futile,  and 
that  the  only  procedure  advisable  would  be  to  tunnel  a  channel  by 
means  of  a  cutting  instrument.  The  oval  black  spot  just  behind  the 
stricture  shows  the  distal  end  of  a  false  passage. 

In  former  years  internal  urethrotomy  by  means  of  Maisonneuve's 
instrument  was  largely  performed  in  cases  of  stricture  in  Region  No.  1. 
My  experience  has  taught  me  to  limit  its  use  to  the  fibrous  strictures  in 
the  segment  of  the  urethra  just  named.  The  patient,  being  healthy, 
having  normal  kidneys  and  not  much  if  any  bladder  trouble,  should  be 


376 


OONOEEHCEA   AND  ITS  COMPLICATIONS, 


Fig.  119. 


put  on  moderate  diet  for  a  day  or  two  and  kept  in  bed,  during  Avhich 
time  the  urethra,  and  if  possible  the  bladder,  should  be  Avell  washed  out 
several  times  with  quite  hot  saturated  solution  of  boric  acid  or  Thiersch's 

weak  solution.  The  night  before  the 
operation  he  should  have  a  brisk  ca- 
thartic. When  antisepsis  can  be  prac- 
tised there  is  no  need  for  the  internal 
use  of  boric  acid,  salol,  or  quinine ; 
still,  there  are  no  objections  to  the 
employment  of  these  drugs  if  the 
surgeon  so  wishes.  If  the  patient 
is  a  weakly  man,  he  should  be  pre- 
pared for  some  time  ahead,  by  care 
as  to  diet  and  tonics,  for  the  coming 
operation. 

Ether  narcosis  having  been  pro- 
duced, the  genital  parts  should  be 
shaved  and  rendered  aseptic  (soap 
and  water,  alcohol  and  ether,  and 
bichloride  solution).  Then  the  fili- 
form guide  of  the  Maissonneuve 
instrument  should  be  passed  accord- 
ing to  directions  already  given,  and 
followed  by  the  grooved  conductor 
and  the  knife.  Before  every  inter- 
nal urethrotomy,  just  at  the  time  of 
use,  the  surgeon  should  pass  the  cut- 
ting part  of  the  instrument  down  the 
grooved  conductor,  in  order  to  be 
absolutely  certain  that  there  will  be 
no  impediment.  If  the  soft  French 
filiform  should  kink  or  curl  up  and 
come  back,  the  surgeon  should  screw 
on  the  eyed  or  tunnelled  tip.  Then, 
having  passed  a  long  whalebone  fili- 
form, he  should  slip  the  eye  of  the 
conductor  over  this  guide,  and  then 
cause  the  instrument  to  glide  slowly 
into  the  bladder.  Always  before  ad- 
justing the  cutting  blade  of  the  in- 
strument the  surgeon  should  put  his 
finger  in  the  rectum,  when,  if  every- 

Showing  dense  fibrous  stricture  of  the  ure-  fViiyif,  i<5  nil   rio-bt    bp  -will   fppl   tbp  oor\. 
thra  just  beyond  the  peno-scrotal  angle,  ^J^ng  IS  aii  Ugni,  ne  Win  leei  ine  COn- 

with  dilatation  of  the  bulbous  membran-  ducting  staff  in  the  membranous  ure- 

ous,  and  prostatic  urethra.    Ihe  pendu-     ,  ^   -      ,  ^       c     ^        • 

lous  urethra  is  aiso  much  thickened  and  thra,  and  the  end  01  the  instrument 

infiltrated.    AVallsof  bladder  much  hvper-  ,i  i_       p        i  j   ■       ^t. 

trophied,  orifices  of  ureters  dilated.  (From  Can  then   be  trecly  moved  in  the  ves- 
LndSurleo'Ss^xiw  Yorkf  °^^*'^'''"^^^  cavity.     When   the   urethrotomy 

is  performed  the  instrument  should 
be  held  in  the  line  of  the  thighs,  the  patient  lying  on  his  back  at  full 
length.  It  is  never  well  to  use  a  large  cutting  blade.  Too  deep  incisions 
may  be  followed  by  hemorrhage  and  perhaps  urinary  infiltration  and  fever. 


STRICTURE  OF  THE   URETHRA.  377 

Mj  custom  for  years  has  been  to  cut  the  urethra  to  the  extent  of  21  F., 
and  on  the  withdrawal  of  the  urethrotome  to  pass  an  olivary  bougie, 
No.  21  F.,  with  a  very  small  opening  on  its  extreme  end,  into  the  blad- 
der, and  to  allow  any  contained  urine  to  run  out,  and  then,  by  means 
of  Ultzmann's  hand  syringe  or  the  soft-rubber  bag.  to  inject  five  to  eight 
ounces  of  warm  boric-acid  solution  or  Thiersch's  solution,  and  there  leave 
it.  This  antiseptic  solution,  when  voided  later  on,  thoroughly  bathes 
the  wound  and  is  productive  of  much  good. 

The  bougie-catheter^  may  be  introduced  again  in  about  four  days, 
and  then  the  bladder  should  be  injected  again.  With  the  urethra  thus 
enlarged  gradual  dilatation  may  soon  be  commenced,  and  should  be 
carried  on  until  a  calibre  of  30  F.  is  produced.  After  that  it  is  well  to 
introduce  the  sound  at  intervals  of  a  week,  a  fortnight,  or  a  month,  and 
perhaps  several  months,  as  the  progress  of  the  case  indicates. 

Internal  urethrotomy  thus  performed  in  appropriate  cases  will  not  be 
attended  with  suffering  or  disaster  to  the  patient,  and  will,  if  properly 
followed  up,  be  productive  of  great  benefit. 

Until  twenty  years  ago  the  operation  just  described  was  quite  gen- 
erally practised  in  America  for  all  deep-seated  strictures.  But  grad- 
ually the  bad  form  of  inodular  stricture  came  to  be  treated  by  ex- 
ternal urethrotomy,  and  to-day  this  is  the  operation  of  choice  of  most 
surgeons. 

Since  there  is  much  confusion  as  to  the  title  and  scope  of  the  various 
operations  in  the  perineum  for  stricture  and  other  conditions,  it  is  well 
to  try  to  present  a  sharply-marked  division  of  them.  These  operations 
may  be  divided  as  follow^s :  1,  external  urethrotomy  with  a  staff  for 
bladder  drainage,  etc. ;  2,  external  urethrotomy  with  filiform  guide 
through  the  stricture,  down  to  the  face  of  which  a  tunnelled  instrument 
has  been  passed  (this  is  the  Gouley  operation) ;  3,  external  urethrotomy 
with  the  staff  passed  down  to  the  stricture  without  a  guide  through  it 
(this  is  the  Wheelhouse  operation) ;  4,  external  urethrotomy  without 
any  instrument  in  the  urethra,  the  membranous  portion  being  incised 
(this  is  generally  known  as  Cock's  operation  or  perineal  section). 

External  Urethrotomy  for  Drainage,  etc. — This  operation  is,  as  a  rule, 


Fig.  120, 


G.TIEM  f\NN-CO 

Grooved  steel  staff. 


very  simple  in  its  performance,  since  there  is  usually  no  impediment  to 
the  passage  of  the  staff.  The  patient  having  been  prepared  and  ether- 
ized, the  perineum  is  shaved  and  the  genito-anal  region  rendered  surgi- 
cally aseptic,  the  patient  being  in  the  lithotomy  position,  the  ordinary 
'  Made  for  me  by  J.  Ellwood  Lee  Co.,  Conshohocken,  Pa. 


378  GOXOERHCEA  AND  ITS  COMPLICATIONS. 

staff  for  median  lithotomy  is  passed  into  the  bladder.  The  scrotum  is 
held  up  by  an  assistant,  who  also  holds  the  staff  and  causes  its  orooved 
convexity  to  bulge  out  the  perineal  tissues.  The  surgeon  then  with  a 
scalpel  carefully  incises,  to  the  extent  of  two  inches,  layer  after  layer 
until  the  urethra  is  reached  and  opened  longitudinally  about  three-fifths 
of  an  inch  or  an  inch.  Then  the  bladder  may  be  Avashed  out,  and  the 
large  catheter  or  perineal  tube  inserted  and  retained.  This  operation  is 
also  performed  for  the  removal  of  calculi  lodged  in  the  membranous  or 
prostatic  urethra  and  of  prostatic  concretions,  and  for  the  digital  explo- 
ration of  these  parts,  the  vesical  orifice,  and  adjacent  tissue.  By  the 
older  surgeons  this  operation  was  called  the  "  boutonniere." 

Gouley's  tunnelled  sound  or  catheter,  or  in  an  emergency  an  ordi- 
nary steel  sound,  may  be  used  as  the  guide. 

Gouley's  and  AVheelhouse's  operations  are  generally  performed  for 
the  relief  of  inodular  strictures  near  and  at  the  bulbo-membranous  junc- 
tion, and  less  frequently  for  fibrous  strictures  the  result  of  traumatism, 
or  soon  or  immediately  after  the  damaging  or  rupture  of  the  urethra 
from  accidents  Avhich  lacerate  or  cut  through  the  bulbous  or  membranous 
portions  of  the  urethra. 

G-ouleys  Operation. — The  operating  table  must  be  in  front  of  a  win- 
dow admitting  plenty  of  light,  and  the  surgeon  should  allow  himself 
fully  two  hours  of  sunshine,  since  the  operation  may  be  much  pro- 
tracted. The  patient  having  been  prepared  and  etherized  and  the 
genitals  shaved,  the  parts  are  well  scrubbed  with  soap,  water,  and 
brush,  and  then  flushed.  Then  they  are  well  rinsed  with  alcohol  and 
ether,  followed  by  a  copious  flow  of  bichloride  solution  (1  :  1000). 

The  patient  should  lie  flat  on  his  back  (so  that  the  perineal  raphd  is 
perfectly  vertical),  and  held  in  the  lithotomy  position  either  with  anklets 

and  Avristlets,  the  crutch,  or  with  cotton  bandages.  Before  commencing: 
1*1 

the  operation  the  surgeon,  seated  on  a  low  stool,  examines  with  his  fin- 
ger in  the  rectum  the  membranous  urethra  and  the  prostate,  and  famil- 
iarizes himself  with  their  condition. 

Fig.  121. 


f\^ 


.^^-___, — — ■ 

G.TIEMANN  S.-CO. 

Tunnelled  catheter  staff,  showing  the  conductor  in  the  terminal  canal  and  the  stylet  a  little 

withdrawn. 

Fig.  122. 


Tunnelled  catheter  staff  with  eye  on  the  concave  side. 

The  long  filiform  having  passed  through  the  stricture  into  the  bladder, 
the  tunnelled  catheter  staff  (see  Figs.  121  and  122)  is  carefully  slipped  over 


STRICTURE  OF  THE   URETHRA.  379 

it,  and  by  it  guided  down  to  the  face  of  the  stricture.  An  assistant  now 
carefully  and  firmly  holds  the  end  of  the  staff  between  the  thumb  and 
the  fore  finger  exactly  in  the  median  line  and  a  few  inches  above  the 
pubes  and  hypogastrium,  while  at  the  same  time  he  elevates  the  scrotum 
and  preserves  the  vertical  direction  of  the  perineal  raph^.  If  the  ure- 
thra is  not  too  deep,  and  if  the  perineum  is  not  too  much  thickened 
with  inflammatory  exudation,  the  assistant  may  by  gentle  upward  pres- 
sure on  the  staff",  by  means  of  his  middle  finger  underneath  it,  make  the 
tissues  tense,  and  by  this  means  clearer  indications  are  given  to  the 
surgeon  as  to  the  precise  position  of  the  staff"  and  the  urethra.  The 
surgeon  then  makes  an  incision  leisurely  dividing  layer  after  layer  of 
the  tissues  in  the  median  line  from  the  base  of  the  scrotum  to  within  an 
inch  of  the  anus,  being  about  two  or  three  inches  in  length  and  involv- 
ing only  the  skin  and  superficial  fascia.  The  dissection  having  been 
carefully  carried  down  to  the  urethra,  the  surgeon  feels  for  the  groove 
in  the  curved  portion  of  the  staff"  with  his  finger-nail.  He  then  enters 
the  urethra,  his  knife  being  held  at  right  angles,  and  cuts  slowly  and 
carefully  downward  about  an  inch,  meanwhile  taking  care  that  the  fili- 
form guide  is  not  cut.  It  is  very  important  to  make  a  good  clean  cut 
into  the  urethra  by  a  continuous  stroke,  the  knife  not  being  withdrawn 
until  the  full  incision  is  made,  otherwise  the  canal  may  be  cut  in  several 
places.  Hemorrhage  is  usually  moderate,  and  is  readily  controlled  by 
clamps.  When  the  urethra  is  opened  a  ligature  two  feet  long  is  passed 
through  each  cut  edge,  and  then  tied  at  the  end.  Thus  we  have  two 
retractors,  which  are  held  with  gentle  tension  by  two  assistants,  which 
take  up  no  space  in  the  wound  and  Avhich  allow  full  inspection  of  the 
field  of  operation.  At  this  time  the  staff"  is  withdrawn  a  little,  so  as  to 
bring  into  view  the  black  guide,  alongside  of  which  the  small  grooved 
probe,  which  should  be  gently  curved  upward  toward  its  tip  in  accordance 
with  the  terminal  half  of  the  subpubic  curve,  should  be  passed  into  the 
bladder.     Then  in  this  groove  Gouley's  beaked  bistoury  is  passed,  and 

Fig.  12.3. 


Amott's  small  grooved  silver  probe  with  a  broad  handle,  which  can  be  bent  to  any  angle. 

the  stricture  is  incised  on  its  upper  Avail,  care  being  taken  to  go  well 
through  the  dense  stricture-tissue,  but  not  into  the  connective  tissue 

Fig.  124. 


Gouley's  beaked  bistoury. 

beyond.  The  probe  is  now  turned  so  that  its  groove  looks  downward, 
along  which  the  beaked  bistoury  is  again  passed,  and  the  lower  Avail  of 
the  stricture  is  carefully  incised  (usually  a  little  less  deeply  than  the 
upper  Avail). 


380 


QONORBHCEA  AND  ITS  COMPLICATIONS. 


It  is  always  well  to  take  care,  when  the  urethra  is  opened  and  the 
parts  exposed,  not  to  let  the  guide  slip  out  or  to  withdraw  it  until  the 
grooved  probe  is  well  in  the  bladder  and  the  incision  of  the  upper  wall 
of  the  stricture  has  been  made.  Then  the  surgeon  is  master  of  the  situ- 
ation, and  the  guide  may  be  withdrawn.  In  some  cases  the  stricture- 
tissues  are  so  densely  fibrous  and  extensive  that  after  a  preliminary 
slight  cut  with  the  beaked  bistoury  the  operation  may  be  completed 
more  satisfactorily  by  means  of  a  blunt-pointed  straight  bistoury. 

When  the  stricture-tissue  has  been  incised  Teale's  probe  gorget  is  an 

Fig.  125. 


Teale's  probe  gorget. 

exceedingly  useful  instrument,  particularly  to  persons  not  very  familiar 
with  the  operation.  By  its  passage  the  parts  may  be  much  dilated,  and 
by  this  means  much  aid  is  given  the  timorous  surgeon  who  fears  to  cut 
too  deeply.  By  means  of  the  probe  gorget  the  catheter  or  perineal  tube 
is  then  passed  into  the  bladder,  which  should  be  well  washed  out  with 
hot  boric-acid  water. 

The  catheter  or  perineal  tube  used  in  this  operation  should  be  quite 
large,  and  should  be  adapted  to  the  calibre  of  the  incised  canal.  As  a 
rule,  tubes  from  30  to  35  F.  should  be  introduced.     The  aim  of  the 

Fig.  126. 


Perineal  tube. 

surgeon  now  is  to  allow  the  urethral  tissues  and  the  ambient  tissues, 
which  have  previously  been  much  congested,  to  drain,  and  also  to  so  act 
upon  the  urethra  by  as  much  dilatation  as  possible  that  absorption  may 
be  produced  and  a  canal  with  a  satisfactory  lumen  shall  be  left.  To 
this  end  I  always,  if  possible,  allow  the  tube  to  remain  in  the  wound  at 
least  fourteen  days,  taking  care  that  the  bladder  is  well  washed  out 
several  times  daily,  and  applying  such  topical  treatment  as  may  be 
necessary.  I  think  that  the  early  closure  of  the  perineal  wound  robs 
the  patient  of  much  of  the  benefit  he  should  derive  from  the  operation. 
The  catheter  is  retained  in  the  wound  by  passing  through  it  at  right 
angles  a  large  safety-pin.  The  patient  having  a  T-bandage  around  the 
waist,  from  it  two  long  pieces  of  gauze  pass  down,  one  on  each  side  of 
the  scrotum,  and  then  they  are  fixed,  one  on  each  end  of  the  safety-pin. 
By  this  method  of  adjustment  the  catheter  can  be  readily  removed  and 
cleaned  at  any  time ;  Avhich  is  a  great  desideratum,  whereas  if  it  is  held 
by  a  ligature  which  passes  through  the  edges  of  the  wound,  removal  is 


STRICTURE  OF  THE    URETHRA. 


381 


difficult  and  painful.  The  wound  around  the  tube  is  carefully  packed 
with  iodoform  gauze,  over  which  are  placed  layers  of  absorbent  cotton 
and  gauze,  which  are  held  in  place  by  a  retentive  bandage.  The  catheter 
is  connected  by  means  of  a  glass  coupling  to  a  long  India-rubber  tube 
(calibre  30  F.),  which  passes  to  a  large  bottle  suspended  to  the  side 
of  the  bed,  which  should  always  be  half  filled  with  1 :  20  carbolic-acid 
solution. 

Now-a-days,  with  our  more  perfected  technique  and  antiseptic  meas- 
ures, it  is  very  rare   to  see  any  bad   results  follow 
external  urethrotomy.      There  may  be  a  very  slight  Fig.  127. 

and  ephemeral  rise  in  temperature,  but  only  in  very 
bad  old  cases  with  vesical  and  renal  complications 
do  Ave  see  urinary  fever  and  sepsis ;  and  these  com- 
plications are  much  rarer  than  they  were  in  former 
days.  Hemorrhage  is,  as  a  rule,  infrequent  after 
this  operation,  as  performed  now-a-days,  and  is 
readily  controlled  by  the  pressure  exerted  by  pack- 
ing the  wound  quite  tightly. 

In  some  rare  cases  healing  is  so  prompt  that  the 
tube  cannot  be  retained  longer  than  a  week.  Some 
nervous  subjects  fret  and  complain  and  cause  us  to 
remove  the  tube  before  it  is  expedient.  As  I  have 
said  before,  the  benefits  resulting  from  the  operation 
are  materially  increased  by  keeping  the  tube  in  the 
urethra  for  at  least  a  fortnight. 

iSi/me's  Operation. — What  is  known  as  Syme's 
operation  is  practically  the  one  already  described, 
except  that  the  instrument  used  in  the  urethra  is 
Syme's  staff.  This  instrument  is  grooved  for  half 
an  inch  at  the  distal  part  of  its  straight  portion 
Avhich  is  joined  by  the  curved  part,  which  is  also 
grooved.  This  curved  portion  at  its  commencement 
is  of  size  No.  8  F.,  and  at  its  tip  it  is  4  French  in 
calibre.  This  long,  thin  curve  makes  the  instrument 
very  difficult  to  properly  introduce  into  very  tight 
strictures,  even  in  skilled  hands,  and  it  has  been 
known  to  cause  death  by  making  false  passages. 
So,  while  it  is  well  to  be  familiar  with  Syme's  staff 
on  account  of  its  history,  it  is  not  well  to  employ  it 
now  that  we  have  the  tunnelled  catheters. 

External  Urethrotomy  without  a  Guide  through 
the  Stricture. — When  the  patient  is  fully  etherized 
a  last  attempt  should  be  made  to  pass  a  filiform. 
This  failing,  we  operate  without  the  great  aid  of 
this  guide.      This  operation   is  performed  with  the  syme's  staff. 

aid  of  a  staff  invented  by  Mr,  Wheelhouse  of  Leeds, 
and  is  known  by  the  name  of  that  surgeon.  The  main  features  of  this 
operation  are  similar  to  those  of  Gouley's  method,  but  its  technical 
points  will  be  here  described:  The  staff  (see  Fig.  127)  is  fully  grooved 
through  its  greater  part,  except  the  last  half  inch,  Avhere  it  stops 
abruptly   and  terminates   in   a  rounded  button-like   end. 


382  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

Mr.  Wheelhouse  ^  gives  the  following  details  of  his  operation : 
"  The  staff  is  to  be  introduced  with  the  groove  looking  toward  the 
surface  and  brought  gently  into  contact  with  the  stricture.     Whilst  an 
assistant  holds  the  staff  in  this  position  an  incision  is  made  into  the 

Fig.  128. 


Wheelhouse's  staff. 

perineum,  extending  from  opposite  the  point  of  reflection  of  the  super- 
ficial perineal  fascia  to  the  outer  edge  of  the  sphincter  ani.  The  tissues 
of  the  perineum  are  to  be  steadily  divided  until  the  urethra  is  reached. 
This  is  noAv  to  be  opened  in  the  groove  of  the  staff,  not  upon  its  point, 
so  as  certainly  to  secure  a  quarter  of  an  inch  of  healthy  tube  immediately 
in  front  of  the  stricture.  As  soon  as  the  urethra  is  opened  and  the 
groove  in  the  staff  fully  exposed,  the  edges  of  the  healthy  urethra  are 
to  be  seized  on  each  side  and  held  apart.  The  staff  is  then  gently 
withdrawn  until  the  button-point  appears  in  the  wound.  It  is  then  to 
be  turned  around,  so  that  the  groove  may  look  to  the  pubes,  and  the 
button  may  be  hooked  into  the  upper  angle  of  the  opened  urethra, 
which  is  thus  held  stretched  open  at  three  points — at  two  by  the  forceps, 
and  at  the  third  by  the  hook  of  the  staff.  The  operator  looks  into  it 
immediately  in  front  of  the  stricture,  inserts  the  director  into  the 
urethra,  and,  if  he  cannot  see  the  opening  of  the  stricture,  which  is 
often  possible,  generally  succeeds  in  very  quickly  finding  it,  and  passes 
the  point  onw^ard  through  the  stricture  toward  the  bladder.  The  stric- 
ture is  sometimes  hidden  among  a  crop  of  granulations  or  warty  growths, 
in  the  midst  of  which  the  probe-point  easily  finds  the  true  passage. 
The  director  having  been  passed  on  into  the  bladder  (its  entrance  into 
which  is  clearly  demonstrated  by  the  freedom  of  its  movements),  its 
groove  is  turned  downward,  the  whole  length  of  the  stricture  is  care- 
fully and  deliberately  divided  on  its  under  surface,  and  the  passage  is 
thus  cleared.  The  director  is  still  held  in  the  same  position,  and  the 
straight,  probe-pointed  bistoury  is  run  along  the  groove  to  ensure  com- 
plete division  of  all  bands  or  other  obstructions.  These  being  thor- 
oughly cleared,  the  old  difficulty  of  directing  the  point  of  a  catheter 
through  the  divided  stricture  is  to  be  overcome.  To  effect  this,  the 
point  of  the  probe  gorget  is  introduced  into  the  groove  of  the  director, 
and,  guided  by  it,  is  passed  onward  into  the  bladder,  dilating  the  divided 
stricture  and  forming  a  metallic  floor,  along  which  the  point  of  the 
catheter  cannot  fail  to  pass  securely  into  the  bladder." 

Works  on  surgery,  as  a  rule,  give  the  reader  the  impression  that  this 
operation  without  a  guide  through  the  stricture  is  in  general  simple 
and  that  the  bladder  is  quite  readily  reached.  In  many  cases  this  is 
true,  but  in  many  others  much  time,  patience,  and  skill  is  required  to 
overcome  the  difficulties  which  present  themselves.  It  is  always  well 
for  the  surgeon  to  keep  cool,  to  be  patient,  and  not  to  be  in  a  hurry. 
Then  the  next  and  the  prime  essential  is  to  have  his  anatomical  know- 
ledge well  in  hand.     The  damaged  urethra  which  he  Avishes  to  traverse 

^  British  Med.  Journal,  June  24,  1876. 


STRICTURE  OF  THE   URETHRA.  383 

is  seated  one  inch  below  the  pubic  arch  and  midway  between  the  ascend- 
ing rami  of  the  ischia.  The  canal  forms  a  gentle  curve  upward.  There- 
fore, it  is  well  to  keep  in  the  middle,  to  remember  that  the  bulbous 
urethra  has  been  opened,  and  that  the  search  should  not  be  made  too 
high  up  or  too  low  down. 

By  means  of  the  grooved  probe  or  of  filiforms  the  surgeon  endeavors 
to  get  through  the  narrowed  channel,  and  he  may  sometimes  be  two  or 
three  hours  in  doing  it.  If  the  grooved  probe  can  be  passed,  the  opera- 
tion is  practically  done.  If  the  surgeon  succeeds  in  passing  a  filiform, 
he  may  by  gentle  manipulation  pass  a  small  tunnelled  catheter  or  per- 
haps Fluhrer's  urethrotome  over  it  into  the  bladder,  and  then  the  parts 
can  be  properly  incised. 

In  some  cases  the  little  procedure  recommended  by  Wheelhouse, 
of  hooking  the  button  of  the  staff  in  the  upper  end  of  the  wound, 
and  thus  by  traction,  aided  by  the  lateral-ligature  retractors,  getting 
a  clear  view  of  the  field  of  search,  works  Avell,  and  really  opens  or 
distends  the  urethral  orifice.  In  other  cases,  however,  this  method  so 
deranges  the  topography  of  the  parts  that  the  urethra  is  made  more 
inaccessible. 

When  the  bladder  has  been  reached  the  subsequent  steps  of  the 
operation  are  the   same   as    those  followed    in    the   Gouley  operation. 

In  the  rare  cases  where  the  surgeon  has  failed  to  traverse  the  urethra 
it  is  well  to  let  the  patient  come  out  of  the  ether  narcosis,  and  after  a 
time  (during  which  his  urine  has  been  accumulating)  to  put  him  on  the 
table  again  in  a  good  light ;  then,  the  edges  of  the  wound  being  held 
apart  by  small  retractors,  the  patient  is  told  to  urinate,  and  the  surgeon 
watches  the  spot  from  which  it  oozes.  Finding  that,  he  can  probably 
get  to  the  bladder  by  means  of  the  probe  or  a  filiform. 

External  Urethrotomy  without  a  Cruide  [CocFs  Operation  or  Perineal 
Section). — For  the  very  worst  and  most  desperate  class  of  cases  in  Avhich, 
either  as  a  result  of  chronic  stricture  or  of  traumatism,  the  urethra 
anterior  to  the  triangular  ligament  has  been  obliterated,  or  in  which  the 
stricture  is  impassable  to  instruments,  the  operation  known  as  Cock's 
operation,  perineal  section,  and  external  urethrotomy  without  a  guide 
may  be  necessary.  This  operation  is  so  clearly  described  by  Mr.  Cock  ^ 
that  I  transcribe  his  words  : 

"  The  only  instruments  required  are  a  broad  double-edged  knife  with 
a  very  sharp  point,  a  large  silver  probe-pointed  director  with  a  handle, 
and  a  cannula  or  female  catheter  modified  so  that  it  can  be  retained  in 
the  bladder. 

"  The  patient  is  to  be  placed  in  the  usual  position  for  lithotomy,  and 
it  is  of  the  utmost  importance  that  the  body  and  pelvis  should  be  straight, 
so  that  the  median  line  may  be  accurately  preserved.  The  left  fore  finger 
of  the  operator  is  then  introduced  into  the  rectum,  the  bearings  of  the 
prostate  are  carefully  examined  and  ascertained,  and  the  tip  of  the 
finger  is  lodged  on  the  apex  of  the  gland;  the  knife  is  then  plunged 
steadily  but  boldly  into  the  median  line  of  the  perineum,  and  carried 
on  in  a  direction  toward  the  tip  of  the  left  fore  finger,  which  lies  in  the 
rectum.  At  the  same  time,  by  an  upward  and  downward  movement, 
the  vertical  incision  may  be  carried  in  the  median  line  to  any  extent 

^  Guy's  Hospital  Reports,  1866. 


384  OONOBRHCEA  AND  ITS  COMPLICATIONS. 

that  is  considered  desirable.  The  lower  extremity  of  the  wound  should 
come  to  within  half  an  inch  of  the  anus. 

"  The  knife  should  never  be  withdrawn  in  its  progress  toward  the 
apex  of  the  prostate,  but  its  onward  course  must  be  steadily  maintained 
until  its  point  can  be  felt  in  close  proximity  to  the  tip  of  the  left  fore 
finger.  When  the  operator  has  fully  assured  himself  as  to  the  relative 
position  of  his  finger,  the  apex  of  the  prostate,  and  the  point  of  the 
knife,  the  latter  is  to  be  advanced  with  a  motion  somewhat  obliquely 
either  to  the  right  or  left,  and  it  can  hardly  fail  to  pierce  the 
urethra.  If  in  this  step  of  the  operation  the  anterior  extremity  of 
the  prostate  should  be  somewhat  incised,  it  is  a  matter  of  no  con- 
sequence. 

"  The  knife  is  now  withdrawn,  but  the  left  fore  finger  is  still  retained 
in  the  rectum.  The  probe-pointed  director  is  carried  through  the  wound, 
and,  guided  by  the  left  fore  finger,  enters  the  urethra  and  is  passed  into 
the  bladder.  The  finger  is  now  withdrawn  from  the  rectum,  the  left 
hand  grasps  the  director,  and  along  the  groove  of  this  instrument  the 
cannula  is  slid  until  it  enters  the  bladder. 

"  The  operation  is  now  complete,  and  it  only  remains  to  secure  the 
cannula  in  its  place  with  four  pieces  of  tape,  which  are  fastened  to  a 
girth  around  the  loins.  A  direct  communication  with  the  bladder  has 
now  been  obtained,  and  the  relief  of  the  patient  will  be  immediate : 
unless  the  kidneys  have  become  irremediably  disorganized,  we  may  con- 
fidently anticipate  a  favorable  result  and  the  restoration  of  the  urinary 
organs  Avill  be  more  or  less  complete  in  proportion  as  the  obstructed 
portion  of  the  urethra  is  more  or  less  amenable  to  the  ordinary  judicious 
treatment  of  stricture.  The  cannula  may  generally  be  retained  in  the 
bladder  for  a  few  days,  and,  if  the  state  of  the  urine  renders  ablution 
necessary,  the  viscus  may  be  frequently  washed  out.  The  cannula  may 
then  be  removed,  cleansed,  and  reintroduced.  A  flexible  catheter  is 
sometimes  more  desirable  and  congenial  to  the  feelings  of  the  patient 
than  a  metallic  cannula. 

"  If  the  previous  destruction  has  not  been  very  great,  and  if  the  case 
progresses  favorably,  the  swelling  of  the  perineum  and  scrotum  gradu- 
ally subsides,  the  induration  disappears,  and  the  urinary  sinuses  become 
obliterated.  The  urethra  may  be  examined  in  the  ordinary  w^ay  to  test 
its  permeability,  and  one  may  be  agreeably  surprised  to  find  that  the 
sound  or  catheter  readily  passes  through  the  former  stricture  until  it 
strikes  against  the  cannula.  An  attempt  may  then  be  made  to  introduce 
a  flexible  catheter  into  the  bladder,  and  its  passage  may,  if  necessary, 
be  facilitated  by  passing  a  director  through  the  perineum  into  the  bladder 
and  guiding  the  catheter  along  its  groove.  The  urethra  once  restored 
to  its  normal  condition  and  calibre,  the  artificial  opening  through  the 
perineum  soon  heals  up,  and,  barring  the  liability  of  stricture  to  return 
if  not  attended  to,  the  cure  may  be  said  to  be  complete." 

Excision  of  Stricture-tissue  tvith  Transplantation  of  Mucous  Mem- 
brane.— This  operation  has  been  performed  within  the  past  ten  years, 
but  it  is  still  in  its  experimental  stage,  and  as  yet  no  conclusions  can  be 
drawn  as  to  its  ultimate  results  and  its  worth.  It  has  been  employed 
in  cases  of  traumatic  stricture  and  in  those  in  which  the  inodular  infil- 
tration invades  the  parts  much  beyond  the  urethra.     In  an  article  giving 


STRICTURE  OF  THE   URETHRA.  385 

the  literature  of  the  subject  Keyes'  details  a  case  on  which  he  operated 
Avith  moderate  success. 

Electrolysis. — This  method  of  treating  stricture  need  only  be  men- 
tioned to  be  condemned.  Its  consideration  is  not  worth  the  time  and 
space  it  would  require.  A  moment's  thought  of  the  pathological  condi- 
tion to  be  treated  in  stricture  of  the  urethra,  and  of  the  mode  of  action 
of  this  electro-chemical  method  of  decomposition,  Avill  convince  any  one 
of  its  futility,  even  harmfulness  if  thoroughly  used.  The  aim  of  this 
treatment  is  to  decompose  the  newly-formed  morbid  tissue  and  to  pro- 
duce its  absorption.  Now,  electrolysis  has  not  an  electro-affinity  for 
the  stricture-tissue,  leaving  the  mucous  membrane  unaffected,  but,  on 
the  contrary,  acts  upon  this  membrane  and  destroys  it ;  and  whenever 
the  mucous  membrane  lining  a  stricture  is  destroyed  there  is  a  grave 
probability  that  the  urethra  will   be  obliterated. 

It  is  probable  in  many  cases  in  which  some  surgeons  have  claimed 
beneficial  results  from  electrolysis  that  this  agent  did  not  exert  its  pecu- 
liar decomposing  power,  but  simply  acted  as  a  stimulant,  which  may 
have,  aided  by  other  measures,  tended  to  cause  the  absorption  of  some 
mild,  soft  stricture. 

Treatment  of  Retention  of  Urine. — In  every  case  of  retention  it  is 
necessary  to  consider  the  age  of  the  patient  and  to  obtain  his  medical 
history  as  relating  to  the  genito-urinary  organs. 

Young  men  in  the  declining  stage  of  acute  gonorrhoea  are  sometimes 
seized  with  retention  of  urine  due  to  mucous-membrane  swelling  and 
perhaps  compressor  spasm.  In  this  case  it  is  always  necessary  to  re- 
member that  filiform  and  small  catheters  may  do  much  harm,  and  Avill 
produce  no  benefit.  The  surgeon  should  take  a  No.  18  or  20  F.  flex- 
ible blunt  or  olivary  catheter  and  slowly  pass  it  into  the  bladder.  If 
at  the  bulb  or  posterior  to  it  he  meets  an  obstruction,  he  should  not  use 
violence  and  he  should  not  be  in  a  hurry.  Gently  pressing  the  end 
of  the  catheter  against  the  obstruction,  he  holds  it  there  and  waits,  and 
usually  in  a  few  minutes  it  will  slowly  pass  into  the  bladder.  If  this 
is  not  accomplished  at  once,  the  patient  may  be  placed  in  a  hot  bath, 
and  ten  or  fifteen  drops  of  laudanum  well  diluted  in  water  may  be  given 
to  him.  As  a  rule,  this  course  will  be  followed  by  the  passage  of  the 
catheter  and  the  patient's  relief.  In  these  cases  the  posterior  urethra 
is  in  all  probability  invaded,  and  the  urethral  trouble  will  not  be  mate- 
rially made  worse  even  if  it  is  necessary  to  pass  the  catheter  several 
times. 

In  older  subjects  retention  usually  results  from  urethral  stricture. 
Having  ascertained  the  patient's  history,  the  surgeon  passes  to  the  face 
of  the  obstruction  a  flexible  catheter  about  20  F.  By  this  he  can  gain 
knowledge  of  the  nature  of  the  obstruction.  If  a  narrow  stricture  is 
present,  it  is  well  to  try  to  get  through  with  the  English  catheters  of 
very  small  size,  which  have  such  stability  that  they  will  frequently  pass 
where  the  French  ones  fail. 

Thompson's  retention  catheter,  when  skilfully  handled,  sometimes 
produces  brilliant  results  in  the  relief  of  retention.  Unskilfully  used, 
it  is  a  dangerous  instrument.  Bumstead's  retention  catheter,  which  has 
a  French  filiform  flexible  guide,  may  be  kept  ready  for  use,  since  by  it 

^  Journal  of  Cutaneous  and  Gen.-urin.  Diseases,  1891,  vol.  ix.  pp.  401  et  seq. 
25 


386  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

the  surgeon  may  sometimes  reach  the  bladder  when  he  has  almost  begun 
to  despair.     For  the  use  of  filiforms  in  retention  due  to  stricture  the 


Fig.  128  a. 


G.1LEM  AN  HrCa. 

j^^w^^pson's  retention  catheter,  with  malleable  silver  probe-point. 

reader  is  referred  to  the  section  thereon.  (See  p.  355.)  Having  trav- 
ersed the  stricture  with  the  filiform,  it  can  be  the  means  of  guiding  a 
small  Gouley  catheter  staff  into  the  bladder. 


Bumstead's  retention  catheter,  with  screw-point  so  that   it  may  be  attached  to   any  filiform 
bougie  employed  with  rupture  or  incision  instruments. 

The  passage  of  instruments  for  prostatic  obstructions  has  been  con- 
sidered (see  page  360),  and  the  directions  there  given  will  hold  good  in 
case  retention  of  urine  is  present. 

It  is  necessary  here  to  warn  young  surgeons  not  to  fully  empty  the 
bladder  in  elderly  and  old  men  who  are  suffering  from  retention  due 
either  to  stricture  or  prostatic  hypertrophy.  At  the  first  attempt  at 
relief  if  the  bladder  is  very  full  and  protuberant,  about  a  pint  of  urine 
may  be  drawn  oflF,  and  before  the  catheter  is  withdrawn  half  a  pint  of 
warm  boric-acid  water  should  be  injected  into  the  bladder.  When  the 
distressing  symptoms  are  again  felt,  a  similar  withdrawal  and  an  injec- 
tion should  be  made.  In  this  way  in  the  course  of  twenty-four  or 
thirty-six  hours  the  patient  can  be  much  relieved.  In  old  stricture  and 
prostatic  cases  there  is  always  a  certain  amount  of  residual  urine ;  conse- 
quently it  is  the  surgeon's  duty  to  ascertain  its  quantity,  and  always 
after  the  final  catheterism  for  relief  of  retention  to  leave  a  similar  amount 
of  boric-acid  water  in  the  bladder.  Failure  to  carry  out  this  cautious 
and  slow  method  of  catheterism  may  result  in  serious  bladder  and  kidney 
lesions,  and  perhaps  in  death.  When  all  urine  is  suddenly  drawn  from 
the  bladder  in  those  cases  where  there  has  been  more  or  less  intense 
vesical,  urethral,  and  kidney  congestion,  the  vessels  at  first  become  sud- 
denly exsanguinated  ;  then,  when  the  circulation  is  re-established,  hem- 
orrhage occurs  into  the  kidneys  and  bladder,  and  death  ensues. 

In  very  urgent  cases  of  retention  of  urine  from  stricture,  particularly 
in  middle-aged  and  elderly  men,  or  of  prostatic  hypertrophy  in  which 
the  surgeon  fails  to  reach  the  bladder  with  a  catheter,  it  may  be  neces- 
sary to  draw  off  the  urine  by  means  of  the  aspirator.  For  this  purpose 
the  instrument  of  Emmet  is  very  serviceable. 

In  performing  aspiration  it  is  important  that  the  pubes  should  be 


STRICTURE  OF  THE   URETHRA. 


387 


shaved  and  rendered  surgically  clean.  Then  the  instrument  should 
be  tested  before  use,  and  it  should  be  made  certain  that  the  needle  is 
pervious.  It  is  then  sterilized.  The  area  of  operation  is  about  one 
inch  above  the  upper  margin  of  the  symphysis  pubis,  and  at  most  one 
inch  on  each  side  of  the  median  line.  In  this  restricted  field,  if  proper 
care  and  caution  are  exercised,  many  punctures  are  made,  and  by  them 
sufficient  time  may  be  gained  to  allow  the  urethra  and  prostate  to  lose 
much  of  their  engorgement  and  to  permit  the  passage  of  catheters.     In 


Fig.  130. 


Emmet's  aspirator. 

many  cases  as  many  as  four  punctures  of  the  bladder  daily  for  six  and 
eight  days  may  be  made  with  local  benefit  and  without  any  untoward 
symptom  whatever. 

On  the  withdrawal  of  the  aspirating  needle  suction  should  be  kept 
up  until  its  point  is  well  out  of  the  wound.  Otherwise,  some  of  the 
urine  (and  it  is  usually  of  septic  character)  may  escape  into  the  cellular 
tissues  and  produce  an  abscess. 

In  very  rare  cases  the  upward  growth  of  the  prostate  is  such  that  it 
shuts  oif  the  bladder  from  approach  above  the  pubes,  in  which  event  the 
aspirating  needle  cannot  reach  the  vesical  cavity. 

Urethral  Fever,  or  Urinary  Infection. — Following  operations 
upon  the  urethra  and  bladder  for  stricture,  cystitis,  vesical  neoplasms, 
calculus,  retention,  and  prostatic  hypertrophy,  particularly  in  chronic 
cases  of  young  men  and  in  men  approaching  middle  age  and  in  old  men, 
certain  febrile  disturbances  of  mild  or  severe  character  and  septic  infec- 
tious conditions  are  sometimes  observed,  which  have  been  variously 
called  urethral  fever,  urinary  fever,  catheter  fever,  urinary  poisoning, 
and  urinary  infection. 

After  such  simple  operations  on  the  urethra  as  the  easy  passage  of  a 
bougie  or  catheter,  incision  of  the  meatus,  and  even  the  introduction  of 
the  meatus  sound,  some  patients  become  faint,  pale,  and  may  lose  con- 
sciousness. This  condition  is  simply  a  mild  form  of  shock,  and  is  anal- 
ogous to  the  fainting  spells  following  blows  on  the  testes  or  cord  or  the 
subcutaneous  ligature  of  the  spermatic  veins.  In  some  cases  these 
symptoms  are  mild  and  very  ephemeral,  while  in  others  they  are  more 


388  GONORRHCEA  AND  ITS  COMPLICATIONS. 

severe  and  prolonged.  Though  these  conditions  are  generally  con- 
sidered under  the  head  of  urinary  fever,  they  are  in  no  sense  related 
to  that  condition.     They  are  the  evidence  of  reflex  nervous  action. 

After  instrumental  operation  on  the  urethra  patients  may  have  a  slight 
rise  in  temperature,  preceded  or  followed  perhaps  by  a  chill,  which  passes 
■off  and  does  not  recur.  This  condition  may  be  observed  in  some  cases 
with  the  passage  of  the  first  urine  after  urethrotomy,  tight  catheterization, 
>or  divulsion.  This  condition  represents  the  mild  and  ephemeral  form  of 
urethral  fever.     In  it  the  patient  is  only  mildly  sick. 

The  second  form  is  that  which  is  called  "acute  urethral  fever,"  in 
ivhich  the  chill  is  severe  and  often  prolonged,  the  rise  in  temperature 
sudden  (104°  to  106°  Fahr.,  and  even  beyond  this),  and  in  which  the 
systemic  symptoms  are  correspondingly  severe.  In  some  cases  defer- 
vescence is  ushered  in  with  sweats.  This  condition  may  last  one  or 
several  days,  and  it  may  recur  at  intervals.  The  patient  is  usually  a 
quite  sick  man. 

This  second  form  may  cease  or  it  may  become  chronic,  and  it  is  then 
called  "chronic  urinary  fever."  This  is  mostly  observed  in  elderly  and 
old  men  suffering  from  stricture,  and  its  pathological  sequences  in  the 
membranous  and  prostatic  urethra,  bladder,  and  perhaps  kidney,  and  also 
in  cases  of  prostatic  hypertrophy,  calculus,  and  vesical  neoplasms. 

The  fever  is  of  a  mild  type,  perhaps  continuous,  and  again  it  may  be 
intermittent.  During  its  course  irregular  slight  chills  or  severe  rigors 
may  be  experienced.  This  condition  is  indicative  of  grave  trouble  of  the 
whole  urinary  tract,  and  it  tends  to  undermine  the  patient's  health.  Per- 
sons thus  affected  lose  flesh,  become  sallow,  suffer  severely  from  dyspepsia, 
and  gradually  lose  ground,  until  they  die  either  from  uremia  or  septi- 
caemia. 

Urinary  infection  with  fulminating  lethal  symptoms  has  sometimes 
been  observed.  In  the  classical  case  of  Banks  a  man  broken  in  health 
and  suffering  from  tight  stricture,  who  was  catheterized  without  violence, 
pain,  or  bleeding,  was  immediately  after  the  operation  seized  with  a  severe 
rigor,  passed  into  syncope,  and  died  in  a  few  minutes.  In  another  case 
reported  by  Banks  ^  the  stricture  in  the  pendulous  urethra  was  long  and 
tight.  It  had  been  mildly  dilated,  and  six  and  a  half  hours  after  the 
passage  of  a  No.  4  E.  sound  the  man  suddenly  collapsed  and  died. 

Thompson  reports  two  cases  in  which  death  followed  in  twenty-four  and 
forty-eight  hours  after  the  passage  of  a  small  instrument  through  tight 
strictures. 

In  most  of  the  very  severe  cases  there  is  suppression  of  urine. 

The  pathology  of  urinary  infection  has  been  studied  by  many  observers, 
particularly  by  the  el^ves  of  Guyon,^  and,  although  absolutely  full  and 
definite  statements  cannot  be  made,  considerable  can  be  said. 

The  underlying  primary  cause  of  urinary  fever  is  some  inflammatory 
focus  in  the  urethra  and  bladder.  When  this  condition  is  well  marked 
and  chronic,  and  the  bladder  is  decidedly  affected  and  the  urine  septic, 
then  the  patient  is  liable  to  urinary  infection.  If  the  pathological  changes 
are  as  yet  not  far  advanced,  the  results  of  instrumental  manipulation  in 

'  "  On  Certain  Eapidly  Fatal  Cases  of  Urethral  Fever  after  Catheterism,"  Edinburgh 
Med.  Journal,  June,  1871,  p.  1074. 
*  Halle,  op.  cit. 


STRICTURE  OF  THE   URETHRA.     '  389 

disturbing  them  are  mild  and  show  themselves  by  the  ephemeral  form  of 
fever.  When  the  changes  are  more  chronic  and  deep-seated,  the  tissues 
react  more  violently  and  the  fever  is  more  severe. 

In  the  grave  order  of  cases  there  is  always  coexisting  renal  impair- 
ment. Now,  on  this  pathological  basis  as  a  result  of  damage,  even  mild, 
done  in  operation,  certain  microbes  seem  to  luxuriate,  and  they  secrete  the 
poison  which  gives  rise  to  the  inflammatory  and  septic  phenomena  already 
described.  An  attentive  reading  of  the  results  of  the  various  investi- 
gators seems  to  show  that  the  chief  morbific  agent  in  urinary  poisoning  is 
the  bacterium  coli  commune.  We  cannot  say  definitely  where  this  microbe 
breeds  and  has  its  being — whether  it  is  in  the  affected  tissues  or  in  the 
urine,  probably  in  the  latter,  and  perhaps  in  both.  It  seems  certain  that 
without  tissue-disturbance  and  trauma  this  micro-organism  may  remain 
dormant,  but  that  when  the  condition  of  the  tissues  has  become  altered  by 
loss  of  epithelium  and  other  unknown  states,  it  becomes  hostile  and  pro- 
duces urinary  poisoning.  On  this  point  the  following  carefully  observed 
case,  reported  by  Achard  and  Hartmann,^  throws  much  light : 

A  prostatic  patient  incompletely  emptying  his  bladder  for  several  years 
was  attacked  by  retention,  which  necessitated  catheterism,  which  at  first  was 
difficult  and  attended  with  a  flow  of  blood.  For  twenty  days  this  was  done 
regularly ;  then  the  patient  was  allowed  to  urinate  unaided,  which  he  did 
easily.  Shortly  after  he  was  attacked  with  a  chill,  fever,  and  sweats.  The 
catheter  was  then  used  and  no  fever  was  observed.  A  month  later  no  bad 
symptoms  were  noted,  even  though  the  patient  passed  the  first  few  drops 
of  urine  naturally.  He  was  then  allowed  to  urinate  spontaneously,  which 
he  did  readily,  but  as  a  result  suffered  from  the  same  symptoms.  Eight 
days  later,  to  satisfy  his  curiosity,  he  passed  his  urine  normally,  and  in  a 
few  hours  had  a  mild  fever  again.  Urine  drawn  aseptically  from  his  blad- 
der and  deposited  upon  various  culture-media  produced  a  microbe  having 
all  the  appearances  of  the  bacterium  coli  commune.  The  case  shows  that 
simple  traumatism  by  the  catheter  was  insufiicient  to  produce  an  attack  of 
fever ;  that  absorption  of  the  septic  material  took  place  at  the  part  of  the 
urethra  damaged  by  the  distention  of  the  urinary  flow  ;  and  that  the  infect- 
ing agent  was  the  bacterium  coli  commune,  which  was  found  in  a  state  of 
purity.^ 

In  many  patients  this  microbe  seems  to  hibernate,  and  does  not  become 
pathogenic  even  when  there  is  much  tissue-damage  (they  seem  in  a  meas- 
ure immune  to  its  action),  while  in  others  the  slightest  trauma  seems  to 
be  the  starting-point  of  its  virulence  and  its  wildfire-like  spread.  Per- 
haps in  some  patients  the  nature  of  the  microbe  is  weak,  and  it  is  imper- 
fect in  its  development.  It  is  a  significant  fact  that  in  all  very  grave 
cases  there  is  more  or  less  presumptive  or  conclusive  evidence  of  renal 
derangement.     The  urethral  and  vesical  disturbances  then  seem  (how  we 

^  La  Semaine  medicale,  Jan.  25,  1892,  and  Annales  des  Malad.  des  Org.  Gen.-urin.,  April, 
1892,  p.  299. 

■^  Krogius  ("Bacterium  Coli  dans  I'lnfection  urinaire,"  Arch,  de  Med.  exp.,  No.  1,  1892) 
says  that  as  a  result  of  the  examinations  of  seventeen  specimens  of  pathological  urine, 
antiseptically  obtained,  he  is  certain  that  the  coli  bacillus  is  the  infecting  agent.  The 
bacterium  of  Clado,  the  bacterium  pyogene  of  Albarran  and  Plalle,  present  with  this  bac- 
terium the  greatest  analogies  of  polymorphism  of  culture  and  of  pyogenic  and  toxic 
qualities. 

Finally,  the  bacillus  of  Escherich  is  the  same  micro-organism  as  the  French  authors 
term  bacterie  pyogene. 


390  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

cannot  exactly  say)  to  react  promptly  on  the  kidneys,  and  as  a  result  we 
have  the  mixed  conditions  of  urinary  infection  and  of  ursemia,  and  more 
or  less  total  suppression  of  urine. 

While  we  can  thus  speak  with  considerable  certainty  as  to  the  pres- 
ence, nature,  and  pathological  action  of  the  bacillus  coli  commune,  we 
are  as  yet  in  the  dark  as  to  the  role  of  the  pathological  action  of  the  pyo- 
genic microbes  which  are  also  found  in  pathological  urine  and  in  the 
genito-urinary  tract. ^ 

The  practical  lesson  to  be  learned  from  all  these  researches  is  to  do  as 
little  violence  to  urethral  and  vesical  tissues  as  possible,  and  to  be  thorough 
in  the  matter  of  asepsis  and  antisepsis.  It  can  be  readily  seen  that  drugs 
taken  internally  cannot  efficiently  act  upon  the  morbid  conditions  of  the 
tissues  or  on  the  microbes  and  their  poisons  contained  in  the  urine. 

Treatment  of  Extravasation. — The  general  principles  upon  which  the 
treatment  of  extravasation  of  urine  is  to  be  conducted  are — to  give  free 
exit  by  incisions  to  the  escaped  fluid  and  disorganized  tissues ;  to  support 
the  vital  powers  by  nourishment  and  stimulants ;  to  remove  and  render 
inert  the  noxious  products  of  decomposition  by  cleanliness  and  antiseptics. 
At  the  earliest  moment  that  any  external  symptoms  of  extravasation  can 
be  detected — nay,  before  this,  if  constitutional  shock  and  deep-seated  pain 
lead  to  the  suspicion  of  the  escape  of  urine,  although  its  presence  behind 
the  deep  perineal  fascia  be  indicated  by  no  sign  appreciable  upon  the 
surface — a  free  incision  should  be  made  in  the  median  line  of  the  peri- 
neum, where  there  is  little  danger  of  wounding  important  vessels.  When 
the  extravasation  has  attained  more  superficial  parts,  numerous  incisions 
are  required  in  the  scrotum  and  wherever  else  there  is  distention  and  a 
tendency  to  sloughing  or  gangrene. 

We  are  generally  called  upon  to  sustain  the  sinking  powers  of  life  by 
the  free  exhibition  of  nourishment  and  stimulants,  as  beef-tea,  brandy, 
milk-punch,  carbonate  of  ammonia,  quinine,  etc.  Opium  is  of  much  value 
when  there  is  much  pain  or  nervous  irritability.  Nothing  can  be  done  for 
the  relief  of  the  stricture  during  the  continuance  of  the  shock  consequent 
upon  rupture,  but  usually,  as  this  passes  off,  catheterism  may  be  success- 
fully performed.  In  case  this  cannot  be  accomplished,  and  if  the  bladder 
be  found  on  percussion  to  be  still  distended  owing  to  the  small  size  of  the 
rupture,  it  is  desirable   to  resort  to  puncture  at  once  or  to  extend  the 

1  As  to  the  frequency  and  relative  importance  of  the  different  microbes  much  has 
yet  to  be  learned.  Thus'  far,  different  fields  of  observation  have  been  studied.  Rovsing 
collected  cases  at  random  from  a  general  hospital ;  Halle  got  his  cases  in  the  Xeckar,  a 
special  urinary  hospital.  It  is  fair  to  assume  that  the  microbian  character  of  pathological 
urine  may  vary  according  to  the  place  and  general  conditions  (^and  according  to  the  dis- 
ease which  may  have  preceded  the  cystitis). 

There  is  no  special  specific  organism  of  the  urinary  apparatus.  Probablv  many 
common  forms  which  may  exist  as  saprophytes  only  become  virulent  after  successive  cul- 
tivations in  the  human  iDladder.  Thus  can  be  explained  the  multiplicity  and  irregular 
reappearance  of  pathogenic  microbes. 

Though  the  list  is  long,  the  number  of  microbes  known  to  be  truly  infecting  is  not 
large.  Staphylococci  and  streptococci  can  undoubtedly  cause  suppurating  nephritis  and 
general  febrile  infection.  Halle  says  that,  according  to  his  observations,  these  pyogenic 
microbes  are  not  the  ones  ordinarily  the  cause  of  the  general  infection  due  to  bladder 
inflammation.  Their  action  is  exceptional,  and  to  them  may  be  attributed  the  rare  cases 
of  purulent  infection  with  iiiultiple  abscesses  which  are  out  of  the  usual  category  of  uri- 
nary fever.  Anatomical  and  pathological  examination  of  urinary  infection  in  man  thus 
far  has  only  shown  that  this  condition  is  produced  by— 1,  the  microbes  of  suppuration; 
2,  the  bact^rie  pyogene. 


STRICTURE  OF  THE   URETHRA.  391 

incision  in  the  perineum  to  the  urethra  behind  the  obstruction.  The  dis- 
charge is  fetid  and  ammoniacal  from  the  first,  and  especially  so  as  the 
disorganized  tissues  are  cast  off  by  suppuration  ;  hence  frequent  hot  irriga- 
tions with  the  various  antiseptic  solutions,  followed  by  the  application  of 
iodoform  and  absorbent  gauze  tampons,  are  necessary. 

Treatment  of  Urinary  Abscess  and  Fistula. — Urinary  abscess  may  arise 
from  ulceration  of  the  urethra  and  consequent  escape  of  urine,  often  in 
minute  quantity,  into  the  cellular  tissue,  in  which  case  it  communicates 
with  the  canal  from  the  outset ;  or  it  may  be  produced  by  simple  irrita- 
tion of  the  neighboring  parts,  and,  although  isolated  at  first,  eventually 
open  into  the  urethra.  In  both  cases  the  sooner  the  abscess  is  evacuated 
by  external  incision  the  better — in  the  former,  in  order  to  quiet  the  con- 
stitutional disturbance  which  ordinarily  ensues,  and  prevent  the  extension 
and  burrowing  of  matter ;  in  the  latter,  to  eifect  the  same  purpose,  and 
also  to  avoid,  if  possible,  any  lesion  to  the  urethral  walls  and  the  formation 
of  urinary  fistulas  ;  for  when  once  the  urine  has  found  an  abnormal  outlet,  it 
acts  as  a  constant  irritant,  and  renders  difficult  the  closure  of  the  passage 
either  by  nature  or  by  art.  When  matter  is  pent  up  behind  the  triangular 
ligament,  it  is  often  exceedingly  difficult  to  detect  its  presence  by  external 
examination  :  there  is  usually,  however,  even  in  obscure  cases,  some  degree 
of  hardness  and  tenderness  on  pressure,  and  if  its  existence  is  rendered 
probable  by  the  general  symptoms,  as  a  chill,  nausea,  rapid  pulse,  etc.,  an 
incision  should  at  once  be  made  in  the  median  line  of  the  perineum  in 
front  of  the  anus ;  even  if  pus  be  not  at  first  found,  a  passage  will  be 
formed  for  its  subsequent  exit  and  the  tension  of  the  parts  will  be  relieved. 
In  some  exceptional  cases  urinary  abscess  assumes  a  chronic  character  and 
is  attended  by  little  febrile  excitement  or  inconvenience ;  thus,  a  small 
tumor  formed  by  an  abscess  communicating  with  the  urethra  sometimes 
exists  for  months  before  being  discovered  by  the  patient  or  surgeon,  unless 
a  careful  examination  of  the  perineum  be  made. 

Urinary  fistulce,  in  most  cases,  contract  and  close  spontaneously  when 
the  stricture  has  been  thoroughly  dilated,  especially  if  the  general  condi- 
tion of  the  patient  be  maintained  at  a  proper  standard  of  health.  Assist- 
ance may  be  derived  from  stimulating  applications  to  the  sinus,  as  of 
nitrate  of  silver,  tincture  of  iodine,  or  carbolic  acid.  The  end  of  a  probe 
may  be  coated  with  nitrate  of  silver  and  passed  along  the  fistulous  track  ; 
one  of  the  liquids  just  mentioned,  either  pure  or  diluted  with  water,  may 
be  injected,  and  plugs  of  absorbent  gauze  be  inserted.  The  method, 
however,  I  have  found  to  be  most  successful  is  first  to  thoroughly  cau- 
terize the  fistula,  and  then  pack  it  with  balsam-Peru  gauze,  then  wait  for 
a  few  days,  after  which  the  urine  is  drawn  ofi"  WMth  a  soft  catheter  every 
time  the  desire  to  pass  water  is  felt,  and  the  patient  should  be  taught  to 
do  this  for  himself. 

Fistulge  in  front  of  the  scrotum  frequently  require  plastic  operations. 


392  GONOBBHCEA  AND  ITS  COMPLICATIONS. 

CHAPTER    XXXIII. 
BALANITIS  AND  BALANO-POSTHITIS. 

We  apply  the  term  "  balanitis  "  to  inflammation  of  the  mucous  mem- 
brane covering  the  glans  penis,  and  "posthitis  "  to  inflammation  of  the 
mucous  lining  of  the  prepuce.  Either  part  may  be  afl"ectecl  separately, 
but  when  both  surfaces  are  involved  the  aff"ection  is  called  "balano-pos- 
thitis."  By  many,  however,  the  term  "balanitis"  is  used  to  mean  in- 
flammation of  the  mucous  membrane  of  either  the  glans  or  the  prepuce, 
or  both. 

This  affection  is  most  commonly  seen  in  persons  having  some  abnor- 
mality of  the  prepuce,  such  as  smallness  of  its  orifice,  straightness, 
tightness,  and  redundancy,  and  shortness  of  the  frsenum.  It  is  also 
seen  in  persons  having  a  normal  penis  and  in  those  whose  prepuce  is 
very  short.  In  most  cases  it  shows  a  tendency  to  relapse,  and  one  attack 
predisposes  toward  subsequent  ones.  It  exists  in  an  acute  and  a  chronic 
form,  and  in  all  degrees  from  mild  to  very  severe.  As  remarked  by 
Fournier,  balanitis  is  a  spontaneous,  personal,  and  non-venereal  aff'ec- 
tion  in  the  majority  of  cases. 

In  its  most  simple  form  balanitis  presents  a  very  red,  somewhat  thick- 
ened surface,  covered  Avith  a  milky  secretion  emitting  a  penetrating  and 
offensive  odor.     This  condition  is  very  amenable  to  treatment. 

Balanitis  and  balano-posthitis  in  a  more  advanced  form  present  well- 
marked  features.  The  glans  and  prepuce  are  swollen,  and  when  the 
latter  is  retracted  a  mottled  surface  of  shining  whiteness,  broken  by 
deep-red  superficial  and  irregular  excoriations,  is  seen.  In  this  case  in 
some  parts  the  epithelium  still  remains,  and,  having  been  macerated  by 
the  secretions,  presents  the  whitish-pearly  look  spoken  of,  while  in  other 
parts  it  is  cast  off,  and  as  a  result  the  red  excoriated  patches  are  left. 

In  other  cases  upon  retracting  the  prepuce  it  is  found  that  the  glans 
or  its  covering,  or  both,  are  the  seat  of  redness  and  swelling,  and  that 
their  surface  is  covered  with  minute,  closely-packed  vesicles,  which  rup- 
ture promptly  and  give  rise  to  excoriations. 

The  foregoing,  which  we  may  call  the  simple  forms  of  balanitis  and 
balano-posthitis,  may  be  promptly  cured  by  appropriate  medication. 
But  should,  for  any  reason,  the  irritating  cause  persist,  a  more  severe 
form  of  the  affection  results.  With  the  increase  of  the  redness  and 
swelling  the  excoriations  give  rise  to  ex  ulceration,  which  may  be  super- 
ficial and  covered  with  thin,  soft  greenish  crusts,  and  which  is  called 
"  exulcerated  balanitis  "  or  "  balano-posthitis."  Under  unfavorable  cir- 
cumstances these  superficial  lesions  of  continuity  may  become  trans- 
formed into  deeper  ulcers,  very  often  undistinguishable  from  chancroids. 

Balanitis  is  not  infrequently  seen  in  persons  having  a  short  prepuce, 
which  tends  to  curl  up  in  a  little  bunch  behind  the  corona  glandis — a 
condition  very  often  seen  in  those  having  hypospadias.  In  the  coronal 
sulcus  of  these  cases  there  is  sometimes  found  a  red,  raw,  pus-secreting, 
narrow,  transverse  patch  which  is  very  obstinate  and  annoying.  It 
usually  originates  in  decomposition  of  the  sebaceous  matter,  and  shows 


BALANITIS  AND  BALANO-POSTHITIS.  393 

a  marked  tendency  to  recur  in  consequence  of  very  slight  inattention  to 
cleanliness. 

Under  the  title  "  circinate  erosive  balano-posthitis "  Berdal  and 
Bataille  ^  describe  a  form  of  balanitis  which  in  its  configuration  and 
course  resembles  ringworm  of  the  skin,  and  Avhich  is  considered  by 
them  to  be  due  to  some  microbe  not  yet  clearly  made  out.  The  eruption 
occurs  on  the  glans  and  also  on  the  prepuce  in  the  form  of  segments  of 
circles,  the  convexity  of  which  points  to  the  glans.  These  circles  in- 
crease in  area,  and  as  they  grow  the  tissues  included  in  them  become 
eroded  and  perhaps  ulcerated.  The  advancing  border  is  composed  of  a 
thin  whitish  ring  of  epithelium  which  is  a  little  uplifted.  Inoculation- 
experiments  are  said  to  have  produced  similar  lesions.  The  authors  claim 
that  this  form  of  balanitis  is  contracted  from  women — that  it  is  infec- 
tious, and  must  be  regarded  as  of  venereal  origin. 

Cordier^  reports  under  the  title  a  new  variety  of  balanitis,  a  peculiar 
form  due  to  external  irritation.  The  irritating  agents  are  calomel 
locally  applied  to  the  glans  or  prepuce  and  iodide  of  potassium  taken 
internally.  The  author  details  the  case  of  a  young  man  having  tertiary 
ulcerations  of  the  penis  which  were  dressed  with  calomel ;  he  also  took 
the  iodide,  and  the  urine  then  coming  in  contact  with  the  calomel  pro- 
duced a  decidedly  caustic  effect  with  enormous  swelling  of  the  penis, 
atrocious  pain,  and  much  sero-purulent  secretion.  In  this  form  of  bal- 
ano-posthitis or  balanitis  the  pain  is  very  severe,  the  secretion  most 
abundant,  the  prepuce  is  oedematous  and  often  covered  with  a  pultaceous 
coating,  which  may  cover  up  deep  ulcerations.  Cases  thus  afflicted  are 
chiefly  those  having  very  long  prepuces,  which  favor  the  retention  of 
urine. 

Croupous  and  Diphtheritic  Balano-posthitis. 

This  form  of  balano-posthitis  was  first  described  by  Bokai.^  It  is 
usually  a  sequela  or  complication  of  wounds  or  of  operations  upon  the 
prepuce.  Thus  I  have  seen  it  follow  ritual  circumcision  in  a  young 
child,  and  in  a  young  three-year-old  boy  Avho  had  with  some  violence 
retracted  the  prepuce  and  broken  up  some  adhesions. 

The  clinical  appearances  consist  in  redness  and  swelling  of  the  parts, 
with  superficial  excoriation,  over  which  a  whitish  membranous  exuda- 
tion as  thick  as  writing-paper  is  seated.  Usually  the  membrane  is  read- 
ily stripped  off,  and  healing  will  follow  the  observance  of  cleanliness  and 
the  application  of  a  mild  lotion. 

Diphtheritic  balano-posthitis  is  sometimes  observed  during  or  follow- 
ing diphtheria,  scarlatina,  measles,  variola,  typhoid  fever,  and  other 
infectious  diseases.  The  local  affection  usuall}'^  originates  in  a  simple 
balano-posthitis  resulting  from  want  of  cleanliness  and  care  in  the 
removal  of  smegma  and  of  decomposing  urine. 

The  membrane  in  this  form  of  balano-posthitis  resembles  that  of 
diphtheria  of  the  mucous  membranes.     It  is   of  a  yellowish  or  dirty 

1  La  Medicine  moderne,  1891-92,  pp.  ,340,  380,  400,  and  413,  and  Annalet^  des  Malad.  des 
Organs  Gen.-urin.,  vol.  viii.,  1890,  p.  53. 

^  "Sur  une  nouvelle  Variete  de  Balanite,"  Li/nn  med.,  vol.  Ixiii.,  No.  1.  pp.  5  et  seq. 

'^  "Die^Krankheiten  der  Urogenitalorpfane  des  kindlichen  Alters,"  Gerhardi's  Hand- 
buch  der  Kinderkrankheitm,  4  Ed.,  3  Abtheil. 


394  GONORRHCEA  AND  ITS  COMPLICATIONS. 

grayish-white  color,  sometimes  as  thick  as  blotting-paper,  and  is  with 
difficulty  removed  from  the  underlying  parts,  from  Avhich  hemorrhage 
may  be  caused  by  the  operation.  The  glans  and  prepuce  are  reddened 
and  swollen,  and  may  even  become  phlegmonous.  In  bad  cases  the 
inguinal  ganglia  are  swollen.  Diphtheria  sometimes  attacks  the  cir- 
cumcision-wound in  young  infants. 

I  have  seen  among  the  low,  ignorant  Hebrews  of  the  East  Side  deep 
chronic  ulcers,  and  even  destruction  of  the  penis  and  death,  due  to  diph- 
theritic infection  of  the  preputial  wound. 

Diabetic  Balano-posthitis,  also  called  Phimosis  Acquisita  Diabetica 
(Englisch  and  Leuchert)  and  Balano-postho-mycosis  (Simon). 

In  rare  cases  balanitis  and  balano-posthitis  may  complicate  dia- 
betes. The  subjective  symptoms  of  this  form  are  quite  similar  to,  but 
more  intense  than,  those  of  ordinary  balano-posthitis.  The  patients 
complain  of  severe,  even  atrocious,  itching  and  burning  sensations, 
comparable  to  those  of  pruritus  vulvae,  and  the  mucous  membrane 
looks  oedematous,  and  of  a  color  midway  between  red  and  violet.  A 
profuse  purulent  secretion  is  constantly  seen,  together  with  flakes  or 
masses  of  smegma  and  micro-organisms  which  look  like  croupous 
exudation.  The  surface  of  the  glans  and  prepuce  may  present  a  num- 
ber of  exulcerations,  and  at  the  free  border  of  the  prepuce  small  radiat- 
ing ulcers  frequently  form.  In  severe  chronic  cases  vegetations  appear 
as  complications. 

The  course  of  the  disease  is  essentially  chronic,  and  as  a  result  of  the 
inflammation  and  of  the  ulcers  at  the  end  of  the  prepuce  well-marked 
phimosis  may  be  caused. 

In  very  severe  instances  the  ulcers  lead  to  gangrene,  by  which  more 
or  less  loss  of  the  prepuce  or  glans  is  produced.  These  cases  of  gan- 
grene of  the  penis  from  diabetes  are  sometimes  very  alarming  in  charac- 
ter and  demand  prompt  and  radical  treatment. 

In  some  cases  the  occurrence  of  balanitis  and  balano-posthitis  is  the 
first  evidence  of  the  existence  of  diabetes.  Whenever,  therefore,  these 
conditions  pointing  to  a  local  evidence  of  this  disease  are  observed  in 
persons  who  had  previously  not  suffered  from  any  trouble  of  the  penis, 
particularly  in  those  of  middle  or  old  age,  the  suspicion  of  diabetes 
should  be  entertained  and  a  full  examination  made.  In  like  manner 
the  onset  of  balanitis  and  balano-posthitis,  particularly  in  elderly  per- 
sons who  complain  of  symptoms  peculiar  to  diabetes  or  who  suffer  from 
disseminate  and  patchy  eczematous  eruptions,  from  outbreaks  of  pustules, 
boils,  and  carbuncles,  should  excite  suspicion  as  to  the  existence  of  that 
disease  as  an  underlying  cause. 

Diabetic  balano-posthitis  and  phimosis  are  not  common  affections,  for 
Durand-Fardol  did  not  observe  it  in  344  cases  of  diabetes  mellitus,  and 
Dumas,  a  resident  physician  in  large  practice  at  Vichy,  only  saw  2  cases. 

The  micro-organisms  of  this  affection  are  the  aspergillus  and  the 
penicillium  glaucum.      Friedreich,^  who  carefully  studied  the  bacteri- 

^"Ueberdas  Constante  Vorkomnien  von  Pilzen  bei  Diabetischen,"  Virchoiv's  Archiv 
far  Path.  Anal.,  B.  30,  p.  476,  1864.  In  a  paper  by  Engliscb,  "  Ueber  Erkrankungen  der 
Vorhaut  bei  Diabetes  Mellitus,"  Wien.  med.  Blatter,  Nos.  6-9,  1883,  a  resume  of  the  pub- 
lished cases  of  this  affection  is  given  to  date. 


BALANITIS  AND  BALANO-POSTHITIS.  395 

ology  of  this  affection  in  12  cases,  states  that  in  cases  where  the  quan- 
tity of  glucose  is  too  small  to  show  unequivocal  reaction  to  the  copper- 
and-potash  test  the  presence  of  these  spores  is  sufficient  to  establish  a 
diagnosis  of  saccharine  urine. 

Simple  balanitis  and  balano-posthitis  sometimes  assume  a  very  severe 
form,  particularly  in  uncleanly  persons  and  in  those  Avho  have  been 
intemperately  treated  by  caustic  applications.  The  penis,  particularly 
at  the  glans,  becomes  very  much  swollen,  very  red,  and  perhaps  the  seat 
of  ulceration.  In  some  cases  the  whole  penis  is  involved.  In  this  stage 
the  affection  may  be  mistaken  for  cancer.  I  once  saw  a  case  of  this 
kind  for  which  amputation  of  the  penis  had  been  proposed  by  a  surgeon, 
and  which  was  promptly  cured  by  cleanliness,  soothing  lotions,  followed 
by  mildly  stimulating  applications.  In  this  condition  of  balano-posthi- 
tis we  do  not  see  the  nodulations  and  large,  warty  growths  so  frequently 
seen  in  epithelioma  of  the  penis,  and,  besides,  the  organ  is  not  deformed, 
as  it  usually  is  in  malignant  disease.  Then,  again,  while  in  balano-pos- 
thitis there  may  be  more  or  less  painful  swelling  of  the  lymphatic  ganglia 
of  the  groin,  these  structures  in  epithelioma  are  enlarged,  hardened,  and 
aphlegmasic.  As  a  rule,  severe  balano-posthitis  is  seen  in  young  men 
and  the  malignant  disease  in  older  ones. 

Balanitis  in  Syphilitic  Subjects. 

In  the  early  stage  of  syphilis,  coincidently  Avith  the  erythematous  or 
papular  rash,  balanitis  is  not  uncommon  in  persons  having  long  and  tight 
foreskins,  particularly  if  they  are  careless  in  the  matter  of  cleanliness. 
With  the  erythematous  syphilide  one  or  more  round  or  oval  deep-red  ex- 
coriations are  developed,  which,  with  the  aid  of  uncleanliness,  may  invade 
the  whole  glans  and  prepuce.  Mild  and  ephemeral  in  its  course  as  this 
specific  balanitis  is  in  cleanly  subjects,  it  may,  owing  to  inattention,  be 
followed  by  ulceration  and  diffuse  thickening  of  the  parts. 

Syphilitic  papules  upon  the  glans,  and  less  commonly  the  prepuce,  also 
owing  to  uncleanliness,  very  often  develop  into  red,  exculcerated  patches 
which  may  involve  both  surfaces  in  inflammation.  It  is  not  very  infre- 
quent to  see  in  early  syphilis  red  patches  and  papules,  both  of  which  go 
on  to  cause  balanitis,  which  are  developed  without  coexistent  dermal 
rashes. 

These  forms  of  balanitis  in  syphilitic  subjects,  unless  properly  cared 
for,  are  very  persistent,  and  are  often  followed  by  indurated  oedema  of  the 
parts,  and  also,  later  on,  by  well-marked  sclerosis  and  phimosis.  In  some 
cases  the  subpreputial  papules  become  much  hypertrophied,  and  in  others 
they  are  followed  by  the  growth  of  simple  vegetations. 

A  diffuse  inflammation  of  a  subacute  character  and  infiltration  into 
more  or  less  of  the  surface  of  the  glans  and  prepuce  are  sometimes  seen 
as  the  expression  of  the  initial  manifestation  of  syphilis.  This  so-called 
"infecting  balano-posthitis"  is  soon  followed  by  the  enlargement  of  the 
inguinal  ganglia,  which,  together  with  its  subacute  course,  tends  to  point 
out  its  specific  nature. 

Chronic  Balanitis. 

In  contradistinction  to  the  foregoing  acute  forms  of  balanitis  there  are 
the  chronic  forms.     In  general,  chronic  balanitis  is  seen  in  persons  beyond 


396  QONORBHCEA  AND  ITS  COMPLICATIONS. 

thirty  years  of  age.  It  generally  begins  upon  the  glans  and  prepuce, 
which  are  usually  in  close  coaptation,  owing  to  some  abnormality.  The 
inflammation  is  usually  of  a  subacute  character,  and  shows  decided  ex- 
acerbations and  remissions.  In  this  way  the  aifection  extends  over  years. 
If  retraction  of  the  prepuce  is  more  or  less  possible,  a  somewhat  reddened, 
thickened,  and  perhaps  slightly  excoriated  surface  is  revealed.  Owing  to 
the  thickness  and  lessened  elasticity  of  the  prepuce,  it  rolls  back,  if  at  all, 
with  difficulty,  and  in  many  instances  this  procedure  is  wholly  prevented 
by  the  development  of  a  fibroid  ring  at  the  preputial  orifice.  Such 
patients  say  that  they  have  constant  inconvenience  with  their  penis,  have 
much  difficulty  in  cleansing  the  foreskin  and  glans,  and  have  recurrences 
of  tolerably  mild  inflammation.  When  examined  from  time  to  time  a 
decided  thickening  of  the  epithelium  is  seen,  together  with  considerable 
increase  in  the  submucous  connective  tissue.  The  parts  then  have  a 
bluish-white,  milky-looking  surface,  which  rarely  becomes  frankly  red, 
owing  to  the  fact  that  the  blood-vessels  have  been  narrowed  by  the  gen- 
eral condensation  of  the  mucous  membrane.  To  the  touch  such  a  glans 
and  foreskin  feel  firm,  somewhat  like  wash-leather,  and  as  time  goes  on 
turgescence  of  the  end  of  the  penis  is  never  complete.  Unless  in  such  a 
case  circumcision  is  performed,  the  growth  of  the  epithelial  covering  of 
the  glans  increases  and  much  diminishes  its  size,  and  very  frequently  it 
so  compresses  it  that  it  levels  the  corona  until  it  is  continuous  in  line  with 
the  fossa. 

Not  only  are  these  cases  distressing  in  the  discomfort  and  suifering 
incident  to  the  progress  of  the  aff'ection,  but  they  are  also  attended  with 
much  gravity,  since  as  years  increase  there  is  a  decided  tendency  for  them 
to  undergo  malignant  degeneration.  Upon  this  thickened  epithelial  cov- 
ering excoriations  form,  which  are  often  very  difficult  to  heal  and  should 
always  be  regarded  in  a  serious  light.  Beginning  thus  as  one  or  more 
excoriated  patches,  unless  art  intervenes  very  soon  an  elevation  is  seen 
which  constantly  increases,  and  later  on  shows  signs  of  malignancy.  This 
is  one  of  the  most  common  modes  of  development  of  cancer  of  the  penis. 

Symptoms, — The  symptoms  of  balanitis  and  balano-posthitis  may  be 
simply  a  slight  itching  or  burning  sensation,  or  a  feeling  of  severe  pain 
attended  by  much  heat  may  be  present.  There  is  often  increased  venereal 
desire.  The  end  of  the  penis  becomes  very  tender,  even  to  a  condition 
of  erethism ;  erections  are  painful,  coitus  frequently  impossible,  and  urin- 
ation attended  with  a  burning  sensation.  A  thin,  milky,  or  a  creamy 
purulent  discharge  is  constant. 

Causes. — In  most  cases  balanitis  is  due  to  uncleanliness,  and  results 
from  the  decomposition  of  the  epithelial  matter  which  is  formed  in  the 
crypts  seated  in  the  mucous  layer  of  the  prepuce.  Excess  in  coitus,  coitus 
with  a  woman  with  a  small  vulvar  orifice  or  Avith  one  suff'ering  from  leu- 
corrhoea,  and  masturbation  are  frequent  causes.  The  existence  of  vege- 
tations under  the  prepuce  is  a  frequent  cause  of  balanitis,  and  the  lodge- 
ment of  gonorrhoeal  pus  in  that  position  also  causes  it.  In  some  cases  the 
gonorrhoeal  discharge  excites  inflammation  at  the  preputial  orifice,  which 
extends  to  the  prepuce  and  glans.  Chancroidal  pus  and  the  secretions  of 
primary  and  secondary  syphilitic  lesions,  and  these  lesions  themselves,  are 
also  prolific  causes  of  balanitis. 

Micro-organisms  play  an  important  part  in  the  development  of  balano- 


BALANITIS  AND  BALANO-POSTHITIS. 


397 


posthitis,  as  has  been  shown  in  the  descriptive  part  of  this  chapter.  Much 
study,  however,  is  yet  necessary  to  place  this  subject  on  a  clear  and  scien- 
tific basis. 

Complications. — While  balanitis  may  result  from  phimosis,  the  latter 
may  be  produced  by  balanitis.  Paraphimosis  may  also  result  from  inflam- 
mation of  the  prepuce  and  glans. 

Lymphangitis  of  a  mild  or  severe  type  is  not  at  all  infrequent  in  severe 
balano-posthitis,  and  is  quite  common  when  that  affection  is  complicated 
with  chancroids  and  various  syphilitic  lesions,  also  with  gonorrhoea  and 
vegetations.  In  mild  cases  the  lymphatic  vessels  feel  like  cords  under  the 
foreskin.  In  severe  cases  the  whole  penis  becomes  of  a  deep  red,  greatly 
swollen,  oedematous,  and  the  seat  of  severe  pain — a  condition  incorrectly 
called  "penitis."  In  these  cases  phlegmonous  abscesses  may  form  under 
the  skin.  Following  lymphangitis  of  balanitic  origin,  inflammation  of 
the  inguinal  ganglia,  and  even  suppurating  buboes,  may  result. 

Not  infrequently,  particularly  in  uncleanly  persons,  diabetics,  also  in 
those  debilitated  by  disease  or  excesses,  gangrene  of  the  prepuce  occurs 
from  balanitis.  Owing  to  the  inflammation  of  the  parts  and  swelling  of 
the  glans,  a  black  spot  forms  about 
the  middle  of  the  prepuce,  and 
through  the  buttonhole-like  open- 
ing which  results  the  glans  pro- 
trudes.    (See  Fig.  131.) 

In  cases  of  recurrent  attacks 
of  acute  balanitis  thickening  of  the 
submucous  connective  tissue  is  not 
at  all  uncommon,  and  may  at  times 
present  points  of  resemblance  to 
syphilitic  or  infecting  balano-pos- 
thitis. In  some  cases  of  acute 
balanitis  well-defined,  freel}''  mov- 
able, flat  plates  of  thickened  sub- 
mucous tissue  of  various  sizes  and 
extent,  which  can  be  readily  grasped 
between  the  thumb  and  forefinger, 
may  be  felt.  I  have  frequently 
seen  these  plates  of  such  firm  struc- 
ture and  so  sharply  limited  that 
they  have  been  mistaken  by  my 
internes  for  hard  chancres.       Not 

uncommonly,  after  an  attack  of  acute  balano-posthitis,  a  semicircular  ring 
of  this  thickened  submucous  tissue  is  felt  for  some  time  behind  the  corona, 
and  it  causes  retraction  to  be  less  promptly  performed  than  it  is  normally. 

In  a  phimotic  prepuce,  besides  the  thickening  of  the  tissues,  a  fibroid 
ring  is  formed  around  its  orifice  in  consequence  of  recurrent  inflammation, 
and  in  it  numerous  troublesome  radiating  fissures  may  form. 

Phimosis  and  paraphimosis  as  a  result  of  balanitis  have  already  been 
spoken  of.  By  far  the  most  serious  complication  and  sequela  of  chronic 
balanitis  in  middle-aged  and  old  persons  is  the  tendency  to  hyperplasia 
of  the  epidermis  of  the  glans  and  prepuce,  which  is  so  prone  to  lead  to 
epitheliomatous  degeneration.     Adhesions  of  various  sizes  and  possessing 


Fig.  131. 

■m 

1 

■ 

wSHfr                   "^H 

^^^H 

^^^^■^ 

■f  /                     %         ^ 

!■ 

^H 

Wm^^mj^  . 

j| 

H 

i 

B 

:.^^^H 

^^■H|iM^HB^^^^| 

^^^B 

^^^^^^H 

^^^^H 

■ 

HI 

b 

~4 

Gangrene  of  prepuce,  with  button-hole  opening 
for  glans. 


398  GONOREHGEA  AND  ITS  COMPLICATIONS. 

varying  degrees  of  firmness  are  not  infrequent  in  cases  of  phimosis  com- 
plicated with  balano-posthitis. 

Vegetations  as  results  of  balanitis  will  be  considered  later. 

Diagnosis. — In  mild  cases  the  diagnosis  of  balanitis  is  readily  made 
upon  retraction  of  the  prepuce.  However,  when  there  is  difficulty  of 
retraction  the  case  may  be  mistaken  for  gonorrhoea.  If  the  orifice  of  the 
prepuce  is  large  enough  to  allow  inspection  of  the  meatus,  the  parts  can 
be  carefully  wiped,  and  then,  when  pressure  is  made  upon  the  under  sur- 
face of  the  urethra,  if  gonorrhoea  is  present  pus  will  exude  from  the 
meatus.  If  it  is  suspected  that  both  balanitis  and  gonorrhoea  are  present, 
the  meatus  may  be  carefully  plugged  with  a  little  ball  of  cotton,  and  then 
the  prepuce  may  be  compressed  from  behind  forward.  In  this  way  a 
correct  conclusion  may  be  reached.  If  the  urethra  is  found  to  be  free 
from  inflammation,  pressure  over  the  whole  surface  of  the  glans  from 
behind  forward  will  cause  pus  to  escape  from  the  preputial  orifice.  Be- 
sides these  points  of  diagnosis  the  subjective  symptoms  will  also  be  of 
assistance.  The  presence  of  gonococci  in  the  pus  will  show  that  gonor- 
rhoea is  present.  In  ordinary  balanitis  or  balano-posthitis  pus,  strepto-, 
and  staphylococci  and  the  smegma  bacillus  may  be  seen. 

Herpes  progenitalis,  especially  when,  from  any  cause,  accompanied 
with  much  hypersemia,  may  be  at  first  mistaken  for  balanitis,  but  the 
history  of  the  case  may  be  of  aid,  and  upon  subsidence  of  the  inflamma- 
tion the  sharply-limited  margins  of  the  vesicles  Avill  reveal  the  nature  of 
the  aff"ection. 

The  most  difficult  task,  very  often,  in  the  diagnosis  of  balanitis  is  to 
determine  whether  or  not  chancroids  or  hard  chancres  lodged  under  the 
prepuce  are  at  the  bottom  of  the  trouble.  Chancroidal  ulcers  may  have 
been  seen  before  the  phimotic  balanitis  had  developed,  and  then  its  origin 
is  clear.  But  in  many  cases,  from  carelessness  or  ignorance,  patients  can 
give  no  history  of  a  chancre  or  chancroid.  Subpreputial  chancroids  are 
attended  with  much  more  severe  and  rapid  inflammation  than  simple 
balano-posthitis.  The  pus  becomes  very  copious,  less  thick  and  creamy 
than  in  the  simple  aff"ection,  and  commonly  of  a  rusty  color.  Soon  the 
distal  end  of  the  penis  becomes  swollen,  in  shape  like  an  Indian  club, 
and  of  a  dusky-red  color,  and  very  frequently  chancroids  are  developed 
by  auto-inoculation  around  the  preputial  orifice.  Then  in  chancroidal 
phimosis  there  is  the  early  supervention  of  lymphangitis  and  of  adenitis,, 
both  of  which  show  a  tendency  to  rapid  destruction  of  the  tissues.  It 
should  be  borne  in  mind  that  in  broken-down,  starved,  dissipated,  and 
neglectful  persons  simple  balano-posthitis  may  frequently  become  of  such 
severity  that  the  features  of  chancroidal  phimosis  are  present. 

Subpreputial  hard  chancres  producing  phimosis  may  be  mistaken  for 
simple  balanitis.  This  complication,  as  a  rule,  is  much  less  active  in  its 
nature  than  chancroidal  phimosis.  The  affection  increases  slowly,  usually 
with  much  less  secretion  of  pus,  it  being  at  first  very  often  a  sero-pus. 
The  oedema  increases  slowly,  is  more  aphlegmasic  or  less  red,  but  rather 
firmer.  The  diagnosis  is  usually  soon  cleared  up  by  the  development  of 
the  indurated  ganglia  in  the  groin,  and  perhaps  by  the  induration  of  the 
lymphatics  and  veins  of  the  penis.  In  very  many  cases  it  is  possible, 
upon  careful  palpation,  to  determine  the  presence  of  a  well-defined  indu- 
ration  under  the   prepuce.     It  must   be   remembered  that  subpreputial 


BALANITIS  AND  BALANO-POSTHITIS.  399 

vegetations  also  grow  slowly,  produce  phimotic  balano-posthitis,  and  feel 
like  hard  chancres  under  the  prepuce.  The  secretion  accompanying  them 
is  profuse  and  of  a  disgusting  odor,  the  inflammatory  reaction  is  rather 
late  in  appearing,  and  the  lymphangitis  and  adenitis  are  less  common  and 
of  a  more  inflammatory  nature  than  in  the  phimotic  balanitis  of  hard 
chancre. 

It  is  sometimes  a  difficult  question  to  decide  whether  in  a  given  case 
phimotic  balanitis  is  caused  by  chancroids  or  vegetations,  and  sometimes 
it  can  be  done  only  after  incision  of  the  prepuce. 

Prognosis. — In  general,  the  prognosis  of  balanitis  is  good.  When  due 
to  chancroids,  besides  the  destruction  of  the  prepuce  and  glans — and 
perhaps  of  the  urethra — which  is  so  liable  to  occur  unless  proper  treat- 
ment is  instituted,  chancroidal  ulceration  in  the  lymphatics  and  chan- 
croidal buboes  may  result.  Hemorrhage  also  is  very  common  and  often 
very  persistent,  and  phagedena  may  be  produced.  Balanitis  from  hard 
chancres  may  result  in  more  or  less  destruction  of  the  prepuce  and  glans, 
compression  and  stenosis  of  the  urethra,  and  phagedena. 

Balanitis  and  balano-posthitis  caused  by  early  syphilitic  lesions  are 
easily  cured  if  early  recognized  and  properly  cared  for. 

The  balano-posthitis  of  elderly  persons,  with  its  epithelial  hyperplasia, 
is  the  source  of  great  annoyance  from  the  discomfort  produced  and  the 
hindrance  to  proper  cleanliness,  and  is  of  positive  danger  in  the  tendency 
which  it  induces  to  epitheliomatous  degeneration  of  the  prepuce,  glans^ 
and  penis. 

Treatment. — Mild  cases  of  balanitis  are  readily  relieved  by  the  re- 
traction of  the  prepuce,  cleanliness,  and  the  interposition  of  lint  or  absorb- 
ent cotton  soaked  in  plain  boiled  or  distilled  water.  But  various  lotions 
also  may  be  used.  When  there  is  much  excoriation  a  one-grain-to-the- 
ounce-of-water  solution  of  nitrate  of  silver  is  often  very  efficacious,  or  two 
grains  of  alum  to  the  ounce  of  Avater  may  be  used.  Solutions  of  lead  are 
particularly  useful  when  there  is  much  inflammation  ;  thus : 

^.  Liq.  plumbi  subacetat.,  5ss-3j  ; 

Aquae,  |iv. — M. 

To  this  may  be  added  either  one  drachm  of  laudanum  or  two  drachms  of 
wine  of  opium. 

In  like  manner  the  following  prescriptions  may  be  of  much  service : 

I^.  Acid,  boracic, 

Acid,  tannici,  da.  3ss  ; 

Aqu£e,  Siv. — M. 

I^.  Liq.  sodae  chlorinatae,  .  .5ij  ; 

Aquee,  ovj. — M. 

'Sf.  Zinci  sulphat.,  gr.  vj  ; 

Spts.  lavandulae  comp., 

Vin.  opii,  da.  .^ij  ; 
Aquas,  5iv. — M. 


400  QONOBBHCEA  AND  ITS  COMPLICATIONS. 

I^.   Resorcin,  3j  ; 

Aquae,  ^iv. — M. 

I^,  Zinci  acet.,  gr.  viij  ; 

Listerine,  Siij  ; 

Aquae,  ad  §iv. — M. 

Chichester  ^  speaks  highly  of  the  following  combination : 

]^.  Atropiae  sulph.,  gr.  j  ; 

Zinci  sulph.,  gr.  ij  ; 

Acidi  borici,  gr.  vj  ; 

Aquae  destil.,  5j. — M. 

Sig. — Apply  three  or  four  times  a  day  with  a  brush. 

It  is  assumed  that  the  local  physiological  action  of  the  atropine  is  to  sus- 
pend the  function  of  the  raucous  membrane  and  its  glands  {sic),  and  thus 
jugulate  the  secretions.  The  preparation  is  certainly  very  soothing,  and 
in  ordinarily  mild  cases  efficacious.  Lint  or  cotton  should  be  interposed 
between  the  surfaces. 

In  some  very  rebellious  chronic  and  relapsing  cases  I  have  seen  strik- 
ing results  follow  the  use  of  a  solution  of  chloride  of  zinc,  beginning  with 
half  a  grain  and  going  up  to  two  grains  to  the  ounce  of  water. 

In  obstinate  cases  of  diphtheritic  balano-posthitis  Kaufmann  ^  says  that 
he  obtained  the  best  results  from  the  application  of  strong  tincture  of 
iodine,  either  painted  on  the  parts  or  applied  on  cotton.  In  all  cases  of 
these  affections  the  first  aim  should  be  to  put  and  keep  the  parts  in  as 
nearly  an  aseptic  condition  as  possible. 

The  aromatic  wine  of  the  Pharmacopoeia  is  a. pleasant  and  efficacious 
application,  used  by  means  of  lint  or  absorbent  cotton.  Lime-water  is 
also  a  pleasant  application. 

Balanitis  resulting  from  early  syphilitic  lesions  is  much  benefited  by 
the  use  of  black  wash  or  yellow  wash,  which  is  also  beneficial  in  many 
cases  of  simple  balanitis. 

A  solution  of  bichloride  of  mercury  (1  :  2000  of  water)  is  often  very 
efficacious.  When  excoriations  are  present,  after  superficial  pencilling  with 
a  solution  of  nitrate  of  silver  (ten  grains  to  the  ounce  of  water)  the  sur- 
face may  be  dusted  Avith  iodoform,  and  then  a  little  film  of  perfumed 
absorbent  cotton  placed  over  it.  Boracic  acid,  calomel,  and  subnitrate  of 
bismuth  may  also  be  used,  particularly  toward  the  decline  of  the  affection. 
Aristol  may  also  be  tried. 

Salves  should  not  be  used,  and  poultices  should  be  strictly  prohibited, 
since  they  do  no  good  and  cause  cedema. 

Copious  and  frequent  ablutions  of  the  parts  should  be  practised  several, 
times  a  day,  and  when  there  is  any  tendency  to  phimosis  frequent  injec- 
tions of  hot  water  slightly  alkalinized  by  borax,  or  a  mild  solution  of 
alum,  or  dilute  lead-Avater,  or  a  solution  of  bichloride  of  mercury  (1  :  2000 
to  5000)  or  of  carbolic  acid  (1  :  200),  should  frequently  be  made  as 
directed  in  the  Treatment  of  Phimosis. 

1  Medical  Record,  March  21,  1891,  p.  356. 

*  Verletzungen  und  Krankheiten  der  Mdnnlichen  Harnrbhre  und  Penis,  Stuttgart,  1 886,  p. 
232. 


PHIMOSIS. 


401 


The  penis  should  be  kept  from  hanging  down  by  appropriate  bandaging, 
and,  as  far  as  possible,  the  recumbent  position  should  be  assumed.  In 
these  cases  the  jock-strap  (see  page  249)  Avill  often  be  of  great  service. 

When  phimosis,  congenital  or  acquired,  exists,  circumcision  should  be 
advised.  The  treatment  of  balanitis  complicated  by  chancroids,  hard 
chancres,  and  vegetations  is  given  under  the  appropriate  heads. 


CHAPTER    XXXIV. 


PHIMOSIS. 


Phimosis  is  that  condition  of  the  prepuce  which  prevents  its  retrac- 
tion and  the  exposure  of  the  glans.     It  may  be  congenital  or  acquired. 

The  morbid  structural  conditions  giving  rise  to  congenital  phimosis 
are — first,  the  narrowing,  sometimes  entire  occlusion,  of  the  preputial 
orifice;  second,  a  straitness  and  narrowness  of  the  prepuce  itself;  and 
third,  shortness  of  the  frgenum.  To  these  may  be  added,  in  the  acquired 
form,  redundance  of  the  prepuce.  The  orifice  of  the  prepuce  may  be 
as  small  as  a  pin's  head,  when  it  may  oJBfer  an  impediment  to  urination 


Fig.  132. 


Fig.  133. 


Congenital  phimosis  in  the  infant. 


and  prevent  inspection  of  the  meatus,  and  as  large  as  the  diameter  of  a 
pea.  Not  infrequently  boys  who  have  not  suffered  from  phimosis  in 
their  youth  do  so  later  on,  owing  to  the  growth  of  the  glans  penis  and 
to  the  concomitant  imperfect  development  of  the  prepuce. 


26 


402 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


In  most  cases  of  congenital  phimosis  there  are  adhesions  between  the 
mucous  membrane  and  the  glans.  These  may  be  thin,  small,  but  num- 
erous and  easily  broken  up,  or  they  may  be  extensive  and  firm,  even  to 
the  complete  adherence  of  the  whole  prepuce  and  the  glans.  In  Figs. 
132  and  133  are  well  portrayed  the  appearances  of  congenital  phimosis  in 
the  infant.  In  this  case  there  was  constant  erethism  of  the  parts,  and 
the  slightest  handling  of  the  penis  caused  it  to  become  erect  at  once. 
The  preputial  orifice  was  so  small  that  it  prevented  the  free  escape  of 
urine  and  caused  the  distal  portion  of  the  prepuce  to  become  ballooned 
•out.  This  ballooning  of  the  phimotic  prepuce  is  not  uncommonly  seen 
in  later  life.  In  such  cases  children  soon  become  masturbators.  A  case 
is  reported  in  which  the  prepuce  was  attached  to  the  margin  of  the 
meatus  and  formed  a  tubular  prolongation  of  the  urethra  nearly  an 
inch  long.  Redness,  heat,  and  perhaps  superficial  ulceration  often  result 
from  contact  of  the  urine  and  want  of  cleanliness.  These  conditions  in 
their  turn  may  lead  to  cicatricial  stenosis  of  the  orifice. 

In  Figs.  134  and  135  are  shown  the  appearances  of  the  penis  of  a 


Fig.  134. 


Fig.  135. 


(_'uiig<jnital  phimosis 


Congenital  phimosis,  showing  great  development 
of  the  penis  with  lack  of  development  of  the 
glans. 


young  man  who  suffered  from  phimosis  from  infancy.  In  this  case  the 
prepuce  was  long  and  tight,  while  the  body  of  the  penis  was  large.  The 
slightest  touch  caused  erection,  as  shown  in  Fig.  135,  in  which  the  glans 
appears  remarkably  small  for  such  a  penis,  and  it  is  firmly  constricted 
behind  the  glans  by  the  tight  preputial  orifice.  This  patient  suffered  all 
the  discomforts  just  mentioned. 

Congenital  phimosis  gives  rise  to  balanitis,  heat,  itching,  even  pain, 
in  the  head  of  the  penis,  and  a  consequent  erethism  of  the  genitals,  with 


PHIMOSIS. 


403 


Fig.  136. 


frequent  erections,  symptoms  pointing  to  stone  in  the  bladder,  lascivious 
dreams,  seminal  emissions,  and  incontinence  of  urine,  especially  at  night. 
Such  subjects  are  often  addicted  to  masturbation.  As  they  grow  older 
there  is  in  many  an  arrest  of  development  of  the  penis,  and  sometimes 
of  the  testes.  When  puberty  is  reached  any  or  all  of  the  foregoing 
symptoms  may  exist,  and  such  subjects  often  complain  of  too  speedy 
ejaculations  and  a  not  full  and  complete  enjoyment  of  sexual  inter- 
course. At  and  beyond  puberty  phimosis,  in  most  cases  seconded  by 
masturbation,  may  give  rise  to  congestion  and  inflammation  of  the  mem- 
branous and  prostatic  portions  of  the  urethra. 

In  early  life,  as  remote  effects  of  phimosis,  it  has  been  conclusively 
shown  that  nervous  disturbances,  incoordination  of  the  muscles  of  locomo- 
tion and  of  speech,  hyperaesthesia,  amblyopia,  and  hypochondriasis  have 
been  produced. 

It  must  be  remembered,  however,  that  there  are  many  cases  of  phi- 
mosis which  are  not  attended  by  any  of  the  foregoing  symptoms,  direct 
or  remote.  At  puberty  and  later,  however,  phimosis  always  gives  rise 
to  unpleasant  symptoms  of  varying  degrees  of  severity,  such  as  balanitis, 
balano-posthitis,  interference  with  erec- 
tions and  the  sexual  act.  At  this  period, 
particularly,  it  is  a  prolific  cause  of 
masturbation  and  of  a  morbid  desire  for 
coitus. 

While  in  general  phimosis  may  give 
rise  to  balanitis,  the  latter  affection  may 
give  rise  to  phimosis.  This  feature  was 
observed  in  the  case  from  which  Fig. 
136  was  taken.  The  patient  had  a  long 
prepuce,  with  a  not  very  tight  orifice, 
which  would  admit  of  fairly  easy  re- 
traction. He  was  subject,  however,  to 
relapsing  attacks  of  balano-posthitis  of 
some  severity,  in  which  the  prepuce  be- 
came inflamed  and  oedematous,  as  shown 
in  the  figure.  In  this  case  the  peculiar 
pouting  chin  of  phimosis  is  Avell  shown, 
jutting  up  and  filling  in  the  preputial 
orifice.  This  appearance  is  due  to  severe 
<]edema  of  the  prepuce  near  the  frsenum. 

At  puberty  the  irritation  caused  by 
phimosis  often  results  in  the  develop- 
ment   of    vegetations    or    warts,    and    in       Phimosis  from  Mano-^l^osthitis  with  the 

later  life,  as  a  consequence  of  it,  cancer 

of  the  penis  is  liable  to  occur.     In  tropical  countries  elephantiasis  of 

the  penis  frequently  begins  in  a  phimotic  prepuce. 

There  is  a  condition  of  the  penis  in  which  patients  suffer  much  dis- 
comfort until  relieved  by  operation.  It  is  admirably  shown  in  Figs.  137 
and  138.  This  condition  consists  in  smallness  of  the  preputial  orifice, 
smallness  as  to  calibre,  and  shortness  of  the  prepuce,  together  with  a 
short  fibrous  frsenum.  In  these  cases  all  the  unpleasant  symptoms  of 
phimosis  are   present,  and  a  chronic  rebellious  balano-posthitis  is  an 


404 


GONORRHCEA  AND  ITS  COMPLICATIONS. 


important  factor.     Usually,  in  such   cases,  the  glans  remains  stunted 
and  small  in  circumference  and  length,  as  is  Avell  shown  in  the  figure. 

In   China   and  in  tropical 
Fig.  137.  countries  it  is  not  uncommon 

to  find  a  calculus,  or  several 
of  them,  under  the  prepuce  in 
cases  of  phimosis.  These  cal- 
culi may  be  small,  but  they 
are  sometimes  very  large,  and 
weigh  one  or  more  ounces.  In 
shape  they  are  round  or  oval, 


Fig.  138. 


Smallness  of  preputial  orifice,  with  fibroid  frsenum. 


convex  and  concave,  and  when  there  are  several  in  apposition  they  are 
facetted. 

In  some  cases  of  congenital  phimosis  plates  and  masses  of  smegma 
form  under  the  prepuce,  which  is  bulged  out  by  them.  Sometimes 
these  smegma-masses  are  so  firm  in  structure  that  they  are  mistaken  for 
calculi.  They  may  remain  in  an  indolent  condition  for  years,  and  may 
give  rise  to  no  symptoms. 

The  morbid  process  in  phimosis  of  all  forms  may  be  simply  inflam- 
matory oedema,  or  this  condition  plus  simple  or  specific  cell-infiltration. 

Acquired  or  accidental  phimosis  may  exist  in  a  prepuce  normally 
rather  small,  but  capable  of  thorough  retraction,  or  in  one  which  in  the 
normal  state  passes  readily  backward  and  forward  over  the  glans.  The 
causes  of  it  are  want  of  cleanliness,  the  decomposition  of  diabetic  urine, 
excessive  venery,  perhaps  increased  by  the  abuse  of  stimulants,  gonor- 
rhoea, herpes  preputialis,  eczema,  chancroids,  and  hard  chancres.  Trau- 
matism and  compression  of  tightly-fitting  pantaloons  are  also  causes. 
The  symptoms  vary  in  severity  and  in  the  nature  of  their  concomitants 
according  to  the  cause. 

Phimosis  resulting  from  uncleanliness  and  excessive  venery  presents 
nothing  characteristic.  The  prepuce  is  red  and  inflamed,  and  there  is 
more  or  less  balanitis.  It  is  usually  an  ephemeral  trouble  and  readily 
amenable  to  local  remedies.  Phimosis  complicating  gonorrhoea  is  often 
a  troublesome  concomitant,  since  it  interferes  so  much  Avith  the  treat- 
ment of  that  affection.  There  is  commonly  much  redness  and  swelling, 
and  it  often  produces  curious  deformities  of  the  organ,  as  shown  in  Fig. 


PHIMOSIS. 


405 


139,  in  which  the  prepuce  is  much  swollen.  In  some  cases  the  penis  is 
curved  upward,  in  others  downward,  and  sometimes  laterally.  Some- 
times the  intensity  of  the  inflammation  is  seated  in  the  prepuce  near  the 
fraenum,  which  becomes  swollen  and  turned  inward,  giving  the  appear- 
ance of  a  pouting  chin.    (See  Fig.  136.)     Then,  again,  the  whole  extent 


Fig.  139. 


Gonorrhceal  phimosis. 


of  the  foreskin  may  be  involved,  in  which  case  the  distal  end  of  the 
penis  becomes  greatly  swollen  and  comes  to  resemble  a  miniature  Indian 
club.  In  all  of  these  cases  there  is  a  purulent  urethral  discharge. 
Phimosis  caused  by  herpes  progenitalis  consists  of  redness  and  oedema 
of  the  distal  end  of  the  penis,  together  with  vesicles. 

Gangrene  is  a  rather  uncommon  complication  of  the  simple  forms  of 
inflammatory  phimosis,  excepting  when  due  to  traumatism  and  diabetes ; 
it  is  not  rare  in  the  severer  forms. 

Cicatricial  phimosis  belongs  to  the  category  of  the  acquired  affec- 
tions. Cicatrices  frequently  follow  fissures  and  ulceration  which  have 
been  produced  by  forcible  retraction.  A  fibroid  preputial  ring  is  not 
uncommonly  seen  in  cases  of  phimotic  prepuce.  Chronic  balano-pos- 
thitis  also,  in  some  cases  of  long  and  somewhat  phimotic  prepuce,  causes 
a  condition  of  cicatrization  of  its  outer  preputial  layer  which  much 
intensifies  the  phimosis.  This  condition  of  cicatrization  of  the  prepuce 
is  shown  in  the  irregular  white  area  of  the  distal  portion  of  the  prepuce 
in  Fig.  140.  Such  is  the  stenosis  of  the  preputial  orifice  in  these  cases 
that  circumcision  alone  will  relieve  them  of  their  discomfort  and  suffer- 


406 


GONORBHCEA  AND  ITS  COMPLICATIONS. 


Fig.  140. 


ing.  Recurrent  herpes  preputialis  may  cause  stenosis  of  the  orifice^ 
either  from  scars  or  infiltration.  It  is  somewhat  remarkable  that  in 
some  cases  of  phimosis,  where  retraction  has  been  impossible  throughout 
life,  little  if  any  suffering  has  been  produced.     In  Fig.  141  is  shown  a 

phimotic  prepuce  with  a  firm  fibrous 
ring  at  the  orifice,  the  development 
of  twenty-five  years.  In  this  case 
there  was  no  suffering  or  discomfort, 
and  the  development  of  the  fibroid 
tissue  was  so  aphlegmasic  that  it  was 
not  appreciable  to  the  patient. 

From  puberty  to    old  age   recur- 
rent balanitis,  even  in  persons  having 

Fig. 141. 


Cicatricial  phimosis 


Fibroid  ring  at  preputial  orifice. 


roomy  foreskins  and  of  cleanly  habits,  sometimes  leads  to  increase  and 
induration  of  the  subpreputial  connective  tissue,  and  converts  that 
appendage  into  a  rather  resistant,  inextensible  cylinder  which  is  with 
difficulty  retracted.  In  some  cases  the  subpreputial  connective  tissue  is 
converted  into  flat,  firm  plates  of  tissue,  Avhich  prevent  retraction  and 
favor  inflammation. 

In  elderly  men,  as  they  advance  in  age  and  obesity,  the  integument 
of  the  penis  often  becomes  redundant  and  lax.  As  time  goes  on  the  pre- 
puce becomes  much  elongated  and  extends  well  down  beyond  the  end  of 
the  glans.  The  organ  then,  in  many  cases,  becomes  a  source  of  discom- 
fort. The  inner  layer  of  the  prepuce  becomes  hyperpemic  and  the  urine 
and  smegma  readily  decompose  and  cause  irritation,  with  burning  sensa- 
tions. This  phimosis  of  elderly  men  with  a  tendency  to  obesity  is  well 
shown  in  Fig.  142. 

The  initial  lesion  of  syphilis,  when  seated  on  the  inner  leaf  of  the 
prepuce  at  the  fraenum  and  in  the  sulcus,  very  frequently  in  the  lower 
classes  produces  phimosis,  caused  usually  by  want  of  care  and  uncleanli- 
n^s.     The  distal  portion  of  the  j^enis  becomes  much  swollen,  and  in 


PHIMOSIS. 


4or 


typical  cases  the  inflammation  is  of  a  low  grade.  Then  we  find  the 
organ  at  the  preputial  portion  of  a  deep  bluish-red,  not  hot  nor  painful. 
In  some  cases  the  induration  may  be  made  out  by  palpation,  but  usually 
as  the  phimosis  develops  the  sclerotic  mass  or  nodule  is  so  masked  by  the- 


Fig.  142. 


/ 


4^i^0i 


Phimosis  from  obesity  and  laxity  of  the  integument. 


surrounding  oedema  that  it  cannot  be  recognized.  Usually  the  condi- 
tion remains  rather  aphlegmasic.  The  indurated  tissues  continue  to 
have  the  bluish-red  color,  without  heat  or  pain,  and  the  condition  is 
further  complicated  with  typical  enlargement  of  the  inguinal  ganglia. 
In  some  cases  pus,  and  in  others  sero-pus,  escapes  from  the  preputial 
orifice. 

In  other  cases,  however,  the  initial  lesion  under  the  prepuce  in  phi- 
mosis becomes  inflamed,  and  then  the  condition  resembles  chancroidal 
phimosis.  In  many  of  these  cases  chancroids  form  at  the  free  end  of 
the  prepuce,  and  a  mistake  in  diagnosis  is  then  very  liable  to  be  made. 
In  such  cases  the  history  and  the  condition  of  the  .inguinal  ganglia  may 
afford  aid  in  the  recognition  of  the  real  condition  of  affairs.  Chronic 
indurating  oedema  complicating  chancres  and  secondary  lesions  may 
cause  phimosis. 

Chancroidal  phimosis  is  usually  due  to  want  of  care  of  subpreputial 


408 


GONORRHCEA  AND  ITS  COMPLICATIONS. 


Fig.  143. 


lesions,  and  frequently  to  a  too  active  cauterization  of  them.  The  pre- 
puce then  becomes  very  red,  swollen,  and  often  quite  painful,  and  from 
its  orifice  a  dark-green  or  rusty-colored  pus  escapes  in  considerable 
quantity.  The  penis  then  becomes  so  much  swollen  at  the  glandu- 
lar portion  that  it  resembles  a  miniature 
Indian  club.  If  relief  is  not  given  by 
operation  or  the  chancroidal  process 
stayed  by  intra-preputial  antiseptic  in- 
jections, the  whole  prepuce  continues 
to  become  larger  and  more  dusky  red, 
the  suffering  of  the  patient  greater,  and 
the  discharge  is  then  very  copious  and 
of  very  bad  odor.  Then,  not  unfre- 
quently  destruction  of  the  tissues  at  the 
preputial  orifice  occurs,  as  shown  in 
Fig.  143.  If  relief  is  not  afforded, 
the  inner  leaf  of  the  prepuce  or  the 
glans  penis  is  more  or  less  destroyed. 
In  some  cases  ulceration  occurs  through 
the  prepuce,  and  through  the  hole  thus 
formed  the  glans  then  protrudes.  In 
these  severe  cases  nearly  the  whole 
penis  becomes  of  a  dusky-red  color,  and 
the  appearances  presented  are  those  of  a 
very  actively  destructive  subpreputial 
inflammation.  This  condition  is  in 
striking  contrast  with  the  cold,  rather 
unprogressive,  course  of  phimosis  from 
hard  chancres.  In  many  cases  of  chan- 
croidal phimosis  there  is  a  complicating 
chancroidal  bubo  in  the  groin. 
Treatment. — Some  benefit  may  be  derived  in  congenital  phimosis  by 
the  gradual  expansion  of  the  preputial  orifice  by  means  of  Nelaton's 
forceps  or  dilator.     (See  Fig.  144.)     Care  must  be  exercised  that  rup- 


Chancroidal  phimosis  with  Indian-club- 
shaped  penis  and  destruction  of  the 
distal  part  of  the  prepuce. 


Fig.  144. 


Nelaton's  phimosis  forceps. 


ture  of  the  tissues  is  not  produced,  and  that  the  operation  is  not  per 
formed  at  short  intervals :  in  any  case  circumcision  is  far  preferable. 
Slitting  up  the  prepuce  on  the  dorsum,  in  whole  or  in  part,  should  only 


PHIMOSIS. 


409 


very  exceptionally  be  done,  since  good  results  do  not  commonly  follow. 
Very  little  more  trouble  is  involved  in  the  operation  for  circumcision, 
and  the  cure  then  is  perfect.  Dr.  Bumstead's  suggestion,  that  it  would 
be  well  for  the  future  comfort  of  their  boys  if  fathers  would  inquire  into 
the  condition  of  the  penis  while  they  are  young,  should  be  widely 
heeded.  Indeed,  such  attention  to  hygiene  is  very  often  urgently  called 
for  in  infantile  life.  In  children  having  long  foreskins,  when  an  opera- 
tion is  impracticable,  the  utmost  attention  should  be  paid  to  cleanliness, 
particularly  in  removing  sebaceous  matter  and  in  preventing  lodgement 
of  the  urine.  Acute  inflammatory  phimosis  is  not  uncommon  in  chil- 
dren, and  should  be  treated  by  copious  intra-preputial  injections  of  very 
warm  water,  followed  by  a  mild  solution  of  carbolic  acid  or  of  boracic 
acid  or  of  lead- water. 

In  inflammatory  phimosis  the  recumbent  position  should  be  insisted 
upon,  and  a  light  diet  and  a  brisk  cathartic  ordered.  Copious  intra- 
preputial  injections  of  hot  water,  followed  by  a  1  per  cent,  solution  of 
carbolic  acid,  should  be  made  every  two  or  three  hours.  If  the  pre- 
putial orifice  is  too  small  to  admit  the  nozzle  of  a  syringe,  it  may  be 
enlarged  by  the  careful  use  of  Nekton's  forceps  or  by  means  of  a  sponge 
tent. 

Injections  may  be  made  by  various  syringes:  the  one  invented  by 
me  is  of  especial  benefit.    (See  Fig.  145.)    The  nozzle,  which  is  made  of 


Fig.  145. 


Author's  syringe  for  subpreputial  injections. 

India-rubber,  is  about  two  inches  long  and  flat,  and  on  its  rounded  end 
are  several  holes,  and  it  may,  if  desired,  be  used  with  a  fountain  syringe 
or  irrigator.  An  ordinary  small  glass  nozzle  may  often  be  of  very  great 
service. 

Whatever  fluid  is  used,  it  is  necessary  to  see  that  it  reaches  all  of  the 
intra-preputial  cavity,  especially  behind  the  glans. 

While  the  patient  remains  recumbent  it  is  well  to  keep  the  penis 
elevated  and  enveloped  in  old  linen  or  absorbent  cotton,  saturated  either 
with  ice-water,  a  solution  of  muriate  of  ammonia,  or  a  lead-and-opium 
or  carbolic  wash.  The  cold-water  coil  may  be  necessary  in  very  severe 
cases. 

Leeches  should  never  be  used  to  the  penis,  since  they  may  produce 
lymphangitis  or  septic  dermatitis.  In  very  bad  cases  they  may  be  of 
benefit  if  a  sufficient  number  are  applied  to  the  groins. 

As  soon  as  retraction  of  the  prepuce  is  possible  lint  or  old  linen  or 
absorbent  cotton  soaked  in  lead-and-opium  wash  must  be  placed  between 
it  and  the  glans,  and  treatment  followed  as  given  in  the  section  on 
Balanitis. 

Phimosis  from  gonorrhoea  needs  active  and  continuous  treatment,  in 
addition  to  that  of  the  acute  stage  of  the  discharge.  Intra-preputial 
injections,  very  hot,  frequently  made,  and  large  in  quantity,  of  1  part 


410 


GOXOEEHCEA   AXD  ITS   COMPLICATIOXS. 


of  the  bichloride  of  mercury  to  from  10.000  to  30,000  of  "svater,  or  of  a 
saturated  solution  of  boracic  acid,  or  of  a  1  per  cent,  solution  of  carbolic 
acid  in  water,  should  be  employed.  The  penis  should  be  kept  in  an 
elevated  position  ;  care  must  be  taken  to  catch  and  remove  the  discharge, 
and  lead-and-opium  -n-ash,  ice-water,  or  the  cold-water  coil  used  in  the 
acute  stage. 

Circumcision  should  be  performed  as  soon  as  possible  in  cases  of 
chronic  phimosis,  cicatricial  phimosis,  and  phimosis  complicated  by  intra- 
preputial  vegetations. 

In  performing  the  operation  of  circumcision  it  is  necessary  to 
remember  that  the  prepuce  is  composed  of  two  layers,  separated  by 
a  cellular  tissue  of  such  lax  texture  as  to  admit  of  an  almost  indefinite 
amount  of  motion  between  them.  The  internal  or  mucous  layer  is  firmly 
attached  to  the  penis  posterior  to  the  corona  glandis,  and  hence  is  inca- 
pable of  being  drawn  forward  to  any  great  extent  in  front  of  the  glans. 
The  external  or  integumental  layer,  on  the  contrary,  is  continuous  with 
the  flaccid  skin  of  the  body  of  the  penis,  and  may  be  greatly  elongated. 

Previous  to  the  operation  of  circumcision  the  penis  should  be  carefully 
examined  by  the  surgeon  with  a  view  of  acquainting  himself  with  the 
conformation  of  the  parts  and  of  determining  the  amount  of  tissue  to- 
be  taken  away.  If  retraction  of  the  prepuce  is  possible,  it  is  important 
to  study  the  size,  shape,  and  relations  of  the  frsenum  and  the  calibre 
of  the  cutaneous  sheath  at  the  part  where  it  encircles  the  glans.  Then 
it  is  necessary  to  closely  inspect  the  raph^,  in  order  to  see  whether  it 
runs  directly  in  the  median  line,  or  whether  it  deviates,  as  it  sometimes 
does,  to  one  side  or  the  other  toward  the  end  of  the  prepuce. 

The  operation  of  circumcision  which  I  prefer  for  its  simplicity  and 
excellence  of  result  will  now  be  described :  The  hair  from  the  genitals 
and  the  adjacent  parts  of  the  thighs  should  be  shaved  off",  and  the 
patient  thoroughly  washed  with  soap  and  water  and  ether  and  alcohol, 
followed  by  copious  ablutions  of  a  solution  of  corrosive  sublimate,  1 :  2000. 
It  is  always  necessary  to  see  that  the  coronal  sulcus  has  been  thoroughly 
cleansed.  The  patient  then  being  on  the  operating-table,  the  prepuce 
is  drawn  well  forward,  and  the  clamp  or  forceps  (Fig.  116)  is  applied^ 

Fig.  146. 


Author's  circumcision  forceps  or  clamp. 


not  in  a  vertical  direction  at  right  angles  with  the  long  axis  of  the 
penis,  but  in  an  oblique  position,  following  the  line  of  obliquity  of  the 
glans.  When  the  clamp  is  on  (see  Fig.  117).  it  is  necessary  to  examine 
the  skin  of  the  penis,  to  see  that  too  much  of  the  tissues  will  not  be  taken 
away,  and  that  the  organ  in  erection  will  not  be  interfered  with  or 
drawn  backward.  When  the  clamp  is  adjusted,  cocaine  anaesthesia  may 
be  produced  by  the  following  simple  procedure :  A  syringe  being  filled 
with   8   per    cent,    muriate-of-cocaine  solution,   its   needle,    an   inch   and 


PHIMOSIS. 


411 


a  half  long,  is  introduced  between  the  two  layers  of  the  prepuce  on  one 
side  longitudinally,  in  conformity  with  the  blades  of  the  forceps.  When 
the  needle  has  traversed  the  whole  of  one  side  of  the  included  prepuce, 
a  few  drops  of  the  cocaine  solution  are  injected,  and  as  the  needle  is 


Fig.  147. 


Circumcision :  forceps  on  the  tegumentary  layer  of  the  prepuce. 

slowly  withdrawn  the  fluid  is  left  in  its  track.  Then  the  same  procedure 
is  followed  on  the  other  side  of  the  prepuce.  The  parts  are  then  left 
alone  for  a  few  minutes,  in  order  that  anaesthesia  may  be  produced. 
After  the  lapse  of  about  five  minutes  the  blades  of  the  forceps  are 


Circumcision,  showing  the  forceps  on  the  mucous  layer  of  the  prepuce. 


slightly  separated,  and  thus  kept  for  a  few  minutes,  in  which  time  the 
immediate  tissue  behind  the  forceps  blades  will  become  aniiesthetized. 
Then  the  clamp  is  again  put  on  firmly.     By  this  procedure  we  avoid 


412  GONORRHCEA  AND  ITS  COMPLICATIONS. 

the  unpleasant,  even  dangerous,  symptoms  of  cocaine  intoxication  and 
poisoning.  Traction  on  the  distal  end  of  the  prepuce  by  a  ligature  or 
bulldog  forceps  is  now  made,  and  a  sharp,  thin  bistoury  is  introduced 
through  the  middle  of  the  prepuce,  the  flat  of  the  blade  resting  on  the 
clamp.  A  cut  outward  is  then  made,  and  a  second  inward  cut  removes 
the  cutaneous  layer  of  the  prepuce.  Some  cocaine  solution  is  now  poured 
over  the  bleeding  surface.  The  surgeon  then  retracts  the  mucous  layer 
of  the  prepuce,  and  ascertains  its  length  and  the  condition  of  the  frae- 
num.  The  parts  having  become  anaesthetized,  a  ligature  is  run  through 
the  mucous  layer,  and  traction  is  made  by  it,  and  the  forceps  is  applied 
in  the  same  oblique  manner  to  this  part.  (See  Fig.  148.)  The  second 
incision  is  then  made  in  precisely  the  same  manner  as  the  first  was.  It 
is  generally  necessary  to  crowd  the  glans  backward  somewhat,  but  the 
surgeon  should  always  make  allowance  that  one-third  or  one-half  of  an 
inch  of  the  mucous  layer  of  the  prepuce  shall  be  left,  and  that  as  much 
of  the  fraenum  shall  be  spared.  When  too  much  of  the  mucous  layer  is 
taken  away,  and  when  the  frsenum  is  nearly,  if  not  all,  ablated,  a  bad 
result  is  always  obtained,  and  the  patient  may  experience  much  discom- 
fort for  the  rest  of  his  life.  The  incised  mucous  and  cutaneous  layers 
are  then  coapted,  and  before  the  stitches  are  put  in  the  surgeon  should 
study  the  conformation  of  the  parts  with  a  view  to  future  symmetry. 
(See  Fig.  149.)     In  general,  the  raphe  and  the  frsenum  are  in  distinct 

Fig.  149. 


Showing  the  proper  condition  of  the  prepuce  after  the  two  incisions. 

anatomical  continuation,  and  then  the  surgeon  in  his  stitching  simply 
follows  these  natural  landmarks.  If,  however,  there  is  a  deviation  of 
the  raph6  from  the  middle  line,  this  must  be  considered,  and  the  line  of 
union  so  placed  that  a  natural  arrangement  of  the  parts  will  be  produced 
after  healing.  There  is  usually  more  or  less  hemorrhage,  but  this  very 
rarely  gives  any  trouble.  When  the  edges  are  properly  coapted  the 
stitches  of  fine  silk,  or  preferably  catgut,  should  be  put  in  at  a  distance 
of  a  sixth  of  an  inch  from  the  margin  of  the  wound,  well  through  the 
whole  thickness  of  the  skin  and  mucous  membrane.  These  stitches  or 
sutures  should  be  placed  about  one-sixth  or  one-eighth  of  an  inch  apart, 
so  that  no  connective  tissue  will  be  exposed  between  the  cut  edges.  (See 
Fig.  150.)  By  these  quite  numerous  sutures  all  bleeding  is  prevented 
and  prompt  healing  is  produced.  Whenever  the  stitches  are  placed  far 
apart  the  raw  submucous  connective  tissue  pushes  up  between  the  two 
cut  surfaces,  and  the  process  of  healing  is  materially  prolonged.  The 
parts  are  then  dusted  with  iodoform  or  aristol,  and  well  and  sufiiciently 


PHLMOSIS.  413 

firmly  bandaged  with  lint  or  absorbent  gauze.  This  first  dressing  may, 
owing  to  oozing,  have  to  be  removed  on  the  third  or  fourth  day,  and 
then  replaced  by  a  similar  one.  If  the  dressing  looks  clean  and  the 
patient  is  comfortable  (there  being  no  itching,  smarting,  or  uneasiness 
in  the  penis),  the  first  dressing  may  remain  on  several  days.  When 
thorough  antisepsis  is  practised,  perfect  union  may  result  in  six  or  seven 

Fig.  150. 


y 


Shows  the  penis  after  adjustment  of  the  stitches. 


days,  particularly  if  the  patient  can  lay  up  and  if  medication  to  prevent 
erections  has  been  administered.  Erections  sometimes  materially  delay 
union.  The  stitches  may  then  be  removed,  and  a  dressing  applied  for  a 
few  days.  Usually  two  or  three  dressings  are  sufficient.  After  the 
operation  the  parts  may  be  more  or  less  sensitive  for  a  time,  but  they 
gradually  adapt  themselves  to  their  altered  condition. 

In  some  cases  of  urgency  it  may  be  necessary  to  perform  circumcis- 
ion, and  the  proper  instruments  may  not  be  at  hand.  In  this  event 
the  following  simple,  but  not  to  be  commended,  operation  may  be  per- 
formed :  The  parts  being  properly  cleansed  and  shaved,  the  prepuce  is 
draAvn  forward  (if  retractable)  over  the  glans  ;  then,  by  means  of  a  pair 
of  scissors  with  long  blades,  an  incision  is  made  in  the  middle  line  on 
the  dorsum  of  the  penis.  The  prepuce  then  appears  like  two  dog's  ears, 
which  must  be  cut  off  Avith  the  scissors,  following  the  line  of  obliquity 
of  the  glans.  In  this  operation  it  is  necessary  to  be  careful  that  the 
two  incisions  of  the  dog's  ears  are  symmetrical,  that  too  much  tissue  is 
not  taken  away,  and  that  the  frsenum  is  left  intact.  The  parts  are  then 
stitched  together,  the  same  care  being  taken  as  has  already  been  pointed 
out.     The  dressing  is  the  same  as  that  of  the  first  operation. 

In  the  treatment  of  chancroidal  phimosis,  and  of  the  phimosis  which 
sometimes  complicates  hard  chancres,  the  great  bugbear  in  the  past  has 
been  the  fear  of  infecting  the  incised  surfaces.  This  fear  has  led  to 
delay,  to  the  use  of  inefficient  methods  of  treatment,  and  in  many  cases 
to  the  destruction  of  large  portions  of  the  penis.  Such  a  fear  is  entirely 
groundless,  since  the  truth  is,  that  when  properly  treated  by  incision 
these  cases  begin  to  improve  at  once,  and  in  the  end  come  out  well. 
The  rule,  therefore,  in  these  cases  should  be  that  when  such  tentative 
measures  as  hot  antiseptic  injections  and  immersions  in  hot  borax  and 
carbolic  water  have  failed,  and  it  is  evident  that  the  subpreputial  lesions 
are  inaccessible  to  treatment,  even  before  evidences  of  perforation  of 
the  prepuce  are  to  be  seen,  the  parts  should  be  thoroughly  incised,  so 
that  they  may  be  inspected  at  will  and  properly  treated. 


414 


GONORRHCEA  AND  ITS  COMPLICATIONS. 


Fig.  151. 


The  old  operation  for  these  conditions  was  the  dorsal  incision,  which 
in  almost  every  case  fails  to  give  the  expected  relief.  This  dorsal  in- 
cision, even  if  sufficiently  long,  in  most 
instances  only  gives  access  to  the  most 
prominent  portion  of  the  glans  penis, 
while  the  fossae  of  the  frsenum  and  the 
coronal  sulcus  are  inaccessible  or  be- 
come so  in  a  day  or  two  after  the  ope- 
ration. When  the  dorsal  incision  is 
made  in  most  cases  the  condition  of  af- 
fairs portrayed  from  life  in  Fig.  151 
confronts  the  surgeon.  It  Avill  be  seen 
that  the  glans  is  encircled  by  the  lower 
or  frsenal  portion  of  the  prepuce  as  by 
a  pillow,  and  that  the  sulcus  is  inac- 
cessible. Now,  these  are  the  parts  on 
which  chancroids  are  most  commonly 
found,  and  after  this  operation  the  sur- 
geon has  a  large  incised  wound  to  treat, 
and  can  only  with  difficulty  get  at  the 
most  morbid  of  the  parts.  Therefore,  I 
say  that  in  these  cases  the  dorsal  incision 
is  a  most  dismal  form  of  delusion.  More 
than  twenty  years  ^  ago  I  called  atten- 
tion to  this  surgical  failure,  and  pro- 
posed a  different  method  of  operating, 
which  in  the  hundreds  of  cases  which 
have  come  under  my  care  in  the  mean 
time  has  always  proved  satisfactory  and 
successful.  This  operation  is  simplicity 
itself,  and  consists  of  two  lateral  incis- 
ions of  the  inflamed  prepuce.  Prior  to 
the  operation,  which  should,  if  possible, 
be  done  under  ether,  the  preputial  sac 
or  cavity  should  be  thoroughly  irrigated  with  Thiersch's  solution,  car- 
bolic solution  (2  per  cent.),  or  sublimate  solution  (1 :  2000) ;  the  hairy 

Fig.  152. 


Chancroidal    phimosis,  showing  the 
suits  of  the  dorsal  incision. 


G  .  TIEMANN  &  CO 

Author's  phimosis  scissors. 


parts  may  be  shaved  and  the  genital  region  rendered  as  nearlj^^  aseptic 
as  possible.     It  is  necessary  to  remember  that  in  this  form  of  phimosis 

^  "  On  Some  Practical  Points  in  the  Treatment  of  the  Phimosis  produced  by  Chan- 
croidal Ulcers,"  Am.  Jmim.  Syphil.  and  Dermat.,  Oct.,  1872. 


PHIMOSIS. 


415 


— namely,  chancroidal  and  in  that  due  to  hard  chancre — the  prepuce 
becomes  very  much  elongated  by  reason  of  the  inflammatory  oedema, 
and  that  in  most  cases  the  glans  becomes  retracted,  probably  pushed 
back,  by  the  closeness  of  investment  of  the  thickened  and  inflamed 
prepuce.  The  penis  being  held  in  the  line  of  the  thighs  by  an  assist- 
ant, the  patient  being  on  his  back,  the  surgeon  introduces  the  lower  or 
flat  blade  of  my  phimosis  scissors  (see  Fig.  152)  (which  resemble  the 
plaster-of-Paris  scissors)  well  back  to  the 
bottom  of  the  coronal  sulcus  on  one  side, 
exactly  on  the  median  line.  The  scis- 
sors must  be  held  firmly,  and  some  force 
may  be  necessary  in  bringing  the  blades 
together,  for  the  tissues  are  usually  very 
hard  and  brawny  and  show  a  tendency 
to  resist  and  slip  from  the  blades ;   so 

Fig.  153. 


Chancroidal  phimosis,  showing  position  and  depth  of 
lateral  incision. 


Chancroidal  phimosis,  sh()\Mng  the 
long  flaps  held  back  and  the  com- 
plete exposnre  of  the  inner  surface 
of  the  prepuce  and  the  whole  of 
the  glans  penis. 


that  if  the  incision  is  not  sufficiently  deep  to  render  the  coronal 
sulcus  visible  and  accessible,  it  must  be  lengthened.  This  being 
done,  the  same  care  as  to  symmetry  and  to  being  on  the  median 
lateral  line  is  observed  in  the  incision  on  the  other  side.  (See  Fig.  153, 
Avhich  was  taken  from  life  immediately  after  the  operation.)  The  phimotic 
condition  in  this  case  is  shown  in  Fig.  143.  The  surgeon  then  has  full 
access  to  the  whole  of  the  glans,  the  sulcus,  frsKnal  fossae,  and  the  inner 
layer  of  the  prepuce.  This  is  shown  in  Fig.  154,  in  which  the  glans  is 
seen  to  somewhat  resemble  a  bone-stump,  and  the  prepuce  the  two  flaps, 
in  a  case  of  amputation  in  the  continuity  of  a  limb.  It  is  usually  not 
well  to  apply  the  antiseptic   dressing  until  the  bleeding  is  stopped. 


416 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


Fig.  155. 


After  thorough  antiseptic  irrigation  absorbent  gauze  in  several  layers 
may  be  carefully  placed  between  the  inner  layer  of  the  prepuce  and 
the  glans,  and  the  prepuce  then  may  be  put  in  position  and  a  roller 
bandage  of  gauze  applied  around  the  whole  organ.  This  dressing 
may  be  removed  in  about  twelve  hours,  when  the  parts  should  be 
irrigated,  and  then  dusted  with  iodoform  or  aristol,  and  gauze  placed 
between  the  glans  and  flaps,  and  a  gauze  bandage  applied  around  the 
distal  part  of  the  penis  as  firmly  as  can  be  borne.  Usually  the  dressing 
should  be  renewed  daily  after  very  copious  irrigation.  The  ulcerated 
lesions  will  begin  to  improve  at  once.  If  gangrene  or  phagedena  has  been 
present,  either  of  these  processes  will  be  promptly  arrested,  and  the 
raw  surfaces  will  give  no  trouble.  The  period  of  reparation  and  heal- 
ing varies  in  difi"erent  cases,  but  in  general  fully  a  month,  and  even 
longer,  elapses  before  cicatrization  is  perfect.  When  the  parts  have 
healed  the  flaps  will  be  found  to  be  remarkably  short  considering  their 
previous  length.     The  top  one  may  be  simply  a  small  truncated  cone, 

which  can  be  readily  cut  off  by  a  straight 
incision,  or  if  it  is  thickened  the  parts  may 
be  cut  out  by  two  elliptical  incisions,  as 
shown  in  Fig.  155,  which  should  be  con- 
tinued down  fully  half  an  inch  or  deeper, 
in  order  to  remove  redundant  inflammatory 
tissue.  In  the  same  way  the  under  flap 
must  be  treated  by  incisions  in  elliptical 
or  curved  lines,  carried  well  down  to  re- 
move the  redundant  tissue.  It  may  be 
stated,  as  a  rule  in  these  cases,  that  a 
wedge-shaped  mass  must  be  removed  from 
the  lower  flap,  and  this  incision  should  be 
in  keeping  with  the  conformation  of  the 
parts.  The  edges  of  the  flap-wounds  are 
then  brought  together  with  four  silk  stitches 
and  the  parts  antiseptically  dressed.  Usually 
healing  is  prompt,  and  in  the  end  a  very 
good  result  is  obtained.  This  lateral-flap 
operation  is  really  one  of  circumcision  in 
two  stages.  When  there  has  been  much 
destruction  of  the  prepuce  and  glans,  the 
symmetry  of  the  parts  is  correspondingly 
Chancroidal  phimosis,  showing  healed   impaired.       It   is   wonderful,    howevcr,   to 

parts  after  lateral  incision.    Dotted  r   .  i  i  i  t. 

lines  indicate  the  shape  of  the  in-  see   m  some .  cascs  where  there  has  been 

cision  necessary  to  complete  the  cir-  ,     ■,  j.   ,.  ■,  i-iatj. 

cumcision.  much  loss  of  tissuc   how  lavish  JNature  is 

in  her  process  of  repair. 
It  may  be  well  to  warn  young  practitioners  never  to  perform  full  cir- 
cumcision in  cases  of  chancroidal  phimosis.    I  have  seen  some  youngsters 
have  a  very  unhappy  time  after  they  had  had  the  hardihood  to  resort  to 
this  extreme  measure. 


PARAPHIMOSIS. 


417 


CHAPTER    XXXV. 


PARAPHIMOSIS. 

Paraphimosis  is  that  condition  of  the  penis  in  which  the  prepuce, 
retracted  behind  the  corona,  cannot  be  pushed  forward  over  the  glans. 

It  is  found  in  young  boys  who,  perhaps  from  curiosity  and  with  some 
force,  have  retracted  the  prepuce  for  the  first  time.     It  also  occurs  in 
young  subjects  as  a  result  of  mas- 
turbation.   In  these  cases  the  young  Fig.  157. 

Fig.  156. 


Paraphimosis  in  a  young  boy. 


Partial  mild  paraphimosis  from  gonorrhoea. 


boy  usually  complains  of  pain  quite  early,  and  reduction  is  commonly 
not  attended  with  difficulty.     (See  Fig.  156.) 

Paraphimosis  occurs  in  older  persons  Avho  have  a  long  foreskin  and 
narrow  preputial  orifice ;  in  those  who  have  a  long,  straight,  and  more 
or  less  tight  foreskin  ;  in  patients  who  have  a  short  frsenum ;  in  those 
who  have  short  and  rather  tight  foreskins  habitually  worn  over,  and  only 
partially  covering,  the  glans  ;  in  those  having  short,  not  abundant,  fore- 
skins worn  behind  the  glans  ;  and,  finally,  in  those  Avhose  foreskin  is  in 
perfect  proportion  to  the  glans. 

The  causes  of  paraphimosis  are,  primarily,  the  more  or  less  developed 
malformations ;  secondly,  inflammation  causing  constriction,  balanitis, 
balano-posthitis,  excessive  coitus,  perhaps  increased  by  alcoholic  excess ; 
coitus  with  a  woman  having  a  small  vulvar  orifice ;  traumatism,  gonor- 
rhoea, eczema,  lymphangitis :  the  retraction  of  a  phimotic  prepuce  the 
seat  of  intra-preputial  vegetations;  chancroids  and  hard  chancres.  It 
is  seen  in  all  grades  of  mildness,  in  which  it  is  reducible,  and  in  all 
stages  of  severity,  in  which  reduction  is  more  or  less  difficult,  and  even 
impossible  without  operation  or  incision.  A  partial  paraphimosis  of 
mild  character  is  sometimes  met  with  as  a  result  of  gonorrhoea,  par- 
ticularly in  persons  who  have  a  not  long,  but  rather  roomy,  prepuce. 
This  is  well  shown  in  Fig.  158.  "With  ordinary  care  this  condition 
subsides  with  the  decline  of  the  gonorrhoea. 

27 


418 


GONOBRHCEA  AND  ITS  COMPLICATIONS. 


The  mechanism  of  paraphimosis  is  very  simple.  Retraction  of  the 
tight  preputial  orifice  behind  the  glans  leaves  a  fold  or  ring  of  mucous 
membrane  just  behind  and  continuous  with  it,  and  which  ceases  at  a 
more  or  less  deep  furrow,  and  beyond  this  furrow  is  a  swollen  ring  or 
fold  of  integument.  The  ring  of  mucous  membrane  is  the  inner  surface 
of  the  prepuce ;  the  furrow  is  formed  by  the  orifice  of  the  prepuce,  at 
the  bottom  of  which  it  acts  as  a  constricting  ring,  while  the  cutaneous 
fold  or  ring  beyond  is  the  external  layer  of  the  prepuce.  In  this  con- 
dition inflammation  begins  and  increases.  The  glans  becomes  swollen 
and  red,  even  purplish,  in  color  ;  the  mucous  collar  of  the  penis  becomes 
red,  oedematous,  and  puff"ed  out  like  a  bladder ;  the  constricting  preputial 
ring  strangulates  the  parts  more  and  more  as  they  become  swollen ;  and 

the  cutaneous  ring  or  collar  beyond 
Fig.  158.  it  also  becomes  more  red  and  oede- 

matous. In  such  a  case,  if  relief  is 
not  obtained,  the  condition  of  affairs 
becomes  worse.  Besides  the  en- 
gorged glans,  the  chief  swelling  is 
seated  under  and  just  behind  it  on 
each  side  of  the  fraenum.  When 
seen  quite  early  this  chin-like  pro- 
trusion of  mucous  membrane  is 
found  to  be  filled  with  serous  efiu- 
sion.  (See  Fig.  158.)  As  time 
goes  on,  this  is  replaced  by  fibrinous 
and  cellular  exudation,  and  this 
chin-like  body  becomes  hard  and 
resisting.  (See  Fig.  159.)  Coin- 
cidently  with  this  the  strangulation 
of  the  glans  is  greater  ;  the  mucous- 
membrane  pad  behind  it  is  more 
red,  swollen,  and  infiltrated  ;  the 
constricting  ring  is  correspondingly 
smaller ;  the  cutaneous  ring  of  pre- 
puce behind  it  more  swollen.  In 
this  state  the  penis  often  becomes 
twisted  in  spiral  and  other  peculiar 
forms,  curved  nearly  at  a  right  angle,  and  sometimes  distended  to  the  point 
of  strangulation  (Fig.  160).  "  In  conditions  thus  seemingly  desperate  the 
parts  may  thus  remain,  and  become  permanently  fixed  by  cell-exudation. 
(See  Fig.  163.)  Generally,  however,  nature  intervenes,  if  art  is  withheld, 
and  the  constricting  ring  is  attacked  by  ulceration  or  gangrene ;  in  which 
case  a  longitudinal  fissure  forms  along  the  dorsum  in  the  mucous  layer  of 
the  prepuce,  and  a  corresponding  one  in  the  cutaneous  portion.  These  in- 
crease, fuse,  involve  the  preputial  ring,  and  end  by  forming  an  ulcer  seated 
transversely  to  the  axis  of  the  penis  and  behind  the  glans.  Constriction  is 
then  ended,  the  patient's  sufferings  are  relieved,  but  much  oedema  and 
engorgement  may  remain. 

In  somewhat  exceptional  and  anomalous  cases  there  are  two  points  of 
strangulation — the  one  at  the  preputial  orifice  or  ring,  the  other  in  the 
mucous  membrane  at  the  base  of  the  corona  glandis,  and  largely  due  to 


Acute  reducible  paraphimosis  with  profuse 
serous  eflfusion. 


PARAPHIMOSIS. 


419 


the  excessive  engorgement  of  the  part.     (See  Fig.  161.)     Then  in  other 
cases  the  retraction  of  the  prepuce  is  incomplete,  and  the  orifice  or  ring 

Fig.  159. 


/ 


Showing  paraphimosis  in  which  the  parts  have  become  hard  and  resisting. 

only  slips  back  behind,   and  not  much  beyond,  the  corona,  where  it  is 
firmly  held,  and  is  Avith  difficulty  reduced  except  by  operation. 

Fig.  160. 


Paraphimosis,  penis  curved  nearly  at  a  right  angle. 


420 


GONORRHCEA  AND  ITS  COMPLICATIONS. 


Gangrene,  however,  may  occur  under  these  circumstances  and  may 
result  in  the  destruction  of  more  or  less  of  the  integument  or  glans, 
may  involve  the  urethra,  may  perforate  a  blood-vessel,  cause  intense 
suppurative  inflammation,  and  lead  to  erysipelas,  phlebitis,  and  lymph- 
angitis. 

In  those  cases  in  which  reduction  is  accomplished  early  little  if  any 
disfigurement  is  left.     When  only  the  phimotic  ring  has  been  cut,  on  the 


Fig.  161. 


Fig.  162. 


Anomalous  form  of  paraphimosis  in  which  there 
is  strangulation  at  the  preputial  ring  and  at  the 
base  of  the  corona  glandis. 


Preputial  frill  or  chin  following  protracted 
paraphimosis. 


subsequent  pushing  forward  of  the  prepuce  over  the  glans  a  median  cut 
on  its  upper  border  is  seen.  When  the  exigencies  of  the  case  have  neces- 
sitated a  long  incision  through  the  reflected  mucous  layer,  the  preputial 
orifice,  and  the  tegumentary  layer  of  the  prepuce,  on  the  cessation  of  the 
inflammation  and  the  reduction  of  the  foreskin  it  Avill  present  the  same 
lateral  dog's  ears  as  are  seen  when  the  dorsal  incision  is  practised  in 
phimosis.  Not  infrequently,  the  treatment  having  been  delayed,  the 
retracted  portions  of  the  prepuce  on  the  dorsum  of  the  penis  become 
adherent  to  the  corpora  cavernosa,  and  its  under  portion  forms  a  promi- 
nent chin  or  subpreputial  frill  of  firm  structure,  which  protrudes  from  the 
region  of  the  frsenum  forward.     (See  Fig.  162.) 

In  some  cases,  owing  to  ignorance  and  utter  neglect,  paraphimosis 
develops,  the  preputial  ring  ulcerates,  and  no  treatment  is  adopted.  In 
these  cases  the  site  of  the  ring  of  ulceration  becomes  a  ring  of  cicatricial 
tissue  more  or  less  firmly  adherent  to  the  corpora  cavernosa.  Then 
oedematous  hyperplasia  under  the  mucous  layer  and  behind  the  glans 
and  in  front  of  the  ring  occurs,  and  a  hard,  brawny  tissue  is  produced. 
In  these  cases  usually  no  amount  of  incision  will  permit  of  the  replace- 
ment of  the  prepuce  over  the  glans ;  a  tedious  treatment  is  necessary, 


PARAPHIMOSIS. 


421 


which   in   the   end   will   not  leave   the   parts   in   a   normal    state.     This 
condition  is  very  clearly  shown  in  Fig.  163. 

These  are  the  sequelge  in  the  preputial  covering  in  the  simple  inflam- 
matory forms  of  paraphimosis  now  under  consideration. 

In  the  paraphimosis  due  to  the  initial  lesion  the  parts  are  hard  and 
brawny,  and  the  process  is  of  a  subacute  nature.  In  the  paraphimosis 
complicating  chancroids  we  have  the  simple  condition  plus  much  ulcera- 
tion, inflammation,  and  swelling.  In  these  latter  cases,  if  not  treated 
promptly,  there  may  be  destruction  of  tissue  of  greater  or  less  extent. 
There  may  therefore  be  resulting  deformity  in  these  severe  forms  of  para- 
phimosis. 

Fig.  163. 


■Chronic  paraphimosis  with  ulceration  in  the  preputial  furrow,  and  condensation  of  both  layers 

of  the  prepuce. 

Prognosis. — The  prognosis  in  paraphimosis  depends  entirely  upon  the 
stage  of  the  trouble  when  first  seen.  If  the  surgeon  is  consulted  early, 
reduction  can  be  accomplished  without  difficulty.  If  later,  when  strangu- 
lation has  taken  place,  various  sequelae,  from  the  dorsal  ulcer  or  gan- 
grenous spot  to  more  extended  gangrene  and  destruction  of  the  integument 
and  perhaps  portions  of  the  glans  and  urethra,  lymphangitis,  phlebitis, 
and  erysipelas,  may  occur.  Such  structural  eff'ects  as  scars  of  the  pre- 
puce and  the  beard  at  the  frsenum  may  be  removed  by  subsequent 
operation. 

Treatment. — The  first  procedure  necessary  in  a  case  of  paraphimosis 
is  to  thoroughly  wash  the  penis  in  warm  soapsuds,  followed  by  aff"usion 


422 


GONOBBHCEA  AND  ITS  COMPLICATIONS. 


of  a  2  per  cent,  watery  solution  of  carbolic  acid,  or  a  bichloride  solution 
1  :  1000  or  2000,  since  a  phimotic  condition  is  produced  by  reduction,  and 
cleanliness  will  hasten  resolution.  Immersion  in  very  hot  water  for  fully 
half  an  hour  is  of  much  benefit  when  practicable.  When  there  is  much 
pain  and  in  nervous,  fidgety  subjects  a  few  whiffs  of  chloroform  to  induce 
very  slight  narcosis,  or  even  the  full  effects  of  ether,  may  be  necessary. 
Sometimes  the  recumbent  position,  with  elevation  of  the  penis  in  a  cylin- 
der of  pasteboard,  and  a  brisk  cathartic,  followed  by  a  hot  sitz-bath,  will 
lessen  the  oedema  and  render  the  surgeon's  duty  much  easier.  It  is 
always  well  to  knead  the  parts  and  to  press  out  as  much  as  possible  of  the 
serum.  A  little  olive  oil  or  vaseline  may  be  smeared  in  the  balano-pre- 
putial  furrow,  but  not  on  the  glans,  since  it  then  causes  the  operator's 
fingers  to  slip.  In  those  cases  in  which  the  mucous  membrane  of  the 
region  of  the  fraenum  is  translucent  and  much  serum  is  seen  (see  Fig.  158) 


Fig.  164. 


y 


Method  of  reduction  of  paraphimosis. 

multiple  punctures,  followed  by  gentle  pressure  by  the  hand  around  the 
head  of  the  penis,  will  always  be  followed  by  benefit  and  the  reduction  of 
the  parts. 

Several  methods  of  reduction  may  be  employed.  A  simple  plan  is  to 
make  a  ring  of  the  fore  finger  and  thumb  of  the  left  hand,  which  firmly 
encircles  the  penis  behind  the  constriction ;  at  the  same  time  that  this 
hand  is  drawn  forward,  the  glans,  grasped  by  the  fingers  of  the  right 
hand,  and  at  the  same  time  compressed  and  elongated,  is  pushed  back- 
ward, and  reduction  may  follow.  (See  Fig.  164.)  Another  method  is  to 
take  the  penis  behind  the  constriction  between  the  index  and  middle 
fingers  of  both  hands,  and,  making  very  firm  traction  while  the  thumbs 
crowd  down  upon  it,  knead  and  press  the  dorsum  and  base  of  the  glans 
backward.  (See  Fig.  165.)  Still  another  method,  occasionally  successful, 
is  to  strap  the  glans  from  apex  to  base  with  a  half-inch  Martin's  bandage, 


PARAPHIMOSIS. 


423 


Fig.  165. 


^f^'>p!,^m4it^^'^i^pA>  '^^ 


Method  of  reduction  of  paraphimosis. 


then  push  the  retracted  prepuce  forward  by  means  of  the  ring  made  of  the 
thumb  and  forefinger,  and  then,  when  reduction  has  been  effected,  gently 
extricate  the  rubber. 

Bardinet's  ^  method  may  also  be  tried.     He  describes  it  as  follows : 

"  I  bend  the  glans  on  its  anterior 
(lower)  aspect  and  gently  draw  the 
skin  of  the  penis  forward  from  behind 
the  constriction.  I  then  attempt  to 
insert  the  bend  of  a  hair-pin  betAveen 
the  preputial  ring  and  the  body  of  the 
penis.  This  done,  I  have  two  levers 
in  the  branches  of  the  pin,  which  I 
move  back  and  forth  for  a  triple  pur- 
pose— to  depress  the  prominence  of  the 
base  of  the  glans,  to  elevate  the  pre- 
putial ring,  and  to  secure  an  inclined 
plane  upon  which  it  may  gently  be 
made  to  glide." 

Colles's  method  ^  is  to  "  pass  a  direc- 
tor beneath  the  constriction  from  be- 
fore backward,  and  elevate  it  upon  the 
point  of  the  instrument,  while  the 
stem  was  made  to  compress  the  swell- 
ing in  front  and  gradually  force  it 
back  beneath  the  stricture.  This  process  Avas  repeated  on  each  side  of 
the  penis,  after  Avhich  reduction  was  quite  easy." 

Compression  of  the  glans  by  forceps  of  any  kind  usually  fails.  Should 
all  these  efforts  fail,  operative  procedures  are  necessary. 

In  many  cases  incision  of  the  constricting  band  is  sufficient  to  relieve 
the  parts.  Since  in  most  cases  this  is  seated  in  the  furrows  already 
described,  a  curved  bistoury  may  be  introduced  on  the  flat  surface  on 
the  glandular  side  of  the  constriction,  well  down  under  and  through  it, 
taking  care  not  to  wound  the  corpora  cavernosa.  If  the  swelling  is  such 
that  the  curved  bistoury  cannot  be  introduced  beneath  the  band,  a  thin 
straight  one  may  be  used.  This  should  be  introduced  at  right  angles  to 
the  penis  at  the  outer  edge  of  the  constriction,  and  a  number  of  firm  but 
not  deep  cuts  should  be  made,  the  operator  being  slow  and  deliberate  in 
his  movements  with  the  point  of  the  instrument  until  the  band  is  felt  to 
give  way. 

In  some  cases  it  is  necessary  to  incise  the  mucous  membrane  and  skin 
in  the  line  with  the  incisions  already  spoken  of.  When  this  is  done,  it 
is  well  to  inquire  as  to  the  natural  length  of  the  prepuce,  and  to  make 
the  incisions  in  conformity  with  the  facts  ascertained.  Another  rule  is 
to  take  the  length  of  the  glans  as  the  guide,  and  make  the  incision  as 
long  as  that.  As  a  result  of  this  procedure  the  patient  subsequently  has 
the  so-called  dog's-ear  prepuce,  which  requires  a  further  operation  to 
complete  the  circumcision. 

When  the  constriction  exists  just  behind  the  glans,  it  is  sometimes 
with  difficulty  made  out,  and  much  care  must  be  observed  to  cut  it  alone. 

^  "  Nouveau  precede  de  Reduction  du  Paraphimosis,"  U  Union  med.,  Paris,  1873,  p.  900. 
"  Dublin  Quart.  Journ.  Med.  Sciences,  May,  1857. 


424  GONORRHCEA  AND  ITS  COMPLICATIONS. 

Cases  of  chronic  paraphimosis,  such  as  depicted  in  Fig.  163,  re- 
quire long  and  patient  treatment.  The  parts  should  be  soalked  in  hot 
water  two  or  three  times  a  day,  and  then  the  segment  behind  the  glans 
may  be  compressed  for  several  hours  a  day  by  a  rubber  bandage.  When 
absorption  has  gone  on  to  such  an  extent  that  movement,  even  slight, 
of  the  prepuce  over  the  corpora  cavernosa  is  possible,  it  is  well  to  free 
the  cutaneous  ring-like  end  of  the  prepuce  and  the  mucous  end  of  it, 
which  are  at  the  constricting  furrow,  either  by  gentle  dissection  or  by 
tearing  apart  with  a  blunt  instrument.  Then,  when  these  parts  are 
loosened,  a  longitudinal  incision  of  nearly  or  possibly  an  inch  long  is 
made  into  each  of  these  segments  of  the  prepuce.  Then,  after  one  or 
more  attempts,  reduction  will  usually  follow  and  the  typical  dog's  ears 
will  be  seen,  The  case  then  requires  cleanliness,  and  later  on  ablation 
of  the  lateral  portions  of  the  prepuce.  The  preputial  chin  or  frill  may 
be  removed  by  proper  incisions. 

In  the  treatment  of  paraphimosis  due  to  hard  chancres  it  is  first 
necessary  to  reduce  the  hyper?emia  by  immersions  of  the  organ  in  very 
hot  water  ;  then  the  penis  may  be  bandaged  quite  firmly  with  lint  soaked 
in  black  wash.  As  the  process  of  involution  occurs  a  plaster  of  mer- 
curial ointment  may  be  bandaged  around  the  penis.  This  application, 
together  with  constitutional  treatment,  will  cause  resolution  in  most 
cases. 

Chancroidal  paraphimosis  requires  as  the  first  essential  in  treatment 
frequent  irrigations  of  the  penis  with  hot  2  per  cent,  carbolic  water  or 
1 :  2000  hot  sublimate  water.  These  irrigations  should  be  long  con- 
tinued and  thorough.  In  addition,  the  penis  should  be  immersed 
several  times  a  day  in  these  solutions.  Seeing  that  early  reduction 
of  the  parts  would  lead  to  phimosis,  it  is  well  to  take  especial  care  that 
the  ulcers  are  promptly  healed.  Iodoform,  kept  in  place  by  gauze  or 
absorbent  cotton,  may  be  very  effective.  As  a  dressing  the  bichloride 
solution  (1  :  2000)  also  may  be  very  beneficial.  But  in  every  case  most 
reliance  may  be  placed  on  the  irrigations  and  immersions.  In  all  cases, 
even  of  simple  paraphimosis,  where  there  is  tendency  to  ulceration  or 
gangrene  these  antiseptic  measures  should  also  be  adopted.  Chancroidal 
paraphimosis  very  often  leads  to  deformity  of  the  penis,  for  which  par- 
tial ablation  of  the  prepuce  or  circumcision  may  be  necessary. 


CHAPTER    XXXVI. 

HERPES  PROGENITALIS. 


Herpes  progenitalis,  by  some  incorrectly  called  "herpes  preputialis," 
is  a  mildly  inflammatory  affection,  consisting  of  one  or  more  vesicles  or 
groups  of  vesicles.  It  occurs  in  both  sexes,  and  is  perhaps  quite  as  fre- 
quent in  the  female  as  it  is  in  the  male  sex.     In  men  it  occurs  most  com- 


HERPES  PROGENITALIS.  425 

monly  on  the  inner  surface  of  the  prepuce,  in  the  sulcus  behind  the  corona, 
on  each  side  of  the  frsenum,  on  the  lips  of  the  meatus,  on  the  free  margin 
of  the  prepuce,  upon  the  integument  of  the  penis,  and  upon  the  pubic 
region.  In  general,  the  vesicles  are  unilaterally  placed,  though  they  may 
be  symmetrically  developed,  or  those  seated  on  one  half  of  the  organ  may 
encroach  on  the  other  half. 

In  women  herpes  progenitalis  occurs  on  the  inner  aspect  of  the  labia 
majora,  on  all  parts  of  the  labia  minora,  on  the  vestibule  and  prepuce  of 
the  clitoris,  at  the  orifice  of  the  urethra,  and  occasionally  on  the  outer  sur- 
face of  the  labia  majora  and  on  the  mons  Veneris.  I  have  seen  two  cases 
in  which  herpes  of  the  whole  labium  majus  was  accompanied  with  herpes 
zoster  of  the  crural,  external  cutaneous,  and  small  sciatic  nerves  of  the 
same  side. 

As  mentioned  by  Bergh,^  herpes  may  develop  on  the  cervix  uteri, 
either  alone  or  in  association  with  similar  lesions  of  the  vulva.  In  women 
especially,  and  in  men  occasionally,  herpes  is  found  on  the  ano-genital 
region  and  around  the  margin  of  the  anus,  sometimes  synchronously  with 
involvement  of  the  genital  parts.  In  his  statistical  table  Unna^  records 
two  cases  of  herpes  vaginae  which  occurred  in  the  Hamburg  general  hos- 
pital.    I  have  never  recognized  herpetic  vesicles  in  this  region. 

The  evolution  of  the  affection  may  occur  without  any  prodromal  symp- 
toms whatever :  sometimes  it  is  antedated  by  various  neuralgic  phenomena, 
but  in  most  cases  there  are  slight  burning,  heat,  tickling,  and  itching  just 
before  the  outbreak.  In  nervous  and  chlorotic  women  an  intense  pruritus 
often  begins  with,  and  lasts  during,  the  attack.  General  morbid  states 
seem  to  have  little  influence  on  the  evolution  of  this  affection. 

The  eruption  may  consist  of  a  single  vesicle  or  it  may  consist  of  a 
group  closely  packed,  or,  again,  of  a  number  of  scattered  vesicles,  usually . 
followino;  the  course  of  a  nerve.  The  first  morbid  change  observed  is  a 
red  spot,  which  is  soon  the  seat  of  vesicles.  These  lesions  may  be  of  the 
size  of  a  pin's  head  or  of  the  diameter  of  a  line,  and  are  rounded,  trans- 
lucent vesicles  containing  clear  serum.  When  seated  on  the  mucous  mem- 
branes they,  owing  to  the  succulence  of  the  parts  and  thinness  of  the 
epidermis,  soon  rupture ;  indeed,  it  is  very  rare  to  see  such  lesions  intact. 
When  seated  on  the  skin,  however,  they  may  remain  intact  for  some  days, 
and  unless  scratched  their  contents  become  turbid  and  they  dry  into  brown- 
ish scabs.  Herpetic  vesicles  seated  at  the  margin  of  the  prepuce  and  on 
the  outer  rim  of  the  labia  minora,  particularly  when  they  are  long,  may 
be  almost  wholly  obscured  by  the  inflammatory  oedema  which  the  laxity 
of  these  tissues  sometimes  favors.  Rupture  of  the  vesicles  leaves  a  shallow 
exulceration  corresponding  in  size  to  that  of  the  vesicle.  Its  floor  is  at  first 
of  a  deep  rosy-red,  with  a  finely  uneven  surface,  and  its  edges  sharply  cut  as 
if  punched  out,  and  sometimes  undermined,  but  not,  as  a  rule,  to  the  same 
extent  as  in  chancroid.  When  there  is  a  group  of  vesicles,  they  fuse 
together  and  rupture,  forming  a  patch  which  has  been  described  as  having 
a  polycyclical  outline.  This  is  comparable  to  the  outline  presented  by  two 
pieces  of  three-leaf  clover  placed  base  to  base,  Avhich  then  has  a  festooned 
margin  formed  by  segments  of  circles.     Early  in  their  evolution  the  ves- 

^  "Ueber  Herpes  Menstrnalis,"  Mnnntshefte  fur  Prnlc.  Derm.,  vol.  x.,  1890,  pp.  1  et  seq. 
^  "  Herpes  Progenitalis,  especially  in  Women,"  Journ.  Cut.  and  Ven.  Diseases,  vol.  i. 
pp.  322  et  seq. 


426  GONORBHCEA   AND  ITS  COMPLICATIONS. 

icles  are  surrounded  by  a  well-marked  redness,  the  tendency  of  which  is 
to  gradually  decline  until  a  mere  hyperaemic  rim  remains. 

Usually  the  vesicles  heal  in  a  few  days ;  in  some  cases  they  are  very 
persistent,  and  in  others  they  become  ulcerated  and  undistinguishable 
from  true  chancroids.  In  this  state  their  secretion  is  sometimes  auto- 
inoculable,  and  in  some  cases  the  cause  of  buboes.  (See  section  on  Chan- 
croids.) When  seated  on  an  inflamed  prepuce  and  irritated  by  decom- 
posed smegma  or  gonorrhoeal  pus,  herpes  progenitalis  sometimes  assumes 
a  more  or  less  destructive  tendency.  I  have  very  frequently  seen  vesicles 
become  covered  with  a  thin  blackish,  very  adherent  crust,  and  thus  they 
may  remain  indolent  with  no  tendency  to  healing. 

When  fully  developed  there  is  usually  an  amelioration  or  subsidence 
of  the  itching,  heat,  or  burning,  but  somewhat  exceptionally  the  excoriated 
surfaces  are  exquisitely  sensitive,  and  the  patient  shrinks  from  the  slightest 
touch  of  them.  Uncomplicated  cases  last  from  a  few  days  to  two  weeks. 
Untreated  cases,  particularly  in  uncleanly  subjects,  are  sometimes  per- 
sistent and  rebellious  to  treatment. 

Under  the  name  "neuralgic  herpes  "  Mauriac^  first  described  an  affec- 
tion of  considerable  gravity  in  which,  besides  the  eruption,  there  is  a 
coexistent  neuralgia  of  various  branches  of  the  sacral  plexus.  He  cites 
the  case  of  a  man  Avho  for  eleven  days  previously  had  felt  a  slight  sensa- 
tion of  heat  in  the  prepuce,  and  was  suddenly  attacked  by  a  severe  prick- 
ing and  itching  in  the  part.  Mere  pressure  of  the  clothes  became  insup- 
portable, and  the  pain  was  so  intense  that  sleep  was  impossible.  Four  or 
five  days  later  he  was  attacked  by  darting  pains  down  the  leg  and  in  the 
perineum,  buttocks,  and  scrotum.  Ansesthesia,  alternated  with  hyper- 
sesthesia,  made  the  patient's  sufferings  nearly  unbearable.  Two  years 
later  the  patient  had  another  attack,  only  one  vesicle  being  present, 
during  which  he  suffered  from  boring  pains,  neuralgia  of  the  urethra, 
and  disturbances  of  sensibility.  In  a  second  case  observed  by  Mauriac 
forty-eight  hours  preceding  the  appearance  of  a  single  vesicle  paroxysmal 
pains  radiated  through  the  penis  and  perineum,  and  subsequently  darted 
up  and  down  the  leg.  A  short  time  after  a  vesicle  appeared  at  the  orifice 
of  the  meatus,  accompanied  by  hypergesthesia  of  the  urethrse,  painful  mic- 
turition, and  pain  in  the  bladder. 

In  my  experience,  herpes  progenitalis  is  not  infrequently  preceded  or 
accompanied  with  neuralgia  of  some  part  of  the  male  genito-urinary 
apparatus.  I  have  seen  several  cases  of  vesicles  seated  on  either  lip  of 
the  meatus  attended  with  neuralgia  of  the  bladder  and  urethra.  The 
canal  itself  was  of  a  deep-red  color,  and  was  bathed  with  a  scanty  mucous 
secretion  in  which  no  pus-cells  could  be  detected.  The  affection  usually 
lasts  a  week  or  longer,  and  is  painful  during  the  first  few  days.  I  have 
also  seen  several  cases  in  which  pain  on  the  side  of  the  scrotum  correspond- 
ing to  the  situation  of  the  vesicles  on  the  penis,  of  a  burning  and  exqui- 
sitely sensitive  character,  was  experienced  during  the  existence  of  the 
herpetic  eruption.  It  sometimes  appears  as  a  concomitant  of  acute  and 
subacute  gonorrhoea. 

The  following  well-marked  case  of  neuralgic  herpes  was  for  a  long  time 
under  my  care  :  A  man  thirty-five  years  old,  thin  and  pale,  but  of  average 
good  health,  whose  father  and  whose  sisters  had  been  for  years  subject  to 

^  Legons  sur  V Herpes  nevralgique  des  Organes  genilaux,  Paris,  1S68. 


HERPES  PRO  GENITALIS.  427 

sciatica  and  other  neuralgias,  had  since  his  fifteenth  year  suifered  from 
sciatica,  which  during  a  period  of  twenty  years  had  returned  every  three 
months.  The  attacks  were  usually  preceded  by  gastric  disturbance.  The 
pain  began  just  above  the  knee  and  extended  upward  to  the  gluteal  region. 
In  a  few  days  he  experienced  a  sensation  of  heat  and  burning  on  the  side 
of  the  penis  corresponding  to  the  sciatica,  followed  promptly  by  a  group 
of  vesicles  which  Avas  painful.  There  was  burning  in  the  urethra,  stran- 
gury, and  pain  on  the  same  side  of  the  scrotum  as  the  sciatica.  In  seven 
out  of  ten  attacks  of  sciatica  herpes  progenitalis  was  present. 

This  affection  is  peculiarly  prone  to  relapse,  as  shown  by  Doyon,^  at 
longer  or  short  intervals,  occasionally  with  distinct  periodicity  for  many 
years.  Sabraz^s  ^  reports  the  case  of  a  man  twenty-nine  years  old  who 
for  nine  years  had  relapses  of  herpes  of  the  mouth  and  penis. 

In  exceptional  cases  there  are  swelling  and  pain  in  the  inguinal  ganglia 
of  the  corresponding  side.  Sometimes,  when  the  vesicles  become  much 
inflamed  and  ulcerated,  suppurating  buboes  occur.  I  have  several  times 
seen  this  happen  in  syphilitic  subjects,  and  have  been  led  to  think  that 
most  authors  are  too  positive  in  asserting  that  these  glands  possess  an 
immunity  in  herpes  progenitalis. 

This  affection  is  peculiar  to  adults  as  late  as  middle  life,  and  is  rarely, 
if  ever,  seen  in  old  persons. 

Etiology. — Various  constitutional  conditions — neurotic,  gouty,  rheu- 
matic, and  plethoric — were  formerly  regarded  as  the  causes  of  herpes 
progenitalis,  but  their  influence,  if  such  exists,  is  simply  that  of  greater 
or  less  predisposition.  Extended  clinical  observation  has  shown  that 
local  determining  conditions  are,  as  a  rule,  the  existing  causes  of  the 
affection.  These  may  be  briefly  stated  as  any  or  all  congestions  and 
inflammations,  ephemeral  or  long  continued,  of  various  grades,  affecting 
one,  several,  or  all  portions  of  the  genito-urinary  tracts  of  both  sexes. 
Thus,  following  balanitis,  particularly  when  resulting  from  phimosis, 
gonorrhoea,  chancroids,  and  hard  chancres,  especially  in  severe  instances, 
herpes  progenitalis  frequently  appears.  In  patients  subject  to  strictures 
— particularly  when  deep  seated — and  to  lesions  at  the  neck  of  the  blad- 
der herpes  has  been  known  to  occur,  commonly  at  or  following  an  exacer- 
bation. Following  exploratory  operations  upon  the  urethra  and  bladder, 
particularly  when  protracted,  herpes  of  the  penis  has  been  found  to 
develop.  I  have  seen  recurring  herpes  appear  coincidently  with  renewed 
inflammation  in  a  man  suffering  from  chronic  epididymitis.  In  like  man- 
ner, long-continued  turgescence  of  the  penis  from  any  cause  may  be  followed 
by  the  appearance  of  the  affection. 

As  causes  predisposing  to  herpes  progenitalis  in  the  male,  uncleanliness 
and  decomposition  of  the  sebaceous  matter,  excessive  venery  and  over- 
indulgence in  alcoholics,  hot  weather,  obesity,  and  plethora  are  frequently 
noted.  The  neuropathic  condition  may  act  as  an  underlying  predisposing 
cause. 

In  women,  as  in  men,  congestions  and  inflammations,  ephemeral  or 
long  continued,  are  always  the  underlying  causes  of  herpes  progenitalis. 
Prostitutes  are  those  who  suffer  in  greatest  number  from  this  affection, 
due,  undoubtedly,  to  the  very  frequent  irritation  of  their  genital  apparatus 

^  De  V Herpes  recidivnnt  des  Partes  genUales,  Paris,  1868. 

^  Annales  de  la  Polyclinique  de  Bordeaux,  January,  1890,  p.  1888. 


428  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

in  coitus.  Many  years  ago  I  saw,  weekly,  large  numbers  of  puellce 
puhlicce,  and  observed  a  goodly  proportion  thus  affected.  Such  is  its  fre- 
quency among  these  Avomen  that  Unna  calls  it  the  "  vocation  disease." 
Violence  to  the  female  genitals  in  rape  and  from  excessive  size  of  the 
penis,  and  in  masturbation,  particularly  when  large  and  firm  substitutes 
for  the  penis  are  employed,  often  produces  herpes  of  the  parts.  Vulvitis, 
vaginitis,  simple  or  severe,  are  frequently  the  forerunners  of  the  affection. 
Congestion  of  the  pelvic  organs,  dysmenorrhoea,  pelvic  cellulitis,  metritis, 
inflammation  of  the  ovaries  and  tubes,  and  endometritis  are  likewise 
occasional  excitants  of  the  affection.  It  is  also,  as  recently  pointed  out 
by  Bergh,^  a  frequent  forerunner  and  concomitant  affection  of  menstrua- 
tion, so  that  in  France  the  term  houton  de  regie  has  been  applied  to  it. 
During  this  epoch  it  frequently  attacks  young  girls,  young  women,  and 
even  those  of  middle  age.  The  attacks  may  come  on  every  month  or 
there  may  be  intervals  of  freedom  of  several  months.  It  is  perhaps  rather 
more  frequent  in  sexually-inclined  and  neurasthenic  women,  as  claimed 
by  Bergh.  As  in  men,  so  in  women,  herpes  progenitalis  is  seen  in  early 
and  late  adult  life,  and  found  to  relapse  in  the  same  exasperating  manner. 

It  is  probable  that  in  all  cases  of  herpes  progenitalis  disturbance 
occurs  in  the  nervous  arc  which  exists  between  the  genital  apparatus  and 
the  spinal  cord,  and  that  irritation  is  transmitted  from  the  external  or 
deep  portions  of  the  genital  apparatus  backward  to  the  spinal  nerve- 
centres,  and  from  these  conveyed  to  some  portion  or  portions  of  the  penis, 
vulva,  or  mons  Veneris.  Clinically,  many  cases  of  herpes  progenitalis 
present  features  of  similarity  to  herpes  zoster,  even  to  the  point  of  being 
coexistent  with  it. 

Although  it  has  been  suspected  that  herpes  progenitalis  may  be  of 
microbic  origin,  little  is  known  in  support  of  such  an  hypothesis.  Diday 
and  Doyon^  state  that  Zeissl  informed  them  that  he  had  found  cocci,  but 
not  micrococci,  in  the  serum  of  an  unruptured  vesicle.  Rohrer  ^  found 
very  few  diplococci  and  bacteria,  and  Pfeiffer*  in  a  case  of  menstrual 
herpes  could  find  no  micro-organism. 

Diagnosis. — Usually,  the  diagnosis  of  herpes  of  the  genitalia  is  readily 
made,  but  when  exulcerated  the  vesicles  may  closely  resemble  chancroid 
or  hard  chancre.  As  a  rule,  the  sensations  of  heat,  itching,  and  burning, 
the  superficial  character  of  the  lesion,  its  less  profuse  secretion,  and  scarcely 
undermined  edges  will  establish  the  diagnosis,  which  may  be  strengthened 
by  the  history  of  relapses.  Further,  the  very  frequent  unilateral  position 
and  peculiar  groupings  of  the  herpes  vesicles  are  important  diagnostic 
aids,  while  in  some  cases  the  arrangement  of  these  lesions  in  the  course 
of  a  nerve  points  undoubtedly  to  their  nature. 

Both  in  its  solitary  and  multiform  conditions  herpes  zoster  may  resemble 
the  syphilitic  chancre  in  its  early  and  erosivie  stage  (chancrous  erosion). 
There  are  probably  more  errors  made  by  mistaking  this  as  yet  undeveloped 
initial  lesion  for  herpes  than  there  are  about  any  other  form  of  the  hard 
chancre.  The  surface  of  the  chancrous  erosion  is  usually  of  a  deeper  and 
duller  red  color,  even  coppery,  and  its  floor  is  smooth  and  shining,  without 


'  Op.  cit. 

■^  Lrs  Herpes  genltnnx,  Paris,  1886,  p.  274. 

^  Monalshefie  fiir  Prnk.  Dermat.,  vol.  vii.,  1888, 

*  Ibid.,  vol.  vi.,  1887,  p.  590. 


p.  991. 


HERPES  PROGENITALIS.  429 

any  small  granulations.  Its  areola  is  very  slight  and  of  a  dull-red  color, 
and  there  is  a  general  absence  of  inflammation  about  the  whole  lesion. 
Leloir^  emphasizes  the  statement  with  much  positiveness  that  pressure 
between  the  thumb  and  forefinger  of  a  chancrous  erosion  will  fail  to  cause 
a  drop  of  serum  to  exude  from  its  surface,  while  if  similarly  treated  an 
herpetic  vesicle  gives  issue  to  repeated  drops.  This  diagnostic  point, 
which  Leloir  calls  the  signe  de  V expression  du  sue,  in  my  judgment 
should  be  interpreted  in  a  contrariwise  direction.  Very  many  times,  for 
purposes  of  getting  a  good  picture  of  these  chancres  and  in  teaching,  I 
have  held  chancres  between  my  fingers  from  five  to  twenty  minutes,  and 
even  longer,  and  have  almost  invariably  seen  an  abundant  and  constant 
oozing  of  serum,  so  much  so  that  great  care  against  infection  Avas  neces- 
sarily taken.  Handling  herpetic  vesicles  in  a  similar  manner  never 
produced  more  than  a  scanty  secretion.  So  that,  in  my  opinion, 
abundance  of  secretion  is  at  least  presumptive  evidence  of  chancrous 
erosions. 

It  is  a  good  rule  to  be  always  guarded  and  reserved  in  the  diagnosis 
of  these  minute  lesions,  particularly  in  cases  in  which  there  is  absence  of 
the  prodromal  and  accompanying  symptoms  of  herpes,  and  especially 
when  the  lesion  seems  particularly  insignificant.  This  point  cannot  be 
stated  in  a  too  impressive  manner.  It  is  these  insignificant  lesions  which 
usually  develop  into  hard  chancres.  In  like  manner,  a  clear  history  of 
antecedent  herpes  should  not  embolden  the  surgeon  to  speak  too  confi- 
dently of  the  simple  character  of  its  successor.  A  group  of  chancrous 
erosions  constitues  what  is  called  the  multiple  herpetiform  chancre,  which 
is  liable  to  be  mistaken  for  a  cluster  of  herpetic  vesicles.  Besides  the 
points  of  difference  already  given  concerning  a  single  erosion,  in  its  multi- 
form condition  the  diagnostic  points  insisted  upon  by  Fournier  may  afford . 
much  aid.  Patches  of  chancrous  erosions  assume  a  round  or  oval  outline 
or  irregularly  round  or  oval  shape.  Herpes  progenitalis,  on  the  contrary, 
has  the  polycyclic  form,  with  its  festooned  and  segments-of-circles-like 
margins,  due  to  the  fusion  of  a  group  of  round  vesicles.  Still,  I  have 
several  times  seen  the  multiple  herpetiform  chancre  present  for  a  few  days 
a  typically  distinct  polycyclic  outline. 

Treatment. — The  first  indication  is  to  remove  irritation  or  inflammation 
from  the  external  and  internal  parts  of  the  male  or  female  genital  appa- 
ratus. If  any  abnormality  of  the  prepuce  exists  as  an  exciting  cause, 
circumcision  should  be  performed  as  early  as  possible  after  the  healing  of 
the  lesions,  since  benefit  is  produced  in  the  vast  majority  of  cases.  Any 
deep-seated  urethral  trouble  or  affection  of  any  of  the  accessory  parts  of 
the  genital  tract  should  receive  appropriate  treatment.  All  sources  of 
irritation  of  the  penis  should  be  avoided,  and  frequent  ablutions  in  hot 
w\ater  made.  Any  coexisting  dyscrasia,  gouty,  rheumatic,  neurotic,  or 
plethoric,  should  receive  proper  attention.  Sexual,  alcoholic,  and  dietary 
excesses  should  be  interdicted. 

In  Avomen,  as  far  as  possible,  irritations,  congestions,  and  inflamma- 
tions should  be  avoided  or  removed  by  appropriate  treatment,  and  the 
frequent  use  of  douches  of  hot  water  should  be  insisted  upon.  Tlie  health 
of  the  patient  should  be  considered,  and  any  deviation  from  the  normal 
attended  to.  Diday  and  Doyon  consider  the  sulphur  waters  of  Uriage  as 
'  Legons  sur  la  Syphilis,  Paris,  1886,  pp.  99  et  seq. 


430  GONOBRHCEA  AND  ITS  COMPLICATIONS. 

of  benefit  in  this  affection.  I  myself  have  never  seen  any  permanent 
benefit  derived  from  natural  waters  taken  internally. 

Locally,  many  agents  may  be  employed.  For  irritable  herpes  in 
either  sex  the  lead-and-opium  wash  is  often  very  soothing.  Very  often 
the  persistent  neuralgic  and  burning  pains  require  for  their  relief  very 
careful  but  thorough  cauterization  with  carbolic  acid,  solutions  of  nitrate 
of  silver  (sixty  grains  to  the  ounce  of  water),  or  perhaps  with  fuming 
nitric  acid,  after  which  the  lead-and-opium  wash  may  be  applied.  As  an 
adjuvant  in  these  cases  frequent  immersions  in  very  hot  water  are  very 
soothing.  Boracic  acid  and  iodoform,  alone  or  in  combination,  are  fre- 
quently of  benefit  where  a  tendency  to  ulceration  exists.  Aristol  and 
europhen  may  also  be  of  service.  Iodoform  and  glycerin,  or  in  ointment 
form  mixed  with  vaseline  (one  drachm  to  the  ounce),  very  frequently  are 
beneficial  in  relieving  the  neuralgia  and  promoting  healing. 

A  solution  of  the  bichloride  of  mercury  (1 :  3000)  or  of  carbolic  acid 
(2  per  cent,  to  the  ounce  of  water)  may  be  found  useful.  Aromatic  wine, 
pure  or  diluted  one  half  with  water,  is  a  pleasant  application. 

The  following  formulas  may  also  be  tried : 

^.  Argenti  nitrat.,  gr.  ij  ; 

Ext.  bellad.,  gr.  x  ; 

Aquse,  |j. — M. 

^.  Zinci  sulphat.,  gr.  vj  ; 

Spts.,  lavandulse,  3ss ; 

Glycerinae,  3iss ; 

Aquae,  ad  ^j. — M. 

^.  Alumini  sulph.,  gr.  xij  ; 

Acid,  carbol.,  "  gtt.  xx ; 

Aquge,  §iv. — M. 

I^.  Resorcin,  3j  ; 

Aquae,  §iv. — M. 

'S^.  Acid,  tannic,  5J  ; 

Aquae,  5iv. — M. 

Black  and  yellow  washes  are  sometimes  very  soothing  and  healing. 

In  several  cases  of  the  relapsing  form  of  herpes  progenitalis,  when 
occurring  on  the  cutaneous  investment  of  the  penis,  I  have  seen  good 
and  even  brilliant  results  in  the  abortion  of  the  vesicles  and  in  the  relief 
of  the  burning  and  pruritus  by  a  method  of  treatment  advocated  by  Dr. 
Dupas  ^  of  Lille.  This  consists  in  the  application,  by  means  of  compresses, 
of  absolute  alcohol  or  alcohol  to  which  resorcin,  2 :  100,  menthol,  1 
gramme  to  100  ;  carbolic  acid,  25  centigrammes  to  100  ;  or  of  tannin,  2 
grammes  to  100, — have  been  added.  I  have  also  seen  benefit  follow  com- 
presses of  spirits  of  camphor.  In  many  cases,  however,  the  abortive 
treatment  fails. 

All  solutions  should  be  carefully  applied  to  the  parts  on  lint  or  ab- 
sorbent cotton.  Calomel,  calcined  magnesia,  oxide  of  zinc,  subnitrate  of 
bismuth,  starch,  l^'-copodium,  and  Venetian  talc  may  be  used  during  the 
stage  of  healing  as  dusting  powders. 

^  Journal  of  Cutaneous  and  Genito-urinary  Diseases,  vol.  vii.,  1889,  p.  474. 


VEGETATIONS. 


431 


CHAPTER    XXXVII. 


VEGETATIONS. 

Vegetations  are  papillary  new  growths  formed  by  hypertrophy  of  the 
papillae,  increase  in  the  epidermis  and  capillaries,  and  hyperplasia  of  con- 
nective tissue.  They  are  known  under  various  names,  the  chief  ones 
being  venereal  Avarts,  pointed  warts,  moist  warts,  fig  warts,  cauliflower 
excrescences,  pointed  condyloma,  verruca  acuminata,  verruca  vegetantes, 
condyloma  acuminata,  spitz  condylom,  and  vegetation  ddrmique.  It  is 
important  to  remember  that  these  names  are  applied  to  vegetations  alone 
which  are  simple  new  growths,  and  that  the  term  "condyloma  latum"  is 
given  to  certain  papillary  growths  of  syphilitic  origin. 

Vegetations  are  not,  in  the  majority  of  cases,  of  venereal  origin,  though 
their  most  frequent  sites  of  development  are  on  or  in  the  neighborhood  of 
the  genitals  of  both  sexes,  particularly  in  persons  who  have  had  gonor- 
rhoea, leucorrhoea,  chancroids,  and  syphilis,  and  in  pregnant  women.  It 
is  incumbent  upon  the  physician  to  be  very  careful  in  the  employment  of 
the  word  "  venereal "  as  applied  to  warts,  for  great  injustice  may  be  done 
to  patients,  male  and  female,  in  whom  these  lesions  may  be  present,  but 
who  may  not  have  been  guilty  of  sexual  transgression.  Their  growth  is 
induced  and  favored  on  mucous  surfaces  and  at  the  junction  of  the  skin 
and  mucous  membrane,  and  on  thin,  delicate  skin,  by  uncleanliness,  by 
the  decomposition  of  sweat  and  of  sebaceous  matter,  and  by  the  presence 
of  gonorrhoeal  and  other  kinds  of  pus.  For  clearness  of  description,  vege- 
tations may  be  divided  into  two  well-marked  classes :  first,  the  soft,  suc- 

FiG.  166. 


Soft  young  vegutatious  in  the  coronal  sulcus  and  near  fraenum. 

culent  warts  of  the  mucous  membranes  and  muco-cutaneous  junctions  ; 
second,  the  harder  and  firmer  warts  which  appear  on  the  skin,  particularly 
near  the  genitals,  since  here  the  two  factors  essential  to  their  growth — 
namely,  heat  and  moisture — exist. 


432 


MISCELLANEOUS  AFFECTIONS. 


Fig.  167. 


The  soft  Avarts  or  vegetations  are  found  in  the  male  upon  the  corona, 
in  the  sulcus  behind  it,  and  on  the  inner  surface  of  the  prepuce,  partic- 
ularly near  the  frsenum  (very  clearly  shown  in 
Fig.  166).  They  also  are  found  around  or  within 
the  orifice  of  the  meatus,  sometimes  to  the  depth 
of  nearly  an  inch.  (See  Fig.  167.)  In  women 
they  commonly  develop  upon  the  fourchette, 
around  the  entrance  of  the  vagina,  and  within 
it  as  far  as  the  uterus,  and  upon  the  inner  sur- 
face of  the  labia  minora  and  majora  and  upon 
the  anal  region.  (See  Fig.  168.)  From  the 
genitals  in  either  sex  they  may  spread  to  neigh- 
borino;  regions. 

Vegetations  begin  as  minute  reddened  ero- 
sions of  the  mucous  membrane,  which  very 
soon  come  to  look  like  pinhead-sized,  rosy-red, 
finely-granular  papules.  In  this  state  I  have 
known  them  to  be  mistaken  for  incipient  hard 
chancres.  From  this  insignificant-lookino;  lesion 
growths  even  of  vast  size  spring.  When  the 
parts  are  moist  and  little  attention  is  paid  to 
cleanliness,  they  grow  rapidly  and  exuberantly,  but  where  the  parts  are 
dried  they  grow  slowly  and  show  less  tendency  to  peripheral  develop- 


Warts  within  tlie  orifice  of  the 
urethra  (lip  of  meatus  me- 
chanically separated). 


Fig.  168. 


Vegetations  of  vulva  and  anal  region,  those  on  the  skin  hard  and  horny. 


ment.     The  close  coaptation  of  parts,  with  their  greater  inaccessibility 
to   care  and  their  increased  secretions,  also  favors  rapid  growth.     The 


VEGETATIONS. 


433 


pinliead-sized  warts  already  described  grow  in  height  and  in  breadth  and 
form  vegetations  of  various  shapes.  They  may  be  rounded  and  sessile 
or  pedunculated  or  Indian-club-  and  mushroom-shaped,  in  which  condi- 
tions they  vary  in  size  from  that  of  a  pea  to  that  of  a  raspberry.  Or, 
instead  of  growing  in  breadth,  when  from  the  formation  of  the  parts  they 
are  subjected  to  lateral  pressure,  they  grow  to  a  length  of  an  inch  and  more, 
and  separated  they  look  like  so  many  thin  red  spears  with  smooth  sides 
jutting  out  and  radiating  in  various  directions.  This  form,  looking  like 
the  blossoms  of  thyme,  which  was  called  by  the  older  Avriters  acrothymion, 
is  seen  chiefly  around  the  introitus  vaginae  and  vulva,  and,  springing 
from   the   balano-preputial  furrow 

in  subjects  having  a  roomy  pre-  Fig.  169. 

puce,  and  from  the  region  of  the 
frtenum,  has  been  called  the  ver- 
ruca dicritata,  or  finger-like  or 
spear-shaped  wart.  The  exube- 
rant development  of  warts  of  the 
sessile  and  pedunculated  or  club- 
shaped  forms  may  result  in  new 
growths  of  enormous  size,  which 
are  called  fungatino;  masses  and 
cauliflower  excrescences.  (See 
Fig.   169.) 

The  color  of  vegetations  varies 
in  diff'erent  subjects  and  at  differ- 
ent times.  They  may  be  of  the 
deep  red  of  the  cock's  comb  or  of 
a  purplish  red,  and  when  rather 

small  they  may  be  but  slightly  more  pink  than  the  mucous  membrane 
upon  which  they  are  seated ;  frequently  they  are  of  a  gray  or  dirty-gray 
color.  Their  surface  is  covered  with  minute  mammillated  warty  eleva- 
tions resembling  those  of  the  strawberry  or  raspberry.  A  very  clear 
idea  may  be  gained  of  the  appearance  of  vegetations  from  inspection  of 
the  foregoing  figures.  On  mucous  surfaces,  particularly  when  covered, 
as  by  the  prepuce,  or  in  close  coaptation,  as  in  the  vulva,  vegetations  are 
attended  by  a  sticky  mucoid  secretion  which  rapidly  undergoes  decompo- 
sition and  gives  rise  to  a  penetrating  and  sickening  odor.  In  the  male 
they  are  frequently  the  cause  of  balanitis  when  seated  upon  the  prepuce 
near  the  frgenum  or  in  the  sulcus  glandis,  and  when  about  the  meatus  a 
purulent  discharge,  resembling  gonorrhoea,  may  be  produced.  Likewise 
in  the  female  a  Avell-marked  purulent  vulvitis  or  vaginitis  is  sometimes 
caused  by  vegetations  and  often  aggravated  by  uncleanliness.  On  the 
other  hand,  they  frequently  develop  around  the  introitus  vaginse  as  a 
result  of  the  irritation  of  gonorrhoea  or  leucorrhoea.  Vegetations  in 
women  are  never,  as  claimed  by  some,  absolutely  diagnostic  of  gonor- 
rhoea. 

Various  annoying  and  injurious  mechanical  conditions  are  sometimes 
caused  by  vegetations  in  both  male  and  female.  Men  having  the  various 
malformations  of  the  prepuce,  such  as  smallness  of  the  orifice,  straitness 
and  tightness  and  redundancy,  and  those  in  whom  the  fra^num  is  short, 
upon  the  development  of  warts  on  these  parts  are  very  liable  to  phimosis. 

28 


Exuberant  warts  ;ii\i>lving'  the  inner  layer  of  the 
prepuce,  the  sulcus,  and  the  greater  portion 
of  the  glans   (cauliflower  appearance). 


434 


MISCELLANEOUS  AFFECTIONS. 


This  complicated  condition  is  often  accompanied  by  much  inflammatory 
action  and  with  a  copious  flow  of  pus.  Warts  thus  concealed  under  the 
prepuce,  the  conditions  being  so  favorable,  grow  rapidly,  sometimes  push- 
in  o-  forward  and  out  of  the  preputial  orifice,  and  again  they  press  upward, 


Fig.  171. 


Showing  perforation  of  the  prepuce  by  warts,  and  their  subsequent  exuberant  development. 

causing  gangrene  and  perforation  of  the  prepuce,  as  shown  in  Fig.  170, 
in  which  it  will  be  seen  that  the  meatus  is  covered  with  these  growths. 
When  seated  about  the  frsenum  they  first  cause  difficulties  in  retracting 

the  foreskin,  and  later  on  phimosis  with 
all  of  its  concomitant  uncleanliness  and 
suff"ering.  The  flow  of  urine  and  the 
ejaculation  of  semen  are  often  rendered 
difficult  by  vegetations  around  the  urethra 
and  at  the  frsenum,  and  coitus  is  rendered 
impossible. 

Then,  again,  warts  are  not  infre- 
quently the  cause  of  paraphimosis.  In 
Fig.  171  is  well  shown  a  half  ring  of 
hard  small  warts,  very  characteristic  in 
appearance,  seated  on  the  inner  surface 
of  the  prepuce  and  at  the  frjBnum. 
These  have  given  rise  to  much  inflam- 
matory hyperplasia.  In  this  state  the 
patient,  with  some  force,  retracted  the 
prepuce  and  produced  a  rebellious  condi- 
tion of  paraphimosis. 

In  women  vegetations  at  the  meatus 
and  in  the  vestibule  very  often  give  rise  to  irritation,  often  severe  in 
character,  spasmodic  pains,  burning,  and  a  discharge,  and  sometimes  a 
frequent  desire  to  pass  water,  and  they  may  act  as  an  impediment  to 


Showing  hard,  corneous  warts  on  the  in- 
ner lamella  of. the  prepuce  and  at  the 
frsenum,  complicating  paraphimosis. 


VEGETATIONS.  435 

urination.  In  the  vulva  and  around  the  introitus  vaginae,  besides  these 
inflammatory  accompaniments,  when  small  they  interfere  with  the  intro- 
duction of  specula  and  with  coitus,  and  when  excessively  large,  even  to 
the  size  of  an  egg  or  an  orange,  they  impede  urination  and  effectually 
block  up  the  vaginal  orifice.  Cure  of  such  cases  often  involves  partial 
stenosis  of  the  orifice.  The  lot  of  women  thus  afflicted  is  indeed  a  sorry 
one,  and  those  in  whom  the  growth  of  vegetations  has  extended  around 
the  anus  further  suffer  from  irritation,  spasmodic  contractions,  and  pain 
and  difficulty  of  defecation. 

The  soft,  succulent  vegetations  sometimes,  when  irritated  or  subjected 
to  traumatism,  become  very  much  inflamed,  and  even  gangrenous,  and  in 
the  inflamed  condition  have  been  regarded  as  exuberant  epitheliomata. 
Long-continued  irritation  has  been  known  to  transform  these  growths  into 
true  epithelioma  in  both  male  and  female,  particularly  after  middle  age. 
Indeed,  the  occurrence  of  warts  about  the  genitals  in  elderly  subjects, 
male  and  female,  should  never  be  passed  over  lightly.  Such  subjects 
should  be  informed  of  their  frequent  tendency  to  malignancy.  All  such 
growths  should  be  promptly  and  thoroughly  removed.  Epithelioma  of 
the  penis  and  vulva  very  frequently  begins  in  simple  vegetations.  As 
instances  I  recall  the  case  of  a  gentleman,  aged  forty-eight,  who  had  on 
the  inner  layer  of  the  prepuce  a  rough,  flat  patch  of  vegetations  which 
had  existed  several  years,  and  which  developed  into  fungating  epithelioma. 
Further,  I  preserve  a  vivid  recollection  of  the  case  of  a  lady,  aged  fifty- 
three,  who  had  a  seemingly  insignificant  wart  just  to  the  right  of  the 
clitoris.  She  refused  treatment,  the  growth  increased  and  became  trans- 
formed into  epithelioma,  which  caused  her  death  fifteen  months  after  its 
development.     The  lesson  presented  by  these  cases  is  obvious. 

The  hard  or  corneous  warts  of  the  skin  may  exist  alone  or  follow  the 
successive  crops  of  soft  ones  which  begin  on  mucous  surfaces.  They  con- 
sist of  small  red,  sometimes  dirty-brown,  sessile,  rounded  or  pointed 
tumors,  quite  firm  in  structure,  of  an  area  of  a  line  or  more,  and  of  a 
height  of  two  or  more  lines.  Their  features  are  usually  very  striking  and 
in  marked  contrast  to  condylomata  of  syphilis.  In  structure  they  are 
similar  to  the  soft  ones,  except  that,  owing  to  the  nature  of  the  skin,  their 
epidermal  covering  is  thicker,  their  papillae  shorter,  and  the  connective 
tissue  more  condensed.  They  occur  on  the  penis,  on  the  scrotum,  in  the 
crural  folds,  and  about  the  anus  in  the  male,  and  on  the  labia  majora, 
inner  surface  of  the  thighs,  on  the  perineum,  and  about  the  anus  in 
women.  Like  those  of  the  soft  variety,  they  increase  in  great  numbers, 
though  more  slowly.  On  coapted  surfaces  their  epithelial  covering  may 
be  rubbed  off,  and  they  then  give  issue  to  a  sticky,  fetid  secretion,  which, 
mixed  with  sebum  and  sweat,  is  sometimes  copious.  Their  further  course 
is  influenced  by  the  conditions  which  surround  them.  If  the  parts  are 
the  seat  of  heat  and  moisture,  especially  if  the  patient  is  uncleanly,  they 
grow  and  multiply  luxuriously  ;  but  if  they  occur  on  exposed  surfaces, 
and  particularly  if  they  are  carefully  cleansed  or  dusted  Avith  absorbent 
powders,  they  may  remain  quiescent  indefinitely.  In  like  manner,  the 
soft  warts,  when  seated  on  parts  which  can  be  kept  dry  and  are  either 
exposed  to  the  air  or  to  the  action  of  absorbent  powders,  become  hard 
and  corneous  and  permanently  lose  their  softness  and  succulence.  This 
transformation  occurred  in  the  case  pictured  in  Fig.  171.     When  para- 


436  MISCELLANEOUS  AFFECTIONS. 

phimosis  was  developed  the  warts  became  dry  and  the  epithelial  coating 
became  hardened. 

It  is  not  at  all  uncommon  to  see  vegetations  in  syphilitic  subjects  in 
the  neighborhood  of  condylomata  lata.  In  chronic  cases  in  uncleanly  sub- 
jects syphilitic  condylomata  sometimes  undergo  papillomatous  hyper- 
trophy, by  which  the  specific  lesions  become  transformed  to  lesions 
which  to  the  eye  look  pi'ecisely  like  vegetations.  It  is  important  to  bear 
in  mind  the  possibility  of  this  transformation. 

Veo-etations,  especially  of  the  soft  kind,  are  mostly  seen  in  subjects  of 
from  twelve  years  to  adult  life,  and  in  the  male  and  female  in  about 
equal  proportions.  As  age  advances  they  are  less  frequently  observed, 
and  in  middle-aged  and  old  persons  they  are  harder,  firmer,  and  sessile, 
less  vascular,  and  fewer  in  numbers,  most  commonly  resembling  the 
chronic  seed-warts  of  the  hands. 

The  question  of  the  contagiousness  of  venereal  warts  is  a  very  old  one, 
and  is  to-day  in  an  unsettled  condition.  There  is  a  popular  impression 
among  the  laity  that  warts  about  the  hands,  face,  and  genitals  are  con- 
tagious to  their  bearers  and  to  others,  and  seemingly  convincing  instances 
of  such  contagion  are  frequently  given  with  a  wealth  of  detail.  Giintz  ^ 
of  Dresden  is  the  chief  advocate  of  the  doctrine  of  this  form  of  contagion. 
He  reported  the  case  of  a  child  who  contracted  these  growths  from  having 
used  repeatedly  the  same  chamber  as  its  nurse,  upon  whose  genitals  at  the 
time  innumerable  vegetations  were  seated.  He  quotes  the  so-called  suc- 
cessful vaccinations  of  Dr.  Kranz  ^  in  Lindwurm's  clinic. 

Guntz  further  quotes  the  case  of  Sir  Astley  Cooper's  assistant,  who, 
during  the  ablation  of  a  large  condylomatous  growth,  was  wounded  in  the 
vicinity  of  the  finger-nail,  and,  as  a  result,  there  was  developed  at  the 
point  of  injury  a  growth  of  condylomata  acuminata.  Giintz  himself  in 
six  experiments  removed  vegetations  from  the  genitals  and  placed  them  in 
incisions  on  the  arms,  in  each  instance  with  a  negative  result. 

The  late  Prof.  Potters  ^  was  the  chief  opponent  of  the  doctrine  of  the 
contagiousness  of  venereal  warts,  and  those  interested  in  this  question  are 
referred  to  his  exhaustive  essay,  which  contains  the  details  of  twelve  care- 
fully conducted  but  negative  experiments. 

The  following  facts  show  clearly  the  state  of  opinion  on  tlie  subject: 
Hebra  disbelieved  in  the  contagiousness  of  these  lesions,  and  Ricord  was 
of  the  same  mind.  Reder  considers  the  contagion  probable,  while  Geigel 
regarded  it  as  certain.  Zeissl  admitted  their  contagiousness,  and  Neumann, 
while  conceding  the  possibility,  was  in  doubt.  Lebert,  on  the  contrary, 
gives  it  as  his  opinion  that  these  growths  are  positively  not  contagious. 

Certain  it  is  that  we  sometimes  hear  of  very  plausible  cases  which  seem 
to  carry  conviction,  but  experimental  inoculation  has  resulted  either  in 
untrustworthy  results  or  absolute  failure. 

In  women  warts  about  the  vulva  sometimes  lead  to  great  hypertrophy 
and  disfigurement  of  the  parts. 

This  form  of  hypertrophy  of  the  vulvo-anal  region  of  women,  I  believe, 

^  "  On  the  Question  of  the  Contagiousness  of  Venereal  Warts,  the  so-called  Condylo- 
mata Acuminata,"  Archives  of  Dermatology,  vol.  iii.,  1S77,  pp.  14  et  seq. 

''"Beitrag  zur  Kenntniss  des  Schleimhaut  papilloms,"  Deut.  Archiv  fiir  klin.  Med., 
1867,  B.  11,  pp.  79  et  seq. 

^  "Zur  Frage  der  Anstekungsfiihigkeit  der  Vegetationen  oder  der  Spitzen  Condylo- 
men,"  Vierteljahr.  fiir  Derm,  unci  Syphilis,  vol.  vii.,  1875,  pp.  255  et  seq. 


VEGETATIONS.  437 

has  not  heretofore  been  mentioned  by  authors.  The  initial  stage  of  it 
consists  in  the  development  of  simple  vegetations  on  any  part  of  the  ex- 
ternal genitals.  Owing  to  neglect,  want  of  care  and  cleanliness,  and  of 
surgical  intervention  these  growths  become  enlarged,  and  they  then  usually 
increase  in  numbers.  As  they  grow  in  height  and  breadth,  particularly 
those  on  the  outer  portions  of  the  labia  majora  (where  they  are  subject 
to  continuous  friction),  they  lose  their  warty  appearance  and  come  to  look 
like  nodules,  processes,  or  tabs  of  skin.  They  are,  as  it  were,  polished 
oif,  losing  entirely  their  granular,  raspberry-like  look,  and  taking  on  the 
appearance  of  fleshy  integument. 

Unless  ablated,  these  tumors  inevitably  lead  to  great  hypertrophy  and 
disfigurement  of  the  parts.  They,  acting  as  low-grade  inflammatory  foci, 
induce  hypergemia  and  hyperplasia  in  the  vulva,  and  in  the  end  lead  to 
its  great  distortion.  I  have  many  times  seen  this  general  hypertrophy 
of  the  external  genitals  by  warts,  and  I  recall  an  instance  in  which  these 
growths,  being  very  large,  were  ablated,  and  in  their  stumps  hyperplasia 
took  place,  which  led  to  great  deformity.  The  practical  teaching  of  these 
cases  is  not  only  that  these  new  growths  should  be  thoroughly  removed, 
but  that  great  care  should  be  taken  that  their  sites  shall  not  become  the 
foci  of  hyperplastic  new  formations  which  later  on  may  become  malig- 
nant- 
Diagnosis. — So  well  marked  are  the  features  of  full-developed  vegeta- 
tions that  their  nature  is  readily  recognized.  When,  however,  they  have 
undergone  condensation  and  have  become  flattened,  they  may  be  mistaken 
for  condylomata  lata,  especially  when  the  latter  have  become  hypertrophic. 
The  latter  usually  have  a  clear  syphilitic  history,  and  are  perhaps  accom- 
panied by  other  specific  lesions,  active  or  declining.  Condylomata  lata 
begin  as  small  flat,  papular,  firmly-consistent  formations,  usually  of  slow 
growth  at  first,  not  very  many  in  number,  and  may  thus  remain  for  a 
long  time ;  whereas  the  vegetations  or  warts  grow  rapidly  and  present  the 
cleanly-cut  features  already  given.  In  many  cases  of  chronic  metamor- 
phosed simple  vegetations,  so  close  is  their  resemblance  to  condylomata 
lata  that  their  nature  can  only  be  determined  by  a  painstaking  study  of 
the  case.  The  hard  form  of  wart  found  in  older  subjects  is  very  often  a 
sign  of  evil  omen.  Portions  should  be  removed  and  their  nature  deter- 
mined by  the  aid  of  the  microscope. 

Prognosis. — Though  of  simple  nature,  vegetations,  from  their  great 
exuberance  of  growth,  should  never  be  slightingly  regarded.  Their  fre- 
quent causation  of  acute  purulent  inflammation  in  both  male  and  female, 
their  tendency  to  induce  phimosis,  Avith  gangrene  and  perforation  of  the 
prepuce  and  paraphimosis,  their  interference  Avith  the  functions  of  the 
female  genito-urinary  tract,  and  their  liability  when  large  to  become  gan- 
grenous, should  be  borne  in  mind  and  explained  to  patients.  Further, 
their  inevitable  growth  and  reproduction  should  not  be  forgotten.  Then, 
again,  particularly  in  old  subjects,  they  are,  as  Ave  have  seen,  prone  to 
undergo  malignant  degeneration — usually  in  Avomen  earlier  than  men. 
It  may  be  stated,  Avithout  fear  of  contradiction,  that  a  large  proportion 
of  the  cases  of  epithelioma  of  the  uterus  and  vagina  and  of  the  penis 
have  begun  in  a  seemingly  insignificant  Avart.  It  is  the  duty  of  the  sur- 
geon to  impress  upon  the  patient  the  fact  that  as  middle  nge  approaches 
and  increases  warts  on  any  portion  of  the  body  are  menaces  to  his  or  her 


438  MISCELLANEOUS  AFFECTIONS. 

safety.  This  is  particularly  true  as  to  the  genital  organs  of  both  male 
and  female.  An  aged  male  patient,  having  from  any  cause  difficulty  in 
retracting  the  prepuce  with  warts  around  or  beneath  it,  should  be  informed 
that  they  are  especially  prone  at  his  time  of  life  to  undergo  malignant 
degeneration. 

Treatment. — The  indications  for  the  treatment  of  vegetations  ai'e  their 
complete  removal  and  the  prevention  of  their  return.  In  every  instance 
the  immediate  and  accessory  parts  should  be  thoroughly  washed  or  irri- 
gated with  solutions  of  carbolic  acid  (1 :  100)  or  of  the  bichloride  of  mer- 
cury (1 :  2000) ;  then  the  surfaces  and  interstices  of  the  warts  should  be 
thoroughly  coated  with  an  8  per  cent,  solution  of  muriate  of  cocaine.  In 
very  nervous  subjects  and  in  men,  but  especially  in  women  in  whom  the 
lesions  cover  a  large  or  delicate  surface,  mild  chloroform  or  ether  narcosis 
may  be  required.  This  condition  being  induced,  the  necessary  treatment 
can  be  more  thoroughly  and  easily  instituted. 

It  may  be  stated  as  an  axiom  that  surgical  procedures  for  the  removal 
of  vegetations  are  much  more  rapid  and  effectual  than  caustics  are.  The 
latter,  hoAvever,  are  useful  under  certain  circumstances.  When  the  vege- 
tations are  small,  they  are  readily  removed  by  the  dermal  curette  or 
Volkmann's  spoon,  the  scraping  being  carried  well  to  the  level  of  the 
tissues,  which,  however,  must  not  be  wounded.  A  solution  of  persulphate 
or  perchloride  of  iron  should  be  carefully  touched  to  the  bleeding  points, 
and  the  parts  when  dry  quite  firmly  covered  either  with  iodoform  or 
absorbent  gauze — never  with  watery  solutions.  Such  is  the  tendency  to 
recurrence  of  these  growths  that  the  cure  cannot  be  considered  complete 
until  the  surfaces  are  smooth.  In  cases  of  recurrence  before  the  little 
growths  have  reached  much  salience,  chloro-acetic  acid,  lactic  acid,  acid 
nitrate  of  mercury,  nitric  acid,  the  various  solutions  of  iron  just  spoken 
of,  and  strong  tincture  of  iodine,  may  be  employed.  Bichloride  of  mer- 
cury (thirty  grains  to  the  ounce  of  collodion)  or  salicylic  acid  (one  drachm 
to  the  ounce  of  the  same  fluid)  is  sometimes  a  very  effectual  solution  for 
small  warts  and  those  for  which  curetting  is  contraindicated. 

Strong  solutions  of  chromic  acid  (3j  to  3iv  to  the  ounce  of  water)  have 
been  used  by  some  surgeons  in  the  treatment  of  warts.  I  regard  this 
deliquescent  drug  as  a  very  inappropriate,  and  even  dangerous,  agent 
in  the  treatment  of  these  cases.  Its  action  is  subject  to  no  control,  and 
when  applying  it  to  warts  we  never  positively  know  how  deeply  we  are 
cauterizing  into  healthy  tissue.  Then,  again,  it  produces  eschars  which 
are  slow  in  being  thrown  off  and  in  subsequent  healing.  Dr.  J.  W.  White  ^ 
has  reported  the  case  of  a  young  woman  who  had  a  very  large  mass  of 
warts  on  the  genital,  pubic,  and  anal  regions.  To  this  mass  half  an  ounce 
of  a  watery  solution  of  chromic  acid,  one  hundred  grains  to  the  ounce,  was 
applied.  The  woman  passed  a  restless  night,  and  died  twenty-seven  hours 
after  the  application  in  collapse.  Having  so  many  efficient  and  harmless 
agents  at  our  command,  it  is  well  to  leave  this  particular  one  alone. 

Sessile  or  pedunculated  warts  of  an  area  of  an  inch  or  more  may  be 
readily  removed  by  strangulation  with  a  silk  ligature.  In  some  cases  this 
object  may  be  accomplished  by  the  elastic  ligature,  using  the  ordinary 
small  India-rubber  bands,  fixed  firmly  around  the  base  of  the  warts ;  still, 
in  all  cases  in  which  it  is  practicable  scraping  is  the  best  treatment. 

'  Journal  of  Cutaneous  and  Genito-iirinary  Diseases,  vol.  vii.,  1889,  p.  300. 


VEGETATIONS.  439 

Warts  of  larger  area  than  an  inch  are  best  treated  by  the  galvano- 
cautery  loop,  since  these  cases  are  the  only  ones  in  Avhich  this  method  of 
removal  is  really  indicated.  Their  removal  must  be  slowly  and  carefully 
effected  Avith  the  least  loss  of  blood.  Their  further  treatment  is  similar  to 
that  of  the  small  growths.     Rigid  antisepsis  is  required  in  every  case. 

In  cases  in  which  the  warts  are  seated  under  a  tight  prepuce  the  utmost 
care  should  be  observed  that  inflammation  be  not  produced,  since  phimosis 
would  inevitably  occur  and  delay  the  cure.  In  many  cases  of  both  sexes, 
particularly  when  the  lesions  are  very  large  and  exuberant,  I  have  re- 
peatedly seen  the  most  satisfactory  results  follow  a  preliminary  treatment 
of  immersing  or  bathing  the  parts  for  as  much  as  an  hour  several  times  a 
day  in  water  as  hot  as  can  be  borne.  By  this  means  the  hypersemia 
and  hyperplasia  of  the  tissues  under  and  around  the  w^arts  are  reduced, 
and  these  growths  become  smaller  and  more  condensed,  and  are  more 
readily  tied  or  ablated  without  the  troublesome  hemorrhage  which  is  other- 
wise so  constant. 

The  utmost  care  must  be  observed  in  removing  vegetations  about  the 
meatus,  and  when  possible  scraping  or  tying  should  be  employed.  "When 
these  means  are  impracticable,  the  salicylic  or  bichloride  collodion  or 
tincture  of  iodine  may  be  used  very  carefully.  The  idea  is  to  simply 
remove  the  new  growth  and  avoid  damaging  the  parts  and  causing  stric- 
ture of  the  meatus.     As  a  rule,  acids  are  contraindicated  in  this  region. 

In  cases  where  operative  procedures  are  not  admissible,  whether  owing 
to  the  size  or  situation  of  the  warts,  it  is  well  to  apply  freely  to  them, 
after  the  preliminary  fomentations  with  very  hot  water,  followed  by  w^ash- 
ing  with  bichloride  or  carbolic  solutions,  equal  parts  of  calomel  and  sali- 
cylic acid.  At  Charity  Hospital  I  have  cured  many  unpromising  cases 
by  this  method. 

Bockhart  ^  speaks  very  highly  of  plumbum  causticum  in  the  treatment 
of  vegetations.  This  preparation  in  a  83  per  cent,  solution  of  oxide  of 
lead  is  a  strong  potash  solution  and  forms  a  grayish-green  turbid  mixture. 
It  should  be  applied  very  carefully  to  the  warts  alone,  the  surrounding 
parts  being  smeared  with  vaseline.  In  a  number  of  cases  thus  treated  by 
me  the  warts  were  promptly  converted  into  black  gummy  masses,  which 
fell  off  in  a  few  days,  leaving  a  slightly  reddened  surface.  The  agent  is 
worthy  of  use. 

Warts  on  the  female  genitals  should  be  treated  on  the  lines  just  indi- 
cated, care  being  taken  that  their  removal  be  completed  without  damage 
to  the  tissues.  When  seated  around  the  urethra  or  vaginal  orifice  several 
of  the  methods  of  removal  may  be  necessary,  the  surgeon  always  aiming 
to  preserve  the  lumen  of  these  canals.  When  practicable,  frequent 
copious  injections  of  very  hot  solutions  of  the  bichloride  (1  :  2000  or 
1  :  5000)  should  be  used  and  the  parts  kept  as  dry  as  possible.  There  is 
a  popular  fallacy  that  warts  in  pregnant  women  should  not  be  removed  for 
fear  of  producing  abortion.  This  view  was  the  outcome  of  the  old  and 
now  happily  nearly  obsolete  treatment  by  vigorous  and  intemperate 
cauterization,  Avhich  produced  great  vulvar  and  vaginal  inflammation,  and 
sometimes  rigidity,  even  stenosis,  of  the  genital  tract.  No  such  results 
are  produced  when  the  growths  are  removed  by  curetting  or  other  surgical 
means  supplemented  by  rigorous  antisepsis.      Since  vegetations  may  act  as 

'  Monaishefte  fiir  Praktische  Dermatologie,  vol.  vii.,  1888,  pp.  273  et  seq. 


440  MISCELLANEOUS  AFFECTIONS. 

impediments  to  parturition  by  reason  of  their  own  size  and  position  and 
of  the  oedematous  hyperplasia  which  they  cause,  they  should  always  be 
promptly  and  thoroughly  removed. 

Caesar  Boeck  ^  recommends  a  4  to  6  per  cent.  Avatery  solution  of  resor- 
cin  in  cases  in  which  relapses  show  a  tendency  to  occur  after  curetting. 
This  is  to  be  applied  on  gauze  or  cotton  encircling  the  penis  or  over  the 
female  genitals.  He  sometimes  uses  resorcin  in  combination  with  sugar, 
bismuth  subnitrate,  and  boric  acid,  in  the  proportion  of  8  of  resorcin  to  1 
of  the  powders  just  named.     He  claims  prompt  and  effectual  results. 

The  treatment  of  the  hard  vegetations  of  the  skin  has  for  its  object 
their  evulsion  or  their  absorption  and  withering.  Very  active  measures 
are  liable  to  cause  dermatitis  of  the  parts  around  the  genitalia.  If  there 
are  but  few  of  them,  they  may  be  curetted  and  treated  like  the  soft 
variety.  If  they  are  numerous,  and  if  curetting  is  contraindicated  for  any 
reason,  after  careful  cleansing  of  the  whole  surface  and  ablution  with  car- 
bolic or  bichloride  solutions  of  the  strength  already  mentioned,  each  may 
be  touched  separately  with  the  bichloride  or  salicylic  collodion,  and  the 
parts  kept  dusted  with  subnitrate  of  bismuth,  magnesia,  boracic  acid, 
starch,  or  infant's  powders.  When  these  skin-warts  have  undergone  desic- 
cation and  corneous  degeneration  their  removal  is  often  difficult,  and  the 
following  preparation  will  be  found  efficient : 

I^.  Acid,  salicylic, 

Chrysarobin.,  aa.  3ss; 

Collodion  flex.,  5J.— M. 

They  should  be  kept  covered  with  this  continually. 

After  removal  the  surgeon  should  explain  to  the  patient  the  conditions 
under  which  warts  grow  and  luxuriate,  with  a  view  to  prevent  their  re- 
currence. 

In  persons  beyond  forty  years  of  age  persistent  recurrence  of  an  origi- 
nally simple  wart  should  always  awaken  suspicion  of  malignancy,  and 
prompt  and  radical  extirpation  should  be  practised. 


CHAPTER   XXXVIII. 

HORNY    GROWTHS    OF   THE    PENIS. 

True  horny  growths  of  the  penis  are  sometimes  seen,  and  there  are  in 
literature  less  than  twenty  cases  reported. 

These  growths  are  of  two  kinds  :  first,  horny  plates  of  varying  thick- 
ness, which  may  extend  in  depth  and  constitute  a  distinct  nodule,  or  con- 
sist of  a  band  or  ring  encircling  the  glans  penis;  and,  second,  projecting 
horns.     In  some  cases  both  forms  of  new  growth  are  present. 

^  Monatshefle  fiir  Praktische  Dermatologie,  vol.  v.,  1886,  pp.  93  et  seq. 


HORNY  GROWTHS  OF  THE  PENTS. 


441 


Horns  of  the  penis  take  their  origin  at  the  corona  in  the  coronal  sul- 
cus, and  on  the  inner  aspect  of  the  prepuce,  particularly  near  the  frsenum. 
They  can  better  be  pictured  than  described.     Figs.  172  and  173  rep- 


FiG.  172. 


Fig.  173. 


resent  appearances  presented  by  a  case  reported  by  Dr.  J.  H.  Brinton.^ 
On  the  dorsum  (see  Fig.  172),  half  an  inch  in  front  of  the  corona,  Avas  a 
longitudinally  striated  plate  of  horny  tissue  varying  in  width  from  three- 
quarters  of  an  inch  to  an  inch,  which  encircled  the  end  of  the  glans  and 
narrowed  the  meatus  to  a  pin's  point.  The  horn  sprang  from  the  under 
surface  of  the  glans  and  jutted  forward  and  upward,  being  curved  in  con- 
formity with  the  end  of  the  glans.  The  under  surface  of  the  horn  and 
horny  plate  is  shown  when  the  penis  was  laid  against  the  abdomen.  (See 
Fig.  173.)  In  this  case  the  horn,  which  tapered  slightly  toward  its  end, 
was  one  and  seven-eighths  inches  long  and  three-eighths  in  circumference 
at  the  base.  A  case  reported  by  Pick  is  even  more  remarkable  and 
striking  in  its  appearance.  The  large  hoi*n  sprang  from  the  prepuce  and 
glans,  its  base  being  imbedded  like  a  nail  in  its  matrix  on  the  right  side 
down  toward  the  frsenum.  From  this  base  the  horn  jutted  downward 
and  upward  to  the  left  or  front  of  the  meatus.  From  the  base  of  the 
glans  several  small  horns  sprang,  and  showed  a  tendency  to  curve  upward 
in  front  of  the  glans.  When  the  penis  was  laid  against  the  abdomen  the 
large  horn  presented  an  appearance  not  unlike  the  crest  of  a  dragoon's 
helmet.     The  large  horn  was  two  and  a  half  inches  long. 

These  horns  of  the  penis  are  usually  developed  from  warts  in  persons 
in  whom  there  has  been  some  chronic  irritative  process  on  the  prepuce 
and  glans.  They  have  been  observed  in  persons  having  long,  tight,  and 
straight  prepuces,  in  those  who  suffered  from  balanitis  and  balano-posthi- 
tis,  or  whose  parts  were  rendered  hypersemic  by  uncleanliness.  Their 
chief  starting-point  of  development  is  the  coronal  sulcus,  especially  down 
toward  the  fraenum. 

Horny  plates  and  rings  are  very  rare. 

In  color  these  growths  are  brown,  greenish-brown,  and  even  black. 

'  "  Horny  Growths  of  the  Penis,"  3Iecl.  News,  Aug.  6,  1887.  This  essay  gives  a  toler- 
ably complete  bibliography  of  the  subject.  Many  of  the  cases  in  literature  are  descrilied 
in  an  unsatisfactory  manner.  The  reader  is  also  referred  to  an  essay  by  Peck,  "  Ziir 
Kenntniss  der  Keratosen,"  Vierteljahrs.  fur  Derm,  unci  Syphilis,  vol.  vli.,  1875,  })p.  315 
et  seq. 


442  MISCELLANEOUS  AFFECTIONS. 

There  may  be  but  one  born  or  there  may  be  several.  They  are  of  vary- 
ing lengths,  from  half  an  inch  to  three  and  a  half  inches  long.  In  all 
the  reported  cases  they  were  curved  when  they  had  attained  a  length  of 
an  inch.  They  vary  in  breadth  at  their  base  according  to  their  size,  and 
gradually  taper  off  toward  their  distal  portion,  which  is  usually  truncated. 
As  a  rule,  they  give  rise  to  no  pain,  though  some  patients  have  complained 
of  itching  and  even  burning  sensation.  They  act  as  mechanical  hindrances 
to  coitus,  and  may  more  or  less  impede  or  obstruct  urination.  In  some 
cases  epithelioma  has  been  known  to  coexist  with  and  follow  the  ablation 
of  these  growths.  They  are  mostly  seen  in  elderly  men  of  from  fifty  to 
seventy  years,  but  in  Jouett's^  and  Pick's  cases  the  subjects  were  twenty- 
two  years  old,  and  in  Demarquay's  the  boy  was  nineteen  and  a  half  years 
old. 

Microscopically,  horny  growths  of  the  penis  are  seen  to  consist  of 
fibrillated  layers  of  densely-packed  epidermic  cells. 

The  treatment  of  these  growths  is  by  thorough  ablation,  taking  away 
portions  of  or  the  whole  of  the  glans  if  necessary.  They  sometimes 
return  after  removal. 


CHAPTER    XXXIX. 

CANCER  OF  THE  PENIS. 

Cancer  of  the  penis,  according  to  the  statistics  from  reliable  sources 
collected  by  Kaufmann,  stands  seventh  in  frequency  of  all  cancers  in  the 
male  sex,  and  constitutes  ^y^q  of  all  cancers  in  that  sex.  According  to 
the  statistics  of  Demarquay^  in  97,  and  Kaufmann^  in  130,  cases,  this 
form  of  cancer  belongs  to  the  more  advanced  years  of  life.  In  the  sixth 
decennium  (from  fifty  to  sixty  years)  one-third  of  all  the  cases  of  cancer 
of  the  penis  began.  Next  in  order  is  the  fifth  decennium  (forty  to  fifty 
years)  and  the  seventh  (sixty  to  seventy  years),  in  which  there  is  the  same 
frequency.  It  is  much  less  frequent  earlier  than  the  fortieth  year.  The 
combined  figures  of  Demarquay  and  Kaufmann  are  as  follows : 

Age.  No.  Per  cent. 

21  to  30  years 14  cases 6.1 

31  to  40  years 23  cases 10.1 

41  to  50  years 50  cases 22.0 

51  to  60  years 68  cases 30.0 

61  to  70  years 50  cases  .  ' .  22.0 

71  to  80  years .    .  19  cases 8.4 

81  to  90  years 3  cases 1.4 

In  the  greater  number  of  cases  cancer  of  the  penis  begins  on  the  pre- 
puce, in  a  rather  smaller  proportion  of  cases  on  the  glans,  sometimes  on 

1  New  York  Med.  Times,  1853,  p.  79. 

^  Maladies  chirurgicales  du  Penis,  Paris,  1877,  pp.  387  et  seq. 

^  Verletzimgen  und  Krankheiten  der  Mdnnlichen  Harnrohre  und  des  Penis,  Stuttgart,  1886, 
p.  264. 


CANCER   OF  THE  PENIS.  443 

glans  and  prepuce,  and,  again,  exceptionally,  on  the  cutaneous  sheath  of 
the  penis.  Jacobson^  mentions  the  case  of  a  man,  aged  fifty-five,  in  whom 
a  primary  carcinoma  in  the  form  of  a  fungating  ulcer  two  and  a  half  inches 
long  was  found  on  the  floor  of  the  urethra,  with  masses  growing  into  the 
substance  of  the  penis. 

It  sometimes  happens  that  cancer  of  the  penis  occurs  from  extension  of 
the  disease  from  the  scrotum. 

Etiology. — Besides  that  unknown  factor — tissue-susceptibility  or  pre- 
disposition— and  certain  unknown  conditions  (in  the  majority  of  cases) 
incident  to  age,  chronic  irritation  seems  to  be  the  great  cause  of  cancer  of 
the  penis.  Since  phimosis  is  a  frequent  cause  of  chronic  balanitis  and 
balano-posthitis  in  which  the  irritative  process  is  active,  this  condition 
takes  a  prominent  place  in  the  etiology  of  penis-cancer.  This  form  of 
new  growth,  however,  is  not  at  all  confined  to  cases  of  phimosis,  but  is 
seen  in  persons  with  normal  roomy  prepuces,  and  quite  rarely  in  those 
having  little  if  any  prepuce.  In  all  probability,  the  personal  habits  of 
the  man  in  very  many  cases  have  much  to  do  with  the  development  of 
cancer  of  the  penis.  When  the  organ  is  kept  clean  and  dry,  even  in  the 
aged,  it  is  fair  to  suppose  that  cancer  will  not  attack  it.  On  the  other 
hand,  uncleanliness,  with  the  resulting  harboring  of  decomposed  secretions 
and  of  dirt,  tends  to  cause  a  chronic  irritative  process  which  may,  the  con- 
dition of  the  patient's  system  favoring  it,  eventuate  in  malignant  degen- 
eration. The  occurrence  in  the  majority  of  instances  of  penis-cancer  in 
men  of  the  lower  walks  of  life,  whose  care  of  the  person  is  generally  very 
scant,  seems  to  me  to  warrant  the  opinion  that  the  disease  is  largely,  due 
to  the  results  of  uncleanliness. 

The  subject  of  protozoa  as  appertaining  to  cancer  is  yet  so  vaguely 
understood  that  speculation  upon  it  is  deemed  inexpedient. 

Demarquay  considers  that  syphilis  is  the  second  etiological  factor  in 
the  development  of  cancer  of  the  penis.  It  is  true  that  in  the  mouth  and 
on  the  tongue  a  chronic  irritative  process  due  to  syphilis  not  infrequently 
leads  later  on  to  epitheliomatous  degeneration,  but  I  know  of  no  such  con- 
dition of  the  prepuce  caused  by  syphilis.  Later  syphilitic  disease  of  the 
penis  shows  itself  largely  in  subcutaneous  hyperplasise,  which  commonly 
yield  promptly  to  treatment.  It  is  possible  for  a  chronic  gummatous  nod- 
ule of  the  prepuce  or  the  glans  to  constitute  an  irritative  process  in  the 
mucous  membrane  which  may  lead  to  epithelioma,  but  I  have  never  seen 
or  heard  of  such  case.  I  once  saw  a  case  of  cancer  of  the  penis  which 
had  its  origin  in  the  scar  left  by  an  exuberant  and  persistent  initial 
lesion  which  had  been  present  many  years  before.  Therefore,  syphilis 
can  hardly  be  considered  other  than  as  a  very  exceptional  etiological  fac- 
tor in  cancer  of  the  penis.  The  scars  of  chancroidal  ulcers  may,  like 
those  left  by  syphilitic  lesions,  cause  chronic  irritations  which  may  lead  to 
epithelioma. 

There  are  reported  in  literature,  according  to  Kaufmann,  but  five  cases 
in  which  cancer  of  the  penis  followed  an  injury.  In  two  cases  the  organ 
was  crushed,  and  in  one  it  Avas  torn  at  the  frsenum.  The  fourth  case  is 
that  of  Dupuytren,  in  which  malignant  degeneration  began  in  the  penis 
of  a  patient  who  had  for  four  or  five  years  worn  two  small  gold  padlocks 
afiectionately  placed  on  the  organ  by  his  sweetheart  as  a  safeguard  to  his 
^  The  Diseases  of  the  Male  Organs  of  Generation,  London,  1893,  p.  709. 


444  MISCELLANEOUS  AFFECTIONS. 

loyalty.  The  fifth  case  was  reported  by  Kronlein  of  a  man  twenty-seven 
years  old  Avhose  prepuce  was  nearly  torn  off  by  the  bite  of  a  horse.  A 
symmetrical  Avound  Avas  made  by  the  surgeon,  but  before  healing  was  com- 
plete  the  organ  was  again  bruised,  and  then  cancerous  degeneration  set  in. 
I  recently  ^  reported  a  case  in  which  a  healthy  man  twenty-five  years  old 
had  a  pea-sized  pustule  on  the  side  of  the  penis.  This  lesion  was  picked 
by  the  patient  by  means  of  a  pin,  and  severely  burned  on  many  occasions 
with  various  caustics.      The  result  was  an  epitheliomatous  nodule. 

A  case  is  reported  by  Bruce  ^  in  which  he  thought  that  cancer  of  the 
penis  of  a  man  was  due  to  coitus  with  his  wife,  who  suffered  from  cancer 
of  the  uterus.  Demarquay  also  mentions  a  similar  case.  Such  a  mode 
of  origin,  however,  is  very  doubtful.  In  this  connection  it  is  well  to 
remember  the  case  of  the  Spanish  grandee  reported,  with  much  naivete, 
by  Diday,^  in  which  the  austere  hidalgo  had  repeated  connections  with 
his  wife,  who  was  suffering  from  cancer  of  the  uterus  attended  by  a  sick- 
ening discharge.  This  worthy  was  tormented  by  remorse  on  account  of 
marital  transgressions,  and  labored  in  vain,  by  daily  coitus,  to  contract 
gonorrhoea  from  his  wife  as  a  punishment  for  his  disloyalty.  He  con- 
tracted neither  gonorrhoea  nor  cancer. 

Demarquay  reports  a  ease  in  which  cancer  of  the  penis  originated  in  a 
urinary  fistula. 

There  are  no  facts  at  hand  to  warrant  the  assumption  that  cancer  of 
the  penis  may  more  or  less  remotely  originate  in  heredity,  except  the  case 
of  Bruns,  quoted  by  Kaufmann,  in  which  the  mother  of  a  man  suffering 
from  cancer  of  the  penis  was  said  to  have  died  of  cancer  of  the  breast. 

Course  and  Symptoms. — In  many  cases  of  epithelioma  of  the  penis  the 
initial  symptoms  are  very  insignificant,  and  they  may  pass  unheeded, 
especially  by  patients  of  the  lower  walks  of  life.  .Usually  intelligent  sub- 
jects give  a  history  of  a  mild  pruritus  or  of  a  slight  burning  sensation  at 
the  date  of  onset  of  their  trouble.  The  truth  is,  that  the  condition  of  the 
prepuce  and  the  habits  of  the  patient  have  much  to  do  with  the  mildness 
or  intensity  of  early  symptoms.  When  there  is  marked  phimosis  there  is 
apt  to  be  much  itching  and  burning  in  the  affected  part,  and  these  symp- 
toms are  rendered  much  more  severe  by  uncleanliness. 

Epithelioma  of  the  penis  usually  begins  in  men  who  have  suffered  from 
chronic  balano-posthitis,  from  phimosis,  and  somewhat  rarely  from  chronic 
relapsing  herpes.  In  fact,  any  chronic  irritation  may  give  rise  to  this 
disease. 

In  chronic  balanitis  and  balano-posthitis  the  epithelial  layer  of  the 
glans  and  prepuce  becomes  much  thickened,  while  there  is  much  increase 
and  condensation  in  the  submucous  connective  tissue.  This  chronic  con- 
dition, which  is  attended  with  pain,  itching,  and  burning  sensations,  which 
are  often  paroxysmal  and  almost  unbearable,  is  a  very  favorable  basis 
upon  which  epithelioma  may  develop.  I  have  seen  several  well-marked 
cases  of  this  form  of  epithelioma,  concerning  which  little  has  yet  been 
written.  In  these  cases  warty  growths  may  appear,  and  in  the  course  of 
time  (months  or  years)  a  fungating  mass  may  be  developed  at  the  end  of 
the  penis. 

^  Journal  of  Cutaneous  and  Gen.-urin.  Diseases,  June,  1891,  p.  305. 
^  IVansactions  of  the  Pathological  Society,  London,  1879,  p.  477. 
^  La  Praiique  des  Maladies  ven^riennes,  Paris,  1890,  pp.  15  et  seq. 


CANCER   OF  THE  PENIS. 


445 


Then,  again,  the  cancerous  growth  begins  in  another  way.  One  or 
more  fissures  or  thickened  patches  appear  either  in  the  mucous  layer  of 
the  prepuce,  usually  the  seat  of  chronic  irritation,  or  at  its  free  margin  or 
in  the  coronal  sulcus.  Then  chronic  rebellious  ulceration  of  a  low  grade 
appears,  and  the  parts  become  more  and  more  hard  until  a  dense,  almost 


Fig.  174. 


Cancer  of  the  penis,  showing  very  large  fleshy  masses. 


ligneous,  patch  or  nodule  is  developed.  From  this  starting-point  laro-e 
masses  of  indurated  tissue  develop,  which  produce  exuberant  lesions  and 
much  deformity.     In  these  cases  there  is  no  evidence  of  warty  or  cauli- 

FiG.  175. 


Showing  the  posterior  surface  of  the  glans  penis  after  amputation. 

flower  growth,  but  large,  irregular,  fleshy  masses,  in  the  interstices  of 
which  a  curdy,  smegma-like  secretion,  besides  pus  and  a  horribly  fetid 
sanies,  is  secreted.     This  condition  is  w^ell  shown  in  Figs.  174  and  175, 


446  MISCELLANEOUS  AFFECTIONS. 

which  represent  the  appearances  presented  by  a  case  of  my  own  in  which 
the  new  growths  formed  a  mass  as  large  as  a  good-sized  orange.  The 
glans  penis  was  the  part  involved,  and  the  new  growths  were  seated  at 
right  angles  with  the  long  axis  of  the  penis.  From  the  apex  of  one  of 
the  masses  the  urine  escaped  freely.  The  color  of  the  masses  was  of  a 
dirty  grayish-white.  In  these  cases  hemorrhage,  more  or  less  profuse, 
sometimes  even  alarming,  is  not  uncommon. 

Chronic  ulcers  of  the  penis,  left  untreated,  or,  as  is  so  common,  badly 
treated  by  injudicious  stimulation  and  cauterization,  may  be  the  starting- 
point  of  cancerous  degeneration  like  that  just  described.  Sometimes  they 
give  rise  to  warts,  which  soon  degenerate  into  epithelioma.  The  cases  of 
cancer  of  the  penis  which  originate  in  chronic  ulceration  are  less  frequent 
than  those  having  other  modes  of  origin.  Whenever  in  a  middle-aged  or 
elderly  man  a  very  chronic  rebellious  ulcer  of  the  penis,  with  considerable 
infiltration,  is  observed,  and  syphilis  as  a  cause  has  been  excluded,  the 
fear  of  cancerous  degeneration  may  be  entertained.  Chronic  chancroid 
usually  presents  such  features  that  its  nature  is  readily  recognized. 

The  most  common  mode  of  origin  of  epithelioma  of  the  penis  is  in 
warty  growths,  which  may  promptly,  or  after  the  lapse  of  months  and 
even  years,  degenerate  into  epithelioma.  Such  is  the  liability  of  vegeta- 
tions to  undergo  degeneration  in  those  of  middle  age,  and  particularly  in 
elderly  persons,  be  they  Aveak  or  strong,  that  their  presence  should  imme- 
diately demand  at  the  hands  of  the  surgeon  prompt  care  and  treatment. 

Vegetations  of  the  penis  chiefly  begin  about  the  coronal  sulcus  and 
the  inner  layer  of  the  prepuce  near  it  or  the  frsenum.  Sometimes  these 
growths  are  warty,  cauliflower-like,  or  vegetative,  and  are  of  the  pointed 
variety ;  and  in  these  cases  the  progress  of  the  degenerative  changes  is 
usually  rapid.  It  is  always  difficult,  and  often  impossible,  to  say  where 
benignity  ends  and  malignity  begins  in  these  growths.  In  some  cases 
the  exuberant  development  is  rapidly  accomplished,  and  a  mass  of  cauli- 
flower appearance  as  large  as  a  lemon  or  an  orange  is  found  at  the  end  of 
the  penis  in  a  year  or  even  less.  Exuberant  development  of  warty  growths 
in  middle-aged  and  elderly  subjects  is  always  a  very  suspicious  symptom. 
As  time  goes  on  the  warty,  cauliflower  appearance  is  lost,  and  the  new 
growths  look  like  fleshy  masses. 

Then,  again,  we  see  cases  in  which  the  patient  presents  a  little  nodule 
or  a  patch  of  hard,  warty  growth  on  the  penis,  looking  something  like  the 
seed-warts  seen  on  boys'  hands  and  knuckles.  He  complains  of  little  if 
any  discomfort,  perhaps  a  little  pruritus.  This  seemingly  insignificant 
lesion  grows  slowlv  and  in  a  cold  manner,  and  months  and  even  several 
years  may  elapse  before  it  reaches  such  a  size  as  to  become  annoying. 
Then  it  may  be  cut  out,  only  to  reappear  later  on  in  the  cicatrix.  After 
that  amputation  of  the  penis  is  usually  performed.  I  have  seen  several 
such  cases  as  these  in  which  the  microscope  revealed  malignancy  in  the 
tissues,  and  in  which  amputation  of  the  penis  enabled  the  patients  to  reach 
a  good  old  age  without  any  further  symptoms  of  cancer.  It  is  not  well, 
however,  to  generalize  on  the  few  cases  seen  in  one  man's  experience. 

There  is  still  another,  but  rather  rare,  mode  of  invasion  and  develop- 
ment of  cancer  of  the  penis  of  which  I  have  seen  several  examples.  In 
middle  life  and  beyond  patients  sometimes  consult  the  surgeon  for  a 
chronic  mildly  scaling  aff"ection  of  the  glans  or  prepuce,  or  both.      The 


CANCER   OF  THE  PENIS.  447 

symptoms  attending  this  condition  are  usually  not  well  marked,  and  they 
may  consist  only  of  occasional  slight  heat  or  itching.  The  morbid  areas 
show  slight  thickening  of  the  tissues  and  a  constant  desquamation  of  small 
scales  or  even  lamellge.  This  affection  often  goes  on  in  the  most  exaspe- 
rating manner  in  spite  of  well-directed  treatment,  and  even  in  persons 
whose  prepuce  is  short.  Having  existed  usually  several  years,  the  thick- 
ening of  the  tissues  becomes  greater,  and  then  the  new  growth  more  or 
less  rapidly  develops  and  forms  large  fleshy  masses  like  those  of  Figs.  174 
and  175.  In  these  cases,  in  all  probability,  the  morbid  change  is  first  a 
mild  irritative  process  in  the  epithelium,  which  later  on  takes  on  malig- 
nant degeneration.  Schuchardt  reports  ^  an  interesting  case  which  belongs 
to  this  category,  in  which  a  condition  of  the  mucous  membrane  resembling 
psoriasis  or  leukoplasia  buccalis  existed  before  the  onset  of  the  malignant 
disease. 

When  epithelioma  of  the  penis  is  fully  developed  the  symptoms  become 
more  pronounced  than  they  were  at  first,  and  new  ones  are  complained  of. 
In  some  cases  lancinating  pains  in  the  penis  and  parts  beyond  are  more  or 
less  troublesome.  As  the  new  growth  increases  in  size,  coitus  becomes 
more  and  more  difficult  and  painful,  and  later  on  impossible.  Usually 
there  is  no  tenderness  about  the  new  growth,  and  handling  and  even 
pressure  cause  no  discomfort.  When  the  meatus  is  pressed  upon,  partic- 
ularly by  new  growths  on  the  glans  or  by  those  of  the  prepuce,  difficulty 
in  urination  may  be  experienced.  In  some  cases,  notably  one  reported 
by  Boyer,  retention  of  urine  was  thus  caused.  In  these  cases  the  urethra 
becomes  stenosed  by  the  new  growth,  but  in  a  short  time  the  urine  tun- 
nels a  way  for  its  exit  and  escapes  in  some  of  the  clefts  or  fissures  in  the 
new  growth. 

In  the  later  stages  hemorrhages  occur,  and  they  are  sometimes  very 
troublesome,  and  deplete  the  patient  by  their  copiousness.  The  most 
annoying  complication  is  the  low  grade  of  ulcerative  process  which  goes 
on  in  the  interstices  of  the  masses  and  on  its  surface,  and  produces  a  hor- 
ribly fetid  secretion,  rendering  the  patient  an  object  of  disgust  to  himself 
and  those  with  whom  he  comes  in  contact. 

Some  patients  complain  of  painful  erections  more  or  less  constantly 
during  the  progress  of  the  new  growth. 

As  a  rule,  the  health  of  patients  in  whom  epithelioma  of  the  penis 
develops  is  good  in  the  early  days,  and  it  thus  may  remain  for  several 
years.  Then,  again,  as  time  goes  on  some  patients  lose  flesh,  become 
sallow  and  weak,  and  present  evidence  of  deep  cachexia.  My  studies  and 
observations  lead  me  to  think  that  when  the  new  growth  is  rather  small 
and  increases  slowly  (particularly  in  the  cases  beginning  in  an  old  seed- 
wart,  in  a  fissure,  or  in  a  scaling  patch)  the  health  remains  for  a  long  time 
unaffected.  In  these  cases  the  enlargement  of  the  inguinal  ganglia  may 
not  be  found  until  very  late,  even  when  they  are  carefully  and  repeatedly 
looked  for.  On  the  other  hand,  Avhen  the  new  growth  is  rapid  and  exu- 
berant the  health  is  sooner  afi"ected,  and  the  enlargement  of  the  ganglia  is 
noticed  much  earlier. 

Under  the  title  ^' EpitMliome  henin  syphilolde  de  la  verge''  Fournier 

^  "  Beitriige  zur  Entstehung  der  Carcinome  ans  chronisch  entznndlichen  Zustanden 
der  Schleimhilute  und  Hautdeeken,"  Volbnann's  Minische  Vortruge,  No.  257,  p.  16. 
Schuchardt  gives  the  microscopical  details  of  this  case. 


448 


MISCELLANEO  US  A  FFECTIONS. 


Fig.  176. 


and  Darier  ^  describe  a  peculiar  lesion  observed  in  a  man  aged  sixty -five 
years  which  first  appeared  four  years  before.  The  lesion  consisted  of  a 
rounded,  deep  carmine-red  plaque  of  ten  centimetres  extent,  seated  on  the 
dorsal  internal  surface  of  the  prepuce,  sulcus,  and  corona  glandis.  It  had 
a  distinct  velvety  surface  with  no  signs  of  ulceration  or  vegetation.  To 
palpation  simple  thickening  of  the  tissues  was  revealed.  The  prepuce 
could  be  retracted  with  slight  pain.  The  lesion  began,  according  to  the 
patient's  statement,  four  days  after  a  very  suspicious  coitus.  There  was 
no  ganglionic  complication.  The  patient  suifered  besides  from  the  results 
of  generalized  atheroma.  The  microscopical  examination  of  this  lesion 
showed  great  hyperplasia  of  the  epidermis,  with  marked  enlargement  of 
the  papillae.  Its  chronic  indolent  course  shows  that  the  only  efficient 
treatment  is  complete  removal  of  the  new  growth.  The  lesion  seems  to 
be  the  result  of  a  chronic  irritative  process. 

The  deformities  and  distortions  of  the  penis  produced  by  cancer  are 
many  and  surprising.  Those  shown  in  Figs.  174  and  175  are  very  well 
marked,  and  show  the  exuberant  development  of  the  growth,  which  is  in 

a  chronic  stage  and  no  longer  presents 
a  warty  or  cauliflower-looking  appear- 
ance. In  Fig.  176,  reproduced  from 
Demarquay,  the  well-marked  cauli- 
flower growth  is  seen  at  the  end  of  the 
glans  and  prepuce,  and  a  secondary 
mass,  due  to  lymphatic  infection,  is 
seen  about  the  middle  of  the  penis. 
In  the  greater  number  of  cases  the 
disease  is  localized  to  the  preputial 
and  glandular  portion  of  the  penis, 
and  it  luxuriates  in  the  various  forms 
depicted.  The  corpora  cavernosa,  with 
their  firm  fibrous  sheaths,  off"er  a  strong 
barrier  to  the  cancerous  invasion,  which 
may  remain  intact  for  years.  Conse- 
quently, there  is  a  tendency  in  most 
cases  to  the  localization  of  the  disease 
to  the  distal  portion  of  the  penis.  It 
sometimes  develops  farther  up  the  or- 
gan, its  cells  having  been  carried  there 
by  the  lymphatics.  It  is  rare  to  see 
involvement  of  the  whole  organ  by 
cancer  in  the  primary  attack.  But 
extension  may  occur  by  means  of  the 
corpus  spongiosum,  in  which  case  the 
Avhole  organ  may  be  later  on  involved. 
Recurrence  of  the  cancer  in  the  stump  often  leads  to  its  full  involvement, 
the  corpora  cavernosa  no  longer  acting  as  a  barrier. 

Many  other  appearances  are  presented  by  cases  of  cancer  of  the  penis, 
but  the  illustrations  here  given  will,  I  think,  serve  as  guides  for  its  diag- 
nosis. It  must  be  borne  in  mind  that  the  typical  cauliflower  or  warty 
appearance  is  sooner  or  later  lost,  and  replaced  by  fleshy  nodules,  masses, 

^  Annales  de  Derm,  et  de  Syphil.,  tome  iv.,  May,  1893,  pp.  613  et  seq. 


Epithelioma  of  the  glans  and  prepuce,  with 
a  secondary  mass  farther  up  the  penis. 


CANCER   OF  THE  PENIS.  449 

and  tabs.  Sometimes  these  masses  become  superficially  ulcerated,  and 
again  they  may  undergo  more  or  less  necrosis,  and  sometimes  large  por- 
tions of  them  slough  off. 

As  a  rule,  patients  suffering  from  cancer  of  the  penis  do  not  seek  sur- 
gical relief  promptly. 

Intelligent  patients  and  those  careful  of  the  condition  of  their  genitals 
usually  present  themselves  to  the  surgeon  early  in  the  course  of  their 
malady.  But  those  of  the  lower  walks  of  life,  such  as  we  see  in  dispen- 
saries and  hospitals,  as  a  rule  do  not  present  themselves  until  the  new 
growth  is  quite  well  advanced.  In  the  statistics  of  fourteen  cases  of  v. 
Winiwarter  there  was  an  average  of  twenty  months  elapsing  from  the 
beginning  of  the  trouble,  while  in  Kaufmann's  thirty-eight  cases  there 
was  an  average  of  twenty-two  months  ;  so  that  we  may  say,  as  a  rule, 
that  in  private  practice  patients  with  cancer  of  the  penis  usually  apply  for 
treatment  within  two  or  three  years  after  the  onset  of  the  affection,  and 
sometimes  earlier. 

For  a  greater  or  less  length  of  time  the  inguinal  ganglia  seemingly 
remain  unaffected.  We  have  no  reliable  statistics,  however,  showing  the 
date  at  which  cancer  attacks  these  structures.  In  most  cases  the  patient 
is  seen  late  in  his  affection,  and  then  the  ganglia  are  found  to  be  attacked. 
As  a  general  rule,  the  ganglia  are  affected  on  both  sides,  and  only  on  one 
side  in  about  one-third  of  all  cases.  Ganglionic  involvement  is  deter- 
mined by  the  site  of  the  cancerous  growth  ;  if  that  is  unilateral,  the  groin 
swellings  are  unilateral,  but  if  the  whole  organ  is  involved,  both  groins 
are  attacked.  Gussenbauer'  very  truly  says  that  the  neighboring  lym- 
phatic ganglia  are  more  frequently  involved  than  we  have  been  in  the 
habit  of  thinking,  and  that  in  nine  operated  cases  gland-infection  was 
found  in  two  instances  with  the  aid  of  the  microscope.  It  is  very  prob- 
able that  minute  malignant  changes  may  take  place  in  their  structure 
which  are  not  evident  to  our  most  careful  palpation.  Kaufmann  says  that 
the  general  impression  that  the  glands  in  cancer  are  not  diseased  iti  toto 
is  correct,  but  that  out  of  forty-eight  operated  cases  only  eight  were  seen 
in  which  there  were  no  glandular  changes ;  hence  that  it  happens  in  the 
majority  of  cases.  I  recall  a  case  in  which  epithelioma  of  the  penis 
existed  for  six  years  before  operation,  at  which  time  there  was  no  appar- 
ent glandular  complication,  and  the  patient  lived  ten  years  after  without 
any  metastasis  of  the  disease.  This,  however,  was  a  remarkably  favor- 
able course  of  events  for  cancer  of  the  penis. 

When  affected  by  cancer  the  ganglia  of  the  groin  and  also  of  the  thigh 
become  hard,  smoothly  enlarged,  separable  from  each  other,  and  movable 
under  the  skin.  They  may  thus  remain  for  months  or  for  several  years. 
Then,  again,  exuberant  cancerous  development  may  take  place  in  them, 
and  they  may  become  transformed  into  large  round,  oval,  or  lobulated 
tumors.  This  cancerous  mass  may  remain  unchanged,  but  it  usually 
causes  ulceration  of  the  overlying  skin.  Owing  to  the  proximity  to  the 
femoral  vessels,  mild  or  severe  hemorrhages  are  liable  to  occur  from  erosion 
of  their  walls  by  the  cancerous  growth. 

A  second  order  of  phenomena  may  occur  in  these  cancerous  buboes. 
The  glands  more  or  less  promptly  undergo  acute  inflammation,  suppura- 

^"Ueber    die    Entwickelung    der   Secundiiren   Lymplidriisen-Geschwiilste,"  Prayer 

Zeilsch.  fur  Heilkunde,  1881,  Band  11,  p.   17. 

29 


450  MISCELLANEOUS  AFFECTIONS. 

tion  ensues,  and  the  pus  either  forces  an  outlet  or  is  evacuated  by  the 
knife.  In  most  cases  the  morbid  process  does  not  stop  with  the  destruc- 
tion of  the  glands.  The  connective  tissue  and  the  skin  become  the  seat 
of  secondary  infection,  and  there  is  then  produced  a  formidable  cancer  in 
the  groin. 

Primary  cancer  of  the  urethra  is  very  rare.  Griffiths  ^  reported  one 
case,  and  Oberlander^  another,  in  which  by  means  of  the  endoscope  he 
found  the  cancer  near  the  bulb  of  the  urethra. 

Strange  as  it  may  seem,  tertiary  metastasis  from  the  secondary  groin- 
cancer  is  the  exception  rather  than  the  rule.  It  is  rare  to  see  general 
diffusion  of  malignancy  in  cancer  of  the  penis.  According  to  Kaufmann, 
the  viscera  were  seen  to  be  affected  by  v.  Winiwarter  in  one  case,  by  Read 
in  one,  by  Lebert  in  two,  by  Louis  in  one,  by  Kocher  in  one,  and  by 
Kaufmann  in  one  remarkable  case  in  which  the  cancerous  diffusion  was 
carried  by  the  femoral  vessels,  which  had  become  infected  by  cancerous 
inguinal  glands,  making  seven  in  all  literature. 

Death,  therefore,  from  cancer  of  the  penis  occurs  in  two  ways.  First, 
and  most  commonly,  by  a  cachexia  which  is  developed  by  the  poisonous 
fluids  derived  from  the  infected  ganglia,  and,  secondly,  as  a  result  of 
metastases  into  the  lungs,  pleurae,  liver,  heart,  and  other  organs. 

Death  from  hemorrhage  has  been  noted,  but  that  is  an  accident. 

The  involvement  of  the  inguinal  ganglia  in  epithelioma  of  the  penis  is 
inevitably  followed  by  death  at  an  early  or  late  date. 

There  are  a  number  of  cases  reported  in  medical  literature  in  which 
swelling  of  the  inguinal  ganglia  has  subsided  and  disappeared  after  ampu- 
tation of  the  penis.  It  is  suspected  that  these  glands  were  the  seat  of 
simple  inflammation,  and  as  a  result  resolution  occurred.  This  happy 
outcome  is  very  rare  and  scarcely  to  be  looked  for.-  There  is  usually  more 
or  less  pain  during  the  course  of  cancer  of  the  groin.  As  the  cancerous 
mass  in  the  groin  grows  old  and  larger,  a  deep  cachexia  attacks  the  patient. 
He  looks  pale  and  ashen,  loses  strength  and  flesh,  and  so  continues  until 
death  relieves  him  of  his  hopelessness  and  misery. 

Diagnosis. — The  diagnosis  of  cancer  of  the  penis  may  be  difficult  in 
the  early  stages  of  the  growth.  The  existence  of  chronic  or  oft-recurring 
irritation  of  the  glans  or  prepuce,  followed  by  a  localized  warty  growth 
or  indurated  exulcerated  patch  or  nodule,  should  always  excite  a  sus- 
picion of  cancer,  particularly  in  elderly  men,  and  more  especially  w^hen 
the  existence  of  syphilis  has  been  excluded.  Then,  again,  the  behavior 
of  the  lesion  under  treatment  may  give  a  clue  as  to  its  nature,  for  simple 
processes  are  usually  amenable  to  proper  management,  while  the  malig- 
nant forms  go  on  unchecked  and  uncured.  Constant  examination  of  the 
lymphatic  ganglia  is  necessary,  since  their  enlargement  under  these  cir- 
cumstances will  frequently  lead  to  a  correct  diagnosis  of  cancer.  Por- 
tions of  the  growth  should  be  examined  with  the  microscope  as  early  as 
possible. 

In  the  statistical  table  already  given  it  is  shown  that  between  the 
twenty-first  and  thirtieth  years  of  life  cancer  of  the  penis  existed  in  6.1 
per  cent.  I  am  strongly  of  the  opinion  that  this  rate  is  too  high,  and  I 
have  no  doubt  that  in  some  of  the  cases  the  diagnosis  was  imperfectly 

1  Lancet,  Feb.  9,  1889. 

2  Internat.  Centralbl.  der  Ham.  unci  Sexualorgane,  vol.  iv.,  1893,  pp.  244  et  seq. 


CANCER   OF  THE  PENIS.  451 

made.  On  five  occasions  which  I  distinctly  remember  I  have  had  cases 
referred  to  me  as  being  those  of  cancer  of  the  penis  in  which  amputation 
was  decided  upon,  which  were  really  instances  in  young  men  of  exuberant 
hard  chancre.  Hard  chancres  of  the  prepuce,  and  sometimes  of  the  glans, 
occasionally  assume  huge  proportions  from  the  occurrence  of  hard  oedema 
around  them.  Then  it  frequently  happens  that  the  healing  surface 
becomes  papillated  or  coarsely  warty.  In  this  condition  a  hard  chancre 
is  quite  frequently  diagnosticated  as  of  cancerous  origin  by  reason  of  its 
ligneous  hardness,  its  aphlegmasic  course,  and  its  warty  appearance.  The 
complicating  inguinal  adenopathy  is  then  construed  to  be  an  evidence  of 
cancer  and  secondary  infiltration  of  the  ganglia.  I  feel  certain  that  cases 
like  these  have  swelled  the  statistics  of  cancer  of  the  penis  in  men 
between  twenty  and  thirty  years  of  age.  There  is  no  doubt,  however,  of 
the  occurrence  of  cancer  in  young  persons,  but  it  certainly  is  not  fre- 
quently observed.  Any  warty  mass  or  patch  on  the  penis  in  persons  of 
middle  and  advanced  life,  syphilis  having  been  excluded,  should  be 
regarded  as  a  danger-signal,  and  it  should  be  promptl}^  and  radically 
removed.  The  microscope  then  will  reveal  the  nature  of  the  ablated 
tissue. 

When  seen,  as  most  cases  are,  late  in  the  development  of  the  cancer 
of  the  penis,  its  diagnosis  is  usually  very  easy.  The  large,  fleshy,  hard 
masses,  their  fungating  appearance,  the  distortion  produced,  and  the  fetid 
secretion,  all  point  to  cancer  of  the  penis.  Still,  it  frequently  happens 
that  cases  presenting  the  foregoing  typical  appearances  are  regarded  as 
syphilitic  and  are  treated  for  that  disease. 

Prognosis. — This  depends  upon  the  time  at  which  the  cancer  is  seen 
and  its  nature  recognized.  If  seen  early  and  the  growth  is  small  and 
favorably  situated  for  removal,  its  ablation  may  give  to  the  patient  future 
immunity.  If  the  new  growth  is  very  large  and  if  it  has  existed  for 
several  years,  the  prognosis  is  less  favorable.  In  any  case  the  condition 
of  the  inguinal  lymphatic  ganglia  gives  the  most  reliable  prognostic  data. 
If  the  glands  are  but  slightly  enlarged  and  show  an  indolent  tendency,  a 
year  or  many  years  may  elapse  before  a  fatal  termination  results. 

Cancer  of  the  penis  is  so  well  localized  and  so  sharply  limited  in  many 
cases  that  the  conditions  for  its  removal  and  extirpation  are  more  favor- 
able than  upon  other  regions.  Still,  the  sad  fact  stares  us  in  the  face 
that  in  the  vast  majority  of  cases  cancer  of  the  penis  almost  inevitably 
leads  to  death.  Yet  there  are  cases  reported  in  literature  which  will 
give  hope  to  the  afflicted.  These  have  been  gathered  by  Kaufmann. 
Fabricius  Hildanus  reports  the  case  of  a  man  eighty  years  old  who  lived 
ten  years  after  the  ablation  of  an  enormous  cancer  of  the  penis.  Roux 
operated  on  a  man  for  this  disease  who  lived  many  years  after  and  died 
of  another  disease.  Lebert  says  that  he  has  seen  cancer  of  the  penis 
cured.  Podraski  relates  two  cases  in  which  nine  and  eleven  years  have 
elapsed  after  operation,  and  yet  there  are  no  signs  of  recurrence  of  the 
cancer.  Thiersch  reports  that  in  three  out  of  eight  cases  operated  on  by 
him  there  has  been  no  recurrence  in  four,  six,  and  seventeen  3^ears.  In 
none  of  these  cases  were  the  inguinal  glands  enlarged,  v.  Winiwarter 
knows  of  three  cases  in  Billroth's  practice  in  which  two,  six,  and  seven 
and  a  half  years  have  elapsed  since  the  operation.  Out  of  six  cases  Rose 
claims  that  he  has  cured  three  cases  fully,  and  that  one  lived  five  years 


452 


MISCELLANEOUS  AFFECTIONS. 


and  one  month  after  the  operation,  while  the  two  others  died  respectively 
six  and  three  years  thereafter.  In  my  own  case,  already  spoken  of,  ten 
years  elapsed  after  operation,  and  then  the  patient  died  of  another  disease. 

Recurrence   of   this    disease  in 
Fig.  177.  the  stump  is  not  uncommonly  seen. 

Statistics  on  this  point,  however, 
are  not  sufficiently  clear  and  reliable. 
This  accident  probably  occurs  in 
about  25  per  cent,  of  all  cases. 

Amputation  of  the  penis  has 
been  mentioned  as  having  led  to 
melancholia,  and  to  have  so  preyed 
on  the  minds  of  some  men  that  they 
committed  suicide.  These,  how- 
ever, are  unusual  results. 

Pathological  Anatomy. — Cancer 
of  the  penis  is  of  the  epithelioma- 
tous  variety,  being  the  ordinary 
skin -cancer  involving  squamous 
epithelium.  In  Fig.  177  is  shown 
a  section  through  a  prepuce  the 
seat  of  epithelioma.  The  papillae 
and  mucous  follicles  are  seen  to  be  infiltrated  with  epitheliomatous 
elements  and  the  so-called  nests  or  pearls.     In  Fig.  178  epitheliomatous 


Section  of  glans  penis  through  epitheliomatous 
mass ;  X  75. 


Fig.  178. 


Infected  inguinal  ganglia  from  epithelioma  of  penis ;  camera  lucida  drawing ;  X  200. 

infiltration  is  shown  in  the  alveoli  of  an  inguinal   ganglia  secondarily 
infected   from  the  penis.      In   Fig.    179  epitheliomatous  infiltration  is 


CANCER   OF  THE  PENIS. 


453 


shown  in  newly-formed  connective  tissue  of  the  groin  after  suppuration 
and  extrusion  of  epitheliomatous  ganglia.  The  upper  part  of  the  cut 
shows  the  typical  alveolar  arrangement,  with  bundles  of  new  connective 
tissue  between  the  alveolar  spaces  filled  with  epithelial  cells.  The  lower 
part  of  the  cut  shows  granulating  tissue  from  small  cells,  bundles  of  con- 


FiG.  179. 


Epithelioma  of  connective  tissue  of  groin,  secondary  to  epithelioma  of  penis. 

nective  tissue  more  fully  developed,  the  whole  mass  invaded  here  and 
there  by  rapidly-growing  flat  epithelial  cells.  These  microscopic  draw- 
ings were  made  by  Dr.  E.  M.  Culver  from  sections  taken  from  my  own 
cases. 

Treatment. — According  to  the  severity  of  the  case  amputation  or  ex- 
tirpation of  the  penis  may  be  necessary. 

Too  much  cannot  be  said  in  favor  of  an  early  and  radical  operation  in 
cases  of  cancer  of  the  penis,  since  such  a  course  gives  the  patient  a  much 
greater  immunity  to  subsequent  trouble.  In  every  suspicious  case  the 
the  surgeon  should,  before  operation  if  possible,  remove  a  sufficient 
amount  of  the  mass  in  order  that  a  thorough  microscopical  study  of  its 
nature  may  be  made. 

Amjjutation  of  the  Penis  in  its  Continuity. — The  patient  having  been 
prepared  for  the  operation,  the  pubic  hairs  should  be  shaved  off  and  he 
should  be  well  washed  in  the  usual  antiseptic  manner.  He  is  then  placed 
in  the  lithotomy  position  and  a  soft-rubber  catheter  is  quite  firmly  tied 
around  the  root  of  the  penis,  in  order  to  control  hemorrhage.  The  sur- 
geon may  stand  between  the  patient's  legs  or  on  his  left  side.  Then  two 
long  bonnet-pins  are  thrust  through  the  corpora  cavernosa,  sufficiently 
well  behind  the  tumor  on  each  side,  in  an  X-like  manner,  avoiding  the 
corpus  spongiosum.  Before  inserting  the  pins  it  is  necessary  to  manoeu- 
vre and  manipulate  a  little  so  as  to  get  the  body  of  the  penis  back  about 
three-quarters  of  an  inch  and  to  slide  the  integumentary  sheath  corre- 
spondingly forward.     Then,  traction  being  made  from  the  distal  and  dis- 


454  MISCELLANEOUS  AFFECTIONS. 

eased  portion  of  the  penis  with  the  left  hand  or  by  the  aid  of  an  assistant, 
extension  and  steadiness  are  afforded,  and  a  circular  incision  is  made 
through  the  integument  at  the  distal  portion  of  the  penis,  taking  care  not 
to  cut  the  corpus  spongiosum.  Then  the  corpora  cavernosa  are  cut 
through  downward  until  the  corpus  spongiosum  is  reached.  This  structure 
should  be  carefully  dissected  out,  and  fully  one-half  or  three-quarters  of 
an  inch  should  be  left  to  protrude  beyond  the  amputated  end  of  the  corpora 
cavernosa.  We  then  have  the  latter  structures  as  the  stump  proper ; 
around  it  is  the  ring  of  integument  fully  three-quarters  of  an  inch  longer 
than  it,  and  underneath  the  corpus  spongiosum  is  intact  and  fully  half  an 
inch  longer  than  the  stump.  At  this  time  the  tourniquet  is  moderately 
relaxed,  and  all  oozing  or  spirting  vessels  are  securely  tied,  one  by  one, 
with  gut.  This  part  of  the  operation  being  well  done,  the  occurrence  of 
secondary  hemorrhage,  which  so  often  happens  and  gives  so  much  trouble, 
may  be  avoided.  The  next  step  is  the  formation  of  the  urethral  orifice. 
In  this  procedure  we  should  be  guided  by  our  knowledge  of  anatomy. 
If  only  one  or  two,  or  even  three  inches  of  the  penis  are  removed,  the 
incision  into  the  corpus  spongiosum,  which  should  be  made  with  scissors, 
should  be  vertical,  for  the  reason  that  thus  far  the  urethra  is  a  vertical 
slit.  Farther  down,  where  the  urethra  is  a  transverse  slit,  the  incision 
should  be  transverse.  In  the  first  case  we  have  vertical,  and  in  the  second 
horizontal  or  transverse  flaps.  Then  the  tegumentary  ring  should  be 
stitched  to  the  margins  of  the  corpora  cavernosa  by  means  of  close  inter- 
rupted sutures,  leaving  the  formation  of  the  urethra  to  the  last.  Then 
both  flaps  of  the  corpus  spongiosum  must  be  stitched,  in  case  they  are 
vertical,  to  the  corpora  cavernosa,  and  if  horizontal  the  upper  one  should 
be  stitched  to  those  structures  and  the  lower  one  to  the  integument. 
Catgut  may  be  used  for  stitching  the  urethra.  The  wound  is  dressed 
with  iodoform  and  surrounded  by  absorbent  gauze  kept  in  place  by  means 
of  a  T-bandage.  A  soft-rubber  catheter  may  be  retained  in  the  urethra 
for  a  few  days,  or  the  urine  may  be  drawn  off  by  means  of  a  velvet-eye 
rubber  catheter  of  a  calibre  of  about  No.  12  French.  It  may  be  neces- 
sary for  a  time  to  use  suppositories  of  morphine  to  control  erections. 

The  patient  will  be  confined  to  his  bed  for  about  three  weeks.  As 
healing  takes  place  in  the  stump,  it  is  well  to  carefully  watch  the  new 
urethral  orifice,  and,  if  necessary,  to  introduce  every  few  days  a  soft 
olivary  bougie  (20  F.).  As  a  result  of  this  operation  a  good  stump  is 
left.  There  is  a  redundance  of  integument  beyond  the  ends  of  the  corpora 
cavernosa  which  will  admit  of  erection  of  the  latter  without  pain  or  incon- 
venience.    In  many  such  cases  coitus  is  possible  after  the  operation. 

This  operation  may  be  performed  without  the  aid  of  the  needles. 
Hemorrhage  being  cared  for,  mild  traction  is  made  on  the  glans,  and  a 
circular  cut,  through  the  skin  only,  is  made  with  the  scalpel.  At  the 
corpus  spongiosum  the  parts  may  be  relaxed  so  that  it  can  be  cut  off  fully 
three-quarters  of  an  inch  longer  than  the  integument.  Then  a  soft  gum- 
elastic  catheter  may  be  introduced  as  far  as  the  tourniquet.  Traction  is 
then  carefully  made,  and  at  the  same  time  the  tegumentary  sheath  is 
gently  pulled  or  slid  back  for  nearly  an  inch,  and  then  a  vertical  incision 
is  made  through  the  corpora  cavernosa  quite  well  back,  so  as  to  leave  an 
ample  skin-flap.  This  incision  must  be  carefully  made  at  right  angles, 
so  as  to  ensure  a  squarely-ended  stump,  and  as  the  corpus  spongiosum  is 


CANCER   OF  THE  PENIS.  455 

reached  care  must  be  taken  not  to  wound  it.  With  a  little  careful  dissec- 
tion it  can  be  disengaged,  and  it  should  be  cut  off  squarely  about  three- 
quarters  of  an  inch  or  an  inch  beyond  the  stump  proper.  The  further 
steps  of  the  operation  are  precisely  like  those  already  detailed. 

Mr.  Treves  ^  speaks  of  section  with  flap  as  follows :  "■  Hemorrhage 
having  been  provided  against,  a  rectangular  flap  of  skin  is  cut  from  the 
dorsum  and  sides  of  the  penis,  and  the  dorsal  arteries  are  secured.  The 
flap  may  be  compared  in  miniature  to  the  anterior  flap  in  an  amputation 
of  the  thigh.  A  narrow-bladed  knife  is  then  made  to  transfix  at  a  point 
on  a  level  with  the  base  of  the  above  flap,  between  the  corpora  cavernosa 
and  the  corpus  spongiosum,  and  then  is  made  to  cut  forward,  outward, 
and  downward  for  about  three-quarters  of  an  inch.  From  the  smaller 
inferior  flap  the  urethra  is  dissected  out.  The  corpora  cavernosa  are  then 
cut  vertically  upward  on  a  level  with  the  point  of  transfixion.  The  tour- 
niquet is  removed,  all  bleeding  points  are  tied,  and  the  upper  or  skin  flap 
is  punctured  at  a  point  opposite  to  the  divided  urethra.  That  tube  is 
drawn  through  the  punctured  hole  in  the  flap,  is  slit  up,  and  stitched  in 
situ.  The  two  flaps,  upper  and  lower,  are  then  joined  by  sutures."  Mr. 
Treves  says  that  it  is  claimed  that  a  natural  skin  covering  the  severed 
corpora  cavernosa  is  secured,  and  that  quicker  healing  is  induced.  It  is 
very  doubtful  to  my  mind  whether  the  comfort  of  the  patient  w^ould  be 
conserved  by  this  operation.  It  would  seem  that  sufficient  tissue  had  not 
been  left  to  allow  of  free  erections.  Jacobson  says  that  he  has  performed 
this  operation  in  nine  cases  with  excellent  results. 

Amputation  by  the  galvanic  ^craseur  has,  in  my  experience,  little 
to  commend  it.  It  is  claimed  for  this  operation  that  hemorrhage  is 
avoided,  but  such  a  result  is  far  from  being  constant.  It  is  performed 
as  follows  :  A  soft  catheter  is  introduced  into  the  urethra,  and  the  platinum 
wire  is  carried  by  means  of  a  needle  through  the  penis  between  the  corpus 
spongiosum  and  the  corpora  cavernosa.  The  skin  is  incised  in  the  line  of 
amputation.  The  wire  is  then  tightened,  drawn  upward,  heated  to  a  dull 
heat,  and  made  to  traverse  the  cavernous  bodies  very  slowly.  Then  the 
corpus  spongiosum  is  to  be  divided  in  the  same  way.  Healing  after  this 
operation  is  generally  very  sIoav  and  halting,  and  primary  and  secondary 
hemorrhages  are  not  at  all  uncommon. 

The  patient  whose  penis  has  been  amputated  should  report  to  the  sur- 
geon from  time  to  time,  in  order  that  he  may  see  that  the  urethra  remains 
patulous.  Should  it  be  necessary  by  reason  of  contraction,  the  systematic 
introduction  of  an  olivary  bougie  into  the  urethra  may  be  made  every 
few  days  or  a  Aveek  for  a  longer  or  shorter  period. 

Extir^Jation  of  the  Penis. — This  is  accomplished  in  the  easiest  way 
by  the  operation  described  by  Mr.  Pearce  Gould. ^  The  scrotum  should 
be  split  into  two  halves  in  the  whole  length  of  the  line  of  the  raph^, 
back  to  the  corpus  spongiosum.  A  good-sized  metal  catheter  or  sound 
should  then  be  passed  as  far  as  the  triangular  ligament,  and  the  knife 
inserted  between  the  corpora  cavernosa  and  corpus  spongiosum.  The 
latter  structure  is  carefully  separated  as  far  back  as  the  triangular 
ligament  if  necessary — at  any  rate,  Avell  behind  the  disease.  The  sound 
is  then  withdrawn,  the  urethra  cut  across,  and  carefully  dissected  out. 

'  A  Manual  of  Operative  Surgery,  Philadelphia,  1892,  vol.  ii.  p.  657. 
2  Lancet,  vol.  i.,  1882,  p.  821. 


456  MISCELLANEOUS  AFFECTIONS. 

Then  an  incision  is  made  around  the  root  of  the  penis  on  each  side  up  to 
the  central  incision  below.  The  suspensory  ligament  is  then  cut  through, 
and  the  crura  of  the  corpora  cavernosa  are  detached  by  means  of  the 
periosteal  elevator  knife-point  or  scissors.  If  the  bone  is  involved,  re- 
section must  be  performed.  The  urethra  is  now  brought  out,  slit  up 
vertically,  and  stitched  to  the  lower  angle  of  the  wound  in  the  scrotum. 
If  the  testicles  have  also  been  removed,  the  urethra  is  stitched  to  the 
lower  angle  of  the  perineal  wound.  The  after-treatment  requires  care 
as  to  cleanliness,  the  frequent  renewal  of  dressings,  and  the  withdrawal 
of  the  urine  with  a  small  soft  catheter.  Jacobson  allows  his  patients  to 
turn  on  the  side  and  pass  the  urine  into  a  vessel.  He  also  advises  his 
patients  thus  operated  upon  to  have  a  small  metal  funnel  Avith  a  long 
spout  which  will  carry  the  urine  well  aAvay  from  the  body. 

Mr.  Wheelhouse^  urges  the  advisability,  in  some  cases  of  amputation 
of  the  penis,  of  removing  the  testicles.  He  speaks  of  two  cases,  in  one 
of  Avhich  this  was  done,  and  the  other  in  which  it  was  not  done,  as  fol- 
lows :  "  The  result  in  the  two  cases  was  as  marked  as  it  was  different. 
The  two  patients  lay  in  contiguous  beds,  were  constantly  comparing  notes, 
and  never  failed  to  give  me  the  benefit  of  their  discussion.  The  removal, 
though  it  added  greatly  to  the  severity  and  danger  of  the  operation,  did 
not  prevent  the  patient  from  making  an  excellent  recovery,  and  he  has 
many  times  since  spoken  to  me  with  the  greatest  gratitude  and  thankful- 
ness for  the  complete  relief  I  had  afforded  him  in  every  way.  In  the 
case,  on  the  other  hand,  in  which  I  did  not  remove  them  they  became 
from  first  to  last  a  cause  of  trouble  and  distress.  Soon  after  the  opera- 
tion they  became  swollen,  and  remained  tender  for  a  long  time ;  they 
were  there  as'  a  possible  seat  for  the  return  of  the  disease,  and  by  their 
physiological  action  they  were  a  constant  source  of  annoyance."  Jacob- 
son  says  that  three  patients  thus  treated  by  him  were  most  thankful  for 
the  result.  The  consent  of  the  patient,  after  a  plain  statement  of  the 
advantages  of  this  extra  operation,  must  of  course  be  obtained. 

In  every  case  of  cancer  of  the  penis  the  inguinal,  and  perhaps  the 
femoral,  ganglia  should  be  thoroughly  removed,  preferably  at  the  time  of 
amputation  of  the  penis,  or  a  little  later  on  if  such  delay  is  imperative. 
The  dissection  should  be  thorough  and  complete,  and  care  should  be  taken 
not  to  wound  the  femoral  vessels,  the  anterior  crural  nerve,  and  the  saphena 
vein. 

It  is  utterly  futile  to  apply  ointments  or  liquids  to  cancerously  enlarged 
ganglia  with  a  view  to  produce  absorption  of  the  infiltration.  Such  an 
attempt  entails  a  waste  of  precious  time. 

Sarcoma  of  the  Penis. 

This  form  of  malignant  degeneration  of  the  penis  is  usually  secondary 
to  the  involvement  of  other  parts ;  it  may,  however,  be  pi'imary.  It,  as 
a  rule,  begins  in  the  tissues  of  the  corpora  cavernosa. 

A  case  of  primary  sarcoma  of  the  glans  penis  in  a  boy  aged  eight  is 
reported  by  Mr.  Hutchinson.^ 

Marcus  Beck  ^  reported  the  case  of  a  man  aged  fifty-three  who  had 

^  British  Med.  .lournal,  1886,  vol.  i.  p.  187. 

■''  Pathological  Society's  Transactions,  vol.  vi.  p.  228.  ^  Ibid.,  vol.  xxiv.  p.  153. 


ELEPHANTIASIS  OF  THE  GENITALS.  457 

a  fibrous  tumor  of  the  penis  which  was  removed,  and  two  years  later  a 
new  growth  appeared  in  the  scar.  Nine  years  later  the  tumor  was  as 
large  as  a  hen's  egg  and  decidedly  nodulated. 

Other  cases  have  been  reported  by  Mr.  Battle,  E.  H.  Fenwick,  and 
Kaufmann.  This  new  growth  attacks  both  young  and  old,  and  some- 
times seems  to  follow  traumatisms.  The  clinical  features  are  the  slow, 
and  sometimes  rapid,  development  of  a  tumor  without  any  painful  sensa- 
tions, Avhich  enlarges  and  distorts  the  penis.  After  removal  there  is 
always  great  danger  of  the  return  of  the  morbid  process. 

Secondary  sarcomata  of  the  penis  are  sufficiently  common,  and  they 
present,  in  the  main,  symptoms  similar  to  those  of  the  primary  variety. 


CHAPTER    XL. 

ELEPHANTIASIS   OF  THE   GENITALS. 

Elephantiasis  of  the  male  and  female  genitals  occurs  second  in  fre- 
quency to  the  same  affection  of  the  lower  extremities.  It  occurs  in  rare 
and  sporadic  cases  in  America,  England,  and  on  the  continent  of  Europe, 
but  is  quite  common  and  endemic  in  tropical  and  subtropical  countries. 
It  is  frequently  seen  in  Japan,  India,  and  the  West  Indies,  in  Central 
and  South  America,  in  Southern  and  Western  Africa,  and  in  the  Samoan 
and  Hawaiian  Islands. 

No  better  definition  of  elephantiasis  can  be  given  than  that  of  Kaposi,^ 
who  says :  "  We  use  the  term  elephantiasis  Arabum  to  indicate  an  hyper- 
trophy of  the  fibrous  tissue  of  the  cutis  and  of  the  subcutaneous  connec- 
tive tissue,  affecting  the  latter  primarily,  and  followed  in  the  course  of 
further  development  by  an  increase  in  volume  of  all  locally  implicated 
adjacent  organs  and  tissues,  caused  by  local  disturbances  of  the  circula- 
tion and  chronic  recurrent  inflammation  of  the  vessels  and  lymphatics, 
and  confined  to  isolated  regions  of  the  body." 

For  clinical  description  it  is  best  to  divide  elephantiasis  of  the  gen- 
itals into  the  endemic  and  the  sporadic  forms.  In  this  country  we  see 
nothing  of  the  development  of  endemic  cases,  so  I,  like  Kaposi,  am 
forced  to  take  my  facts  from  Pruner,^  Avho  saw  many  cases  in  the  East. 
According  to  this  observer,  the  disease  generally  begins  as  a  hard 
kernel,  usually  under  the  skin,  at  the  bottom  of  the  left  side  of  the 
scrotum.  This  kernel  enlarges  in  size,  and  thus  the  surrounding  parts 
are  invaded.  As  the  affection  increases  the  surface  of  the  scrotum 
becomes  thickened  and  indurated,  and  is  readily  pitted  on  pressure,  and 
it  appears  furrowed,  channelled,  wrinkled,  and  nodular.  Pruner  says 
that  he  never  could  get  a  history  of  erysipelas  complicating  the  onset 
and  development  of  elephantiasis  of  the  scrotum,  though  he  has  seen  it 

^  Diseases  of  the  Skin,  by  Hebra  and  Kaposi,  vol.  iii.,  London,  1874,  pp.  130  et  seq. 
'  Die  Krankhelten  des  Orients,  Erlangen,  1847. 


458  MISCELLANEOUS  AFFECTIONS. 

during  the  formation  of  elephantiasis  of  the  prepuce,  which  is  of  much 
less  frequent  occurrence.  As  the  scrotum  becomes  large  and  heavy,  it 
drags  down  the  adjacent  skin  of  the  abdomen,  which  is  incorporated 
into  the  scrotal  mass.  In  most  cases  the  organ  is  slowly  absorbed  into 
the  scrotal  mass,  till  it  becomes  completely  hidden  in  the  tumor.  Its 
cutaneous  covering  is  connected  merely  to  the  glans,  and  forms  a  blind 
canal  whose  aperture  is  situated  in  front  in  the  middle  line,  which 
forms  a  kind  of  outward  extension  of  the  urethra.  Sometimes  a  gutter 
is  formed  in  the  scrotal  tissue,  beginning  at  the  urethral  opening  and 
running  down  to  the  bottom  of  the  tumor.  The  skin  of  this  gutter  may 
be  converted  into  mucous  membrane.  In  some  cases  the  tumors  have 
been  known  to  become  very  large,  varying  in  size  and  volume  until  they 
reached  down  to  the  feet.  In  this  condition  the  patient  often  carries 
his  genitals  before  him  on  a  wheelbarrow.  Such  tumors  on  removal 
may  weigh  from  fifty  to  two  hundred  pounds  and  over. 

When  elephantiasis  of  the  genitals  is  very  much  developed,  there  is 
frequently  observed  to  ooze  from  the  scrotum  a  yellowish  serous  fluid 
which  escapes  from  the  elongated  and  dilated  lymphatics  which  have 
become  ruptured.  This  condition  is  called  "  lymphorrhoea,"  and  the 
organ  thus  aff"ected  is  termed  "lymph-scrotum."  This  flow  of  lymph 
was  very  active  in  a  case  observed  by  me,  which  I  had  the  oppor- 
tunity of  carefully  studying.  In  this  case  the  lymph-fluid  exuded 
through  little  crevices  from  the  interstices  of  the  connective  tissue.  In 
most  cases,  however,  according  to  Kaposi  and  authorities  who  have  seen 
the  disease  in  tropical  climates,  the  exudation  is  from  a  large  surface, 
very  much  as.  we  see  it  in  moist  eczema.  In  either  case  the  albuminous 
fluid  forms  crusts,  under  some  of  which  superficial  ulceration  may  occur. 
It  will  be  remembered  that  in  the  endemic  form  of  elephantiasis  of  the 
genitals  there  is  in  the  majority  of  cases  involvement  of  both  penis  and 
scrotum. 

I  have  seen  three  cases  of  sporadic  elephantiasis  of  the  penis  in  New 
York. 

An  interesting  case  occurred  in  the  practice  of  Dr.  D.  B.  Gould, 
who  very  kindly  allowed  me  to  examine  it  on  several  occasions.  The 
patient  was  a  young  man  twenty -two  years  old.  He  had  suffered  from 
gonorrhoea,  and  had  used  very  strong  injections,  which  had  given  rise 
to  inflammation  of  the  whole  penis,  the  organ  being  described  as  much 
enlarged,  red,  and  painful.  This  primary  hypergemia  slowly  subsided, 
and  then  the  penis  began  to  swell  in  its  preputial  portion.  This  swell- 
ing, sometimes  accompanied  by  transient  hypersemia,  went  on  steadily, 
and  in  two  years  produced  the  deformity  seen  in  Fig.  180.  The  penis 
was  so  elongated  that  it  reached  nearly  to  the  knees.  Its  distal  portion 
was  the  largest,  and  its  circumference  was  about  ten  inches.  Near  the 
scrotum  the  organ  was  rather  more  than  twice  its  normal  size.  The 
diseased  tissue  was  firm  and  brawny.  Its  surface  was  channelled  by 
numerous  furrows  running  in  a  longitudinal  direction.  These  furrows 
were  crossed  at  right  angles  and  more  or  less  obliquely  by  other  fur- 
rows, and  thus  the  skin  was  divided  up  into  lobulations  and  nodulations 
which  were  seated  side  by  side  like  paving-stones.  This  tumor  was 
removed,  and  a  very  serviceable  penis  was  produced.  There  was  no 
obstruction  to  urination   in  either  of  these  cases. 


ELEPHANTIASIS  OF  THE  GENITALS. 


459 


The  third  case  seen  by  me  was  one  of  elephantiasis  beginning  in  the 
prepuce,  which  was  much  enlarged,  so  that  the  penis  looked  very  much 
like  an  Indian  club.  The  patient  was  a  young  Hebrew,  who  claimed 
that  his  deformity  dated  from  the  day  when  a  woman  gave  his  penis  a 
vicious  twisting  squeeze.  The  organ  swelled,  particularly  at  the  line 
of  union  formed  by  circumcision.  From  this  the  swelling  increased, 
accompanied  at  times  by  transient  hypersemia.     I  know  nothing  of  the 

Fig.  180. 


Elephantiasis  of  the  penis. 


subsequent  course  of  this  case.  It  is  fair  to  assume  that  if  not  operated 
upon  the  outcome  was  the  involvement  of  the  entire  penis. 

Dr.  R.  F.  Weir  also  reports  a  strikingly  interesting  case  in  a  man 
fifty-nine  years  old.  The  patient  had  had  stricture  of  the  urethra  in  its 
penile  portion,  complicated  by  abscess-formation.  This  left  a  fistula  from 
which  alone  the  urine  thereafter  flowed.  Coincidently  with  the  formation 
of  the  abscess  the  penis  began  to  enlarge,  generally  painlessly,  but  some- 
times pain  was  present.  The  whole  organ  was  much  enlarged,  and  pre- 
sented the  usual  appearances  of  elephantiasis.  Voillemier  ^  also  reported 
a  noteworthy  case  of  elephantiasis  of  the  penis  and  scrotum  in  a  patient 
who  had  always  lived  in  France.  The  origin  of  the  disease  in  this  case 
is  not  known.     The  patient  was  an  inveterate  masturbator. 

There  are  a  few  similar  cases  in  literature.  It  thus  appears  that  ele- 
phantiasis of  the  penis  alone  is  very  rare,  and  that  there  is  usually  in- 
volvement of  the  penis  and  scrotum,  the  disease  most  frequently  beginning 
in  the  latter,  structure,  as  it  did  in  the  case  I  first  alluded  to. 

^  Annales  de  Derm,  et  de  SyphiL,  vol.  v.,  1874,  No.  1.  Voillemier's  paper  is  valuable 
by  reason  of  the  views  therein  expressed  as  to  the  surgery  oi  these  tumors. 


460  MISCELLANEOUS  AFFECTIONS. 

In  the  present  state  of  our  knowledge  it  may  be  said  that  in  sporadic 
cases  of  elephantiasis  of  the  penis  there  is  usually  a  history  of  some  irri- 
tative process  which  antedated  the  onset  of  the  hypertrophy.  In  one  case 
herein  reported  by  me  injury  to  the  vessels  of  the  groin  was  the  starting- 
point  of  the  trouble,  in  another,  inflammation  of  the  penis  from  the  in- 
temperate use  of  injections,  and  in  the  third,  direct  traumatism.  In  Weir's 
case  the  irritation  began  in  inflammation  behind  a  stricture,  which  ended 
in  fistula.  It  may  be  that  the  frequent  daily  acts  of  self-abuse  in  Voille- 
mier's  case  were  the  starting-point  in  the  development  of  the  disease. 

Treatment. — In  some  cases  amputation  of  the  penis  may  be  necessary, 
particularly  in  those,  like  Weir's,  in  which  there  was  a  urethral  fistula  in 
the  body  of  the  penis.  In  other  cases  removal  of  the  mass  of  hypertro- 
phied  tissue  may  be  practised,  the  incisions  being  made  according  to  the 
topography  of  the  parts  with  a  view  of  getting  such  flaps  as  will  after 
healing  produce  a  tolerably  symmetrical  organ.  It  is  the  unanimous 
opinion  of  operators  that  even  if  flaps  are  taken  from  the  hypertrophied 
tissue,  they  do  not  form  the  focus  of  new  development. 


CHAPTER    XLI. 

VAEICOCELE. 

The  term  "varicocele"  is  used  to  denote  a  varicose  condition  of  the 
spermatic  veins  by  which  a  generalized  or  localized  swelling  in  the  scrotum 
is  produced.  It  is  usually  a  mild  afi"ection,  and  occurs,  on  an  average,  in 
well-marked  form  in  10  per  cent,  of  all  male  subjects.  Many  men  have 
slight  fulness  and  tortuosity  of  the  spermatic  veins  who  cannot  be  said  to 
have  varicocele. 

This  aff"ection  is,  as  a  rule,  developed  slowly,  insidiously,  and  usually 
painlessly.  Again,  it  develops  quite  rapidly  and  with  much  discomfort 
to  the  bearer.  Bennett,^  who  has  written  an  excellent  essay  on  this  sub- 
ject, says  that  in  nearly  50  per  cent,  of  cases  of  varicocele  the  bearers 
were  unaware  of  its  presence  until  it  had  been  pointed  out  to  them  or  had 
been  accidentally  discovered.  In  only  20  per  cent,  of  cases  were  the 
symptoms  at  all  marked,  and  in  only  25  per  cent,  did  patients  seek  treat- 
ment. It  is  noted  that  feeble  and  neurotic  subjects  seek  relief  rather 
than  the  robust.  In  the  vast  majority  of  cases  varicocele  is  found  only 
on  the  left  side.  Bennett  says  that  in  100  consecutive  cases  he  found  it 
80  times  on  the  left  side,  19  times  on  both  sides,  and  once  only  on  the 
right  side.  He  says  that  in  3  cases,  in  all,  he  has  seen  right-sided  vari- 
cocele, but  admits  that  his  experience  is  exceptional.  Various  reasons 
are  given  for  the  constancy  of  occurrence  of  varicocele  on  the  left  side. 
The  main  cause  probably  lies  in  the  fact  that  the  left  spermatic  vein 
empties  at  right  angles  into  the  corresponding  renal  vein.     Further,  the 

^  On  Varicocele,  London,  1891. 


VARICOCELE.  461 

left  spermatic  vein  may  sometimes  be  pressed  upon  by  the  sigmoid  flexure 
distended  by  fecal  accumulation.  Whether  our  modern  method  of  "  dress- 
ing" has  any  influence  in  causing  enlargement  of  the  veins  of  the  left 
side  of  the  scrotum  is  yet  an  unsettled  question. 

There  can  be  no  doubt  that  varicocele  is  sometimes  of  congenital  origin, 
though  the  published  cases  are  as  yet  small  in  number.  Bennett  found 
in  the  dissecting-room  a  tortuous  spermatic  vein  and  plexus  in  a  four- 
year-old  boy  and  in  two  foetuses — in  one  abnormality  of  the  veins  of  the 
left  side,  and  in  the  other  in  the  pampiniform  plexus.  Heredity  may 
also  be  an  underlying  cause.  There  can  be  no  doubt  that  vessel-tissue 
may,  like  other  tissues,  be  transmitted  in  a  condition  of  vulnerability. 
Bennett  shows  that  there  is  frequently  found  a  coexistence  of  other  vas- 
cular anomalies  with  varicocele. 

Tumors  in  the  groin,  particularly  when  seated  in  or  near  the  external 
ring,  are  liable  to  press  on  these  veins  and  produce  varicocele.  Various 
other  causes  have  been  thought  to  induce  this  condition.  For  instance,  it 
is  stated  by  some  authors  that  ungratified  sexual  desire  and  exeessive 
venery  are  important  factors  in  its  cause.  My  own  opinion  is,  that  as 
predisposing  causes  these  perhaps  may  be  considered  as  somewhat  influ- 
ential, since  any  condition  which  tends  to  induce  engorgement  of  the 
spermatic  vessels  is  of  course  liable  to  aggravate  this  condition  and  per- 
haps even  to  lead  to  its  development.  There  is  no  scientific  evidence 
whatever  in  existence  in  support  of  the  statement  quite  frequently  made 
that  masturbation  causes  varicocele.  The  latter  by  its  irritating  influence 
may  lead  its  bearer  to  masturbation.  I  have  frequently  seen  the  mild 
congestion  of  the  spermatic  veins  of  continent  young  men  speedily  pass 
away  after  marriage.  Varicocele  very  often  occasions  more  or  less  mental 
sufi"ering  to  some  patients  afflicted  with  it.  Some  patients,  like  many  sur- 
geons, regard  it  as  the  result  of  masturbation  practised  in  early  years,  and 
fear  that  it  Avill  ultimately  lead  to  impotency,  while  in  others,  again,  its 
existence  causes  the  most  gloomy  thoughts,  which  sometimes  end  in  well- 
marked  hypochondriasis. 

While  varicocele  may  sometimes  be  found  in  young  boys  of  twelve 
to  fifteen  years,  it  is  mostly  seen  in  adolescents  and  young  men  up  to 
thirty  years  of  age. 

For  lucidity  of  description  the  classification  of  the  various  forms  of 
varicocele  off"ered  by  Bennett  is  to  be  commended.  It  is  clinically  true, 
according  to  my  observation  : 

There  is,  first,  the  elongated  diffused  swelling,  which  extends  from  the 
external  abdominal  ring  down  to  the  testicle,  which  is  larger  high  up  than 
lower  down  ; 

The  second  form  is  that  of  a  diff"use  tumor  surrounding  the  testicle, 
particularly  its  upper  part,  and  extending  halfway  up  to  the  external 
abdominal  ring  ; 

The  third  form  is  a  goodly-sized  tumor  just  below  the  external  ring 
and  extending  halfway  down  to  the  testis. 

When  a  varicocele  tumor  is  palpated,  a  sensation  is  conveyed  to  the 
fingers  like  that  of  a  mass  of  earth-worms,  and  this  simile  is  sometimes 
rendered  all  the  more  striking  by  the  contraction  of  the  cremaster  muscle. 
Very  often  the  scrotum  is  lax  and  dependent,  and  in  its  walls  tortuous, 
flaccid  veins  can  be  distinctly  seen.     Under  the  influence  of  cold  the 


462  MISCELLANEOUS  AFFECTIONS. 

scrotum  and  its  varicocele  contract  materially,  while  heat  and  excitation 
tend  to  produce  a  marked  laxity  and  elongation  of  the  parts. 

The  symptoms  of  varicocele  depend  largely  upon  the  size  and  condi- 
tion of  the  tumor.  When  it  is  large,  long,  and  dependent,  the  patient 
very  often  complains  of  a  sensation  of  Aveight,  dragging,  and  of  mild 
tension,  Avhich  may  extend  to  the  groin,  loins,  and  even  to  the  lumbar 
region.  All  these  symptoms  may  be  aggravated  by  excessive  heat  and 
over-exertion.  In  other  cases  patients  suffer  from  a  dull  aching  pain, 
which  has  periods  of  intensity  and  intermission.  A  crampy  pain  is 
sometimes  complained  of  in  cases  in  which  the  tumor  is  very  large.  In 
all  probability  this  pain  is  due,  as  explained  by  Bennett,  to  the  over- 
burdened condition  of  the  cremaster  muscle. 

The  sharp  pain  sometimes  complained  of  by  subjects  of  varicocele  is, 
in  all  probability,  due  to  spasm  of  the  cremaster  muscle,  associated  with 
intra-abdominal  pressure. 

Tenderness  of  the  veins  and  of  the  cord  is  a  not  infrequent  symptom, 
particularly  in  nervous,  neurasthenic,  and  over-anxious  patients.  Very 
often  patients  themselves  produce  this  symptom  by  repeated  examination 
and  manipulation  of  their  varicocele.  Heat,  over-exertion,  jolting,  and 
bicycling  also  produce  this  symptom  temporarily.  In  many  cases  there 
are  no  symptoms  whatever. 

Varicocele  consists  in  excessive  development  of  the  veins,  the  walls 
of  which  become  thickened  by  cell-increase,  and  are  subsequently  the 
seat  of  fatty  change  and,  in  some  cases,  even  of  calcareous  degenera- 
tion. Phleboliths  are  sometimes  found  within  them,  while  in  general 
their  valves  are  wholly  effaced  and  their  walls  much  thinned.  Certain 
secondary  changes  in  parts  in  connection  with  the  spermatic  veins  often 
follow  varicocele.  For  instance,  under  the  influence  of  the  presence  of 
the  venous  tumor  the  scrotum  sometimes  becomes  more  or  less  redun- 
dant and  relaxed  and  its  walls  are  much  thinned.  In  such  instances  the 
power  of  the  dartos  muscle  is  more  or  less  impaired.  Further,  in  very 
chronic  cases  a  softened  condition,  with  perhaps  slight  atrophy  of  the 
testis,  is  a  not  uncommon  sequela,  Avhile  early  in  the  course  of  varico- 
cele it  is  not  unusual  to  find  a  slightly  congested  condition  of  this  organ, 
due  of  course  to  the  impediment  to  the  return  circulation.  As  a  result 
of  these  changes  it  often  happens  that  ultimately  the  testicle  grows  grad- 
ually smaller,  until  in  some  cases  it  is  reduced  to  the  size  of  a  pea  and 
sometimes  it  seems  wholly  absorbed.  Hydrocele  is  another  not  infre- 
quent complication,  but  it  is  always  of  a  subacute  character  and  usu- 
ally not  very  extensive.  Thrombus  of  the  veins  is  an  occasional 
complication. 

According  to  Bennett,  the  normal  development  of  the  testis  is  more 
or  less  interfered  with  in  about  70  per  cent,  of  all  cases  of  varicocele. 
In  general,  however,  I  think  it  may  be  said  that  the  patient's  virility  is 
very  exceptionally  impaired  or  destroyed  by  varicocele.  Patients  some- 
times attribute  Avant  of  sexual  power,  due  to  other  causes,  to  varico- 
cele, and  therefore  demand  relief.  So  importunate  are  some  of  them, 
and  so  deaf  to  reasoning,  that  the  surgeon  is  forced  to  perform  the  ope- 
ration for  its  mental  effect.  This  condition  of  mind  is  mostly  found  in 
men  of  and  beyond  forty  years  of  age. 

Diagnosis. — The  diagnosis  offers  no  difficulties  whatever,  since  simple 


VARICOCELE.  463 

inspection  presents  a  conspicuous  clinical  picture,  and  palpation  reveals 
the  worm-like  mass  within  the  scrotum.  In  the  horizontal  state  the 
blood  leaves  the  spermatic  veins  or  can  be  readily  pushed  into  the 
abdominal  cavity.  If  the  external  abdominal  ring  is  now  compressed 
with  the  finger-tips  and  the  patient  told  to  stand  up,  the  veins  will  be 
felt  to  be  empty ;  then,  withdraAving  the  pressure  of  the  finger-tip,  the 
sudden  filling  of  the  veins  can  be  readily  felt.  A  hernia  when  reduced 
may  stay  up ;  if  it  should  come  down,  it  forms  a  cylinder  of  decided  cal- 
ibre, which  gives  an  entirely  diflFerent  sensation  from  that  offered  by 
veins  filling  with  blood. 

Treatment. — Much  relief  can  be  afforded  by  the  use  of  cold  douches 
and  by  attention  to  the  condition  of  the  boAvels.  Patients  in  a  neurotic 
or  neurasthenic  condition  should  be  treated  symptomatically.  Errors  in 
sexual  hygiene  should  be  well  looked  after  and  removed,  according  to 
the  indications  in  each  case.  Since  physical  exhaustion  of  any  kind 
tends  to  aggravate  varicocele,  patients  should  be  put  on  their  guard  in 
this  direction.  When  an  operation  is  not  admissible,  much  comfort  is 
afforded  to  patients  by  the  use  of  a  nicely-fitting  and  well-supporting 
suspensory.  The  surgeon  should  take  pains  to  see  that  the  bandage  is 
suited  to  each  case,  since  discomfort  may  come  to  a  patient  who  indis- 
criminately purchases  and  wears  a  suspensory. 

The  radical  cure  of  varicocele  can  be  effected  by  a  number  of  surgical 
procedures,  many  of  which  are  complicated  and  attended  with  difficult 
after-treatment,  and  need  not  be  mentioned. 

The  two  operations  now  mostly  employed  are  Howse's  operation  for 
excision  and  its  modification  by  Bennett.  Subcutaneous  ligation  of  the 
veins  is  much  extolled  by  my  friend.  Dr.  Keyes,  who  repudiates  the 
open  operation.  It  certainly  has  its  sphere  of  usefulness  in  the  milder 
form  of  cases.  The  results  of  the  open  operation  are  conspicuously  and 
uniformly  good.  The  parts  are  so  clearly  exposed,  the  ligatures  can  be 
applied  with  such  precision,  and  there  is  so  much  simplicity  about  the 
operation  that  it  cannot  be  commended  too  highly. 

It  is  necessary  to  remember  that  the  veins  to  be  excised  are  those 
of  the  pampiniform  plexus,  which  is  surrounded  by  a  well-defined  con- 
nective-tissue sheath.  These  spermatic  veins  lie  well  in  front,  while 
the  vas  deferens  with  its  artery  and  veins  is  farther  backward  and 
inward  in  the  scrotum.  If  the  testis  is  carefully  pulled  downward,  the 
vas  is  put  on  the  stretch,  and  it  can  be  easily  felt,  it  being  hard  and  firm 
like  a  whip-cord.  The  vas  and  the  deferential  artery  and  veins  should 
be  carefully  avoided.  Only  by  gross  carelessness  will  they  be  included 
in  the  ligation  of  the  veins.  In  that  event  there  may  be  sloughing  of 
the  testicle  from  Avant  of  blood-supply. 

Excision  of  tJie  Spermatic  Veins. — The  patient  is  properly  prepared 
for  the  operation  and  placed  under  the  influence  of  ether.  The  hairs 
of  the  abdomen  and  genitals  must  be  thoroughly  shaved  off,  and  the 
parts — the  scrotum  especially — well  washed  with  soap  and  water,  then 
with  alcohol  and  ether,  and  then  with  bichloride  solution  (1  :  2000). 
An  assistant  holds  the  testicle  firmly  and  draws  it  horizontally  down- 
ward between  the  thighs.  The  parts  are  then  tense,  the  veins  can  be 
distinctly  felt,  and  under  them  the  vas  is  very  perceptible.  An  incision 
is  then  made  for  an  inch  and  a  half  in  the  longitudinal  direction,  and 


464  MISCELLANEOUS  AFFECTIONS. 

over  the  prominence  of  the  veins.  The  edges  of  the  wound  are  then 
separated  by  retractors,  and  the  coverings  of  the  cord  are  carefully  dis- 
sected until  the  sheath  of  the  veins  comes  into  view.  It  presents  a 
shining,  whitish-gray  color,  through  which  the  purple  veins  are  seen. 
This  sheath  of  the  pampiniform  plexus,  which  must  not  be  cut  into,  is 
then  isolated  by  the  knife,  aided  by  the  fingers,  and  then  the  ligatures, 
of  good  strong  silk,  are  to  be  applied  by  means  of  an  eyed  probe  or 
aneurysm  needle  about  an  inch  and  a  half  apart,  in  which  case  a  longer 
incision  is  necessary.  The  lower  ligature  is  tied  first,  and  then  the 
upper  one.  The  vessels  are  then  cut  with  scissors  about  a  quarter  of 
an  inch  from  the  ligatures.  The  wound-cavity  is  then  copiously  irri- 
gated, and  then  put  on  the  stretch,  so  as  to  bring  the  two  edges  of  the 
scrotum  in  coaptation.  This  can  be  done  with  the  fingers  or  by  means 
of  two  blunt  hooks,  one  at  each  end  of  the  wound.  Two  or  three,  or 
perhaps  more,  catgut  sutures  are  now  applied,  thus  firmly  fixing  the 
parts.  A  small  opening  in  the  dependent  part  of  the  wound  is  left  for 
drainage.     Usually  no  drainage-tube  is  necessary. 

Bennett's  modification  of  the  foregoing  operation  is  the  one  I  now 
most  commonly  employ,  since  its  results  are  so  uniformly  satisfactory. 
I  can  do  no  better  than  quote  Mr.  Bennett's  words.  He  says :  "  The 
precise  extent  of  the  varicocele  which  it  is  desirable  to  resect  in  any 
given  case  is  best  determined  by  placing  the  patient  in  the  -standing 
position  and  roughly  estimating  with  the  eye — or,  better,  by  measuring 
with  a  tape — the  degree  of  elongation  of  the  cord ;  for  instance,  should 
the  testis  be  three  inches  lower  than  normal,  then  certainly  not  less  than 
three  inches  of  veins  should  be  included  between  the  two  ligatures,  as  it 
will  be  desirable  to  excise  at  least  two  inches  and  a  half."  Bennett 
dissects  down  to  the  sheath  of  the  fascia,  Avhich  he  also  says  should  not 
be  opened ;  then  he  passes  his  two  ligatures,  ties  and  leaves  them  quite 
long.  Then  he  cuts  out  the  segment  of  the  veins  included  between  the 
ligatures.  "The  cut  ends  of  the  stumps  left  by  the  division  of  the 
varicocele  are  then  brought  together  and  retained  in  permanent  apposi- 
tion by  knotting  the  ends  of  the  upper  ligature  to  those  of  the  lower, 
thus  at  once  raising  the  testis  to  about  its  natural  level.  The  ligature 
ends  are  cut  off  quite  short." 

Then,  after  the  operation,  the  wound  is  dusted  with  iodoform  and 
bandaged  with  absorbent  cotton  and  gauze.  The  first  dressing  may 
remain  on  for  several  days.  Perfect  healing  usually  occurs  as  early  as 
seven  and  as  late  as  ten  or  twelve  days ;  very  rarely  is  it  found  to  be 
later.  At  first  a  callous  mass  will  be  felt  at  the  point  of  juncture  of  the 
ends  of  the  veins.  This  will  gradually  be  absorbed,  and  in  the  end  a 
little  firm  nodule  will  be  felt.  It  is  well  to  cause  the  patient  to  wear 
a  suspensory  bandage  for  a  short  time  after  any  of  the  radical  operations 
for  varicocele. 

Subcutaneous  Ligature. — It  is  needless  to  describe  the  operations  by 
the  use  of  wire,  which  sloughs  out  and  leaves  the  veins  occluded,  since 
to-day  they  are  practically  obsolete.  This  method  is  looked  upon  by 
most  surgeons  as  unsatisfactory,  particularly  by  reason  of  the  want  of 
certainty  as  to  just  what  is  ligated,  and  of  the  chance  that  some  veins 
may  escape,  in  which  event  recrudescence  would  in  all  probability  occur. 
On  this  subject  I  think  that  Bennett's  contention  is  forcible.     He  says: 


VARICOCELE.  465 

"  Speaking  generally  of  the  subcutaneous  plan,  it  seems  to  me  that  in  the 
present  condition  of  surgery  there  is  a  singular  anomaly  in  performing 
under  cover  of  the  skin — that  is  to  say,  out  of  sight,  and  therefore  neces- 
sarily wanting  in  exactness  and  certainty — an  operation  which  by  the 
open  method  may  be  carried  out  with  absolute  precision,  with  what  I 
believe  to  be  no  unavoidable  risk,  and  with  greater  certainty  in  result." 
Subcutaneous  ligation,  as  proposed  by  Keyes,  is  performed  with  his 

Fig.  181. 


Varicocele  needle. 

modification  of  Reverdin's  needles,  carrying  with  it  stout  twisted  Chinese- 
silk  ligatures.  The  patient  should  not  take  an  anaesthetic.  The  parts 
should  be  shaved  and  washed  as  for  the  open  operation.  If  the  patient 
loses  heart  and  demands  an  anaesthetic,  the  first  or  upper  ligature  should 
be  placed  in  situ  before  he  lies  down,  since  by  this  means  there  can  be 
no  escape  of  the  veins,  owing  to  their  becoming  empty  and  collap.sed. 

The  patient  then  stands  up  near  an  operating  table  or  lounge,  which 
may  be  used  in  case  of  his  fainting.  The  upper  part  of  the  varicose 
veins  are  then  carefully  separated  by  the  thumb  and  forefinger  of  the  left 
hand,  which  compress  the  scrotal  walls  behind  them  and  push  the  vas 
deferens  back.  The  needle  charged  with  the  silk  is  then  firmly  pushed 
through  the  scrotal  walls,  as  high  up  as  may  be  necessary  from  the  shape 
of  the  tumor,  from  before  backward,  behind  the  vein,  and  well  in  front 
of  the  vas  deferens.  This  needle  is  then  left  in  this  position,  and  a  sec- 
ond one  transfixes  the  veins  above  the  globus  major  in  precisely  the 
same  way.  This  needle  is  also  left  in  situ,  an  inch  or  two  of  its  point, 
with  the  silk  in  the  eye,  sticking  out  of  the  hole  in  the  posterior  wall  of 
the  scrotum.  The  following  steps  in  the  operation,  as  described  by 
Keyes,  are  adopted  by  me  when  performing  it.  He  says :  "  With  a 
tenaculum  the  loop  of  silk  is  seized  posteriorly,  and  the  button  of  the 
needle  being  pressed  in  the  handle,  its  eye  is  opened  and  the  loop  of  silk 
released.  This  loop  is  now  pulled  through  posteriorly  until  its  short  end 
emerges,  and  then  the  position  is  that  the  scrotum  is  transfixed  from 
before  backward  by  a  disentangled  single  thread  of  silk  and  an  uncharged 
needle.  The  eye  of  the  needle  is  now  allowed  to  close,  and  the  needle 
itself,  by  widening  the  scrotum,  is  pulled  forward,  but  its  point  is  not  per- 
mitted to  emerge  at  the  anterior  puncture,  while  the  veins  are  all  allowed 
to  fall  away  into  their  natural,  original  position  alongside  the  vas  deferens. 
Then  the  point  of  the  needle  is  again  advanced  under  the  dartos  and  to 
the  outer  side  of  the  veins,  and  cautiously  brought  up  to  the  point  of  pos- 
terior puncture,  out  of  which  the  thread  of  silk  protrudes.  Here  care 
must  be  taken  not  by  a  diagonal  puncture  to  include  any  considerable  bit 
of  dartos  or  any  cutaneous  tissue,  and  not  to  transfix  the  silk,  but  the 
point  of  the  needle  must  be  brought  out,  as  accurately  as  possible,  exactly 
at  the  point  of  original  posterior  puncture,  alongside  of  the  silk.  The 
parts  are  again  freely  irrigated  with  bichloride  solution,  and,  the  eye  of 
the  needle  being  opened  by  pressure  of  the  button  in  the  handle,  the  silk 
is  inserted  into  the  eye,  enough  slack  being  left  upon  the  silk  to  allow 

30 


466 


MISCELLANEOUS  AFFECTIONS. 


the  needle  to  be  easily  extracted ;  and  by  a  sudden,  rapid  motion  the 
needle,  recharged  with  the  silk,  is  withdrawn  through  the  anterior  point 
of  puncture."  When  this  is  done  the  ligatures  include  the  veins,  and 
their  ends  protrude  through  the  little  anterior  puncture  hole.  A  little 
traction  is  then  made  on  the  ligature  in  order  to  thoroughly  free  the  veins 
from  any  connective-tissue  fibres.  Then  the  upper  ligature  is  firmly  tied 
twice  and  cut  off.  Slight  traction  being  made  upon  the  scrotum,  the  liga- 
ture disappears  within  it.  Each  ligature  is  thus  dealt  with.  The  pain  is 
commonly  very  severe,  particularly  on  tying  the  first  ligature.  Usually 
the  scrotum  and  testis  become  somewhat  swollen,  and  thus  remain  for 
a  few^  days.  There  may,  however,  be  little  if  any  reaction.  It  is  best 
for  the  patient  to  remain  in  bed  for  a  few  days,  with  antiseptic  gauze  and 
bandage  applied  to  the  testis.  Then  he  may  go  about  for  a  few  hours 
daily.  The  parts  gradually  become  less  swollen  and  the  pain  shortly 
ceases.  Sometimes,  however,  the  parts  are  painful  for  several  weeks.  In 
the  end,  a  fibrous  cord,  with  two  or  three  (according  to  the  number  of 
ligatures  used)  little  firm  nodular  sAvellings,  are  left  in  place  of  the  varicose 
veins. 

Ablation  of  the  Scrotum. — In  former  years  in  cases  in  which  the 
scrotum  was  flabby  and  redundant  concomitantly  with  varicocele,  some 
surgeons  attempted  to  afford  relief  by  the  ablation  of  that  portion  which 
was  excessive.  The  drawback  to  the  operation  was  that  in  many  cases 
the  redundance  of  tissue  reappeared,  as  a  result  of  the  sagging  down  of  the 


Fig.  182. 


Lewis's  scrotal  clamp. 


varicose  tumor.  Owing  to  the  simplicity  and  success  afforded  by  the  open 
operation  ablation  of  the  scrotum  is  now  rarely  if  at  all  performed  by 
prominent  surgeons.  If,  however,  the  operation  should  be  decided  upon, 
it  can  be  performed  on  general  surgical  lines,  Lewis's  varicocele-clamp 
being  used  to  hold  the  tissues  in  situ  and  to  guide  the  line  of  incision. 


HYDROCELE  AND  HEMATOCELE.  467 

CHAPTER    XLII. 

HYDROCELE  AND  HEMATOCELE. 
Hydrocele. 

By  the  term  "hydrocele"  we  understand  chronic  serous  effusion  into 
the  cavity  of  the  tunica  vaginalis,  producing  more  or  less  distention  of  the 
scrotal  sac.  It  must  be  remembered  that  that  part  of  the  tunica  vaginalis 
in  coaptation  with  the  testis  is  called  the  visceral  portion,  and  that  the 
part  reflected  on  the  inner  side  of  the  scrotal  wall  is  called  the  parietal 
portion.  Since  the  anatomical  structure  of  the  tunica  vaginalis  is  pre- 
cisely similar  to  that  of  serous  membranes,  it  follows  that  any  patho- 
logical processes  attacking  them  are  similar.  In  the  course  of  hydrocele, 
therefore,  there  is,  as  a  rule,  serous  effusion,  and  besides  this  there  may  be 
fibrinous  exudation,  parenchymatous  thickening,  and,  as  a  result  of  infec- 
tion, suppuration  of  the  sac.  For  clearness  of  description  we  may  divide 
the  various  forms  of  hydrocele  as  follows :  1,  hydrocele  of  the  testis ; 
2,  hydrocele  of  the  cord. 

Understanding  by  the  term  hydrocele  a  chronic  process  in  contradis- 
tinction to  the  acute  vaginalitis  of  epididymitis,  we  find  that  there  are 
two  principal  varieties — the  congenital  and  acquired — each  of  which  pre- 
sents further  modifications  of  the  essential  process. 

Congenital  hydrocele  is  mostly  seen  in  young  subjects,  and  consists 
in  the  communication  of  the  tunica  vaginalis  testis  with  the  peritoneal 
cavity  by  means  of  a  crowquill-like  or  pinhole-like  duct  or  opening. 
After  the  descent  of  the  testis  from  the  abdominal  cavity  into  the  scrotum 
there  has  been  failure  in  the  obliteration  of  the  channel  of  communication 
between  the  testicular  serous  membrane  and  that  of  the  peritoneal  cavity. 
When  this  communication  exists  there  is  found  an  effusion  in  the  cavity 
of  the  tunica  vaginalis  which  produces  a  scrotal  tumor  when  the  patient 
stands  in  the  erect  position,  but  in  the  horizontal  position  the  tumor  is 
effaced,  owing  to  the  fluid  gravitating  back  into  the  peritoneal  cavity. 
As  the  fluid  thus  flows  backward  it  is  not  accompanied  by  a  gurgling 
noise,  such  as  is  produced  by  the  return  of  the  intestine. 

The  tumor  in  congenital  hydrocele  is  smooth,  transparent,  fluctuating, 
translucent,  and  extends  from  the  bottom  of  the  scrotum  into  the  inguinal 
canal.  The  light  test  and  the  hypodermic  syringe  will  give  much  aid  in 
establishing  the  diagnosis.  Even  in  the  upright  position  the  contents  of 
the  tumor  may  be  by  pressure  forced  into  the  peritoneal  cavity,  while  the 
testicle  remains  in  the  scrotum.  Then  with  the  tip  of  the  finger  over  the 
inguinal  canal,  if  the  pressure  is  slightly  removed  the  fluid  will  gravitate, 
slowly  and  Avithout  sensation  to  the  surgeon,  back  into  the  scrotum. 
An  intestine  in  thus  passing  down  produces  decided  distention,  and  its 
progress  can  be  distinctly  felt. 

In  most  cases  of  congenital  hydrocele  a  firmly-applied  truss  over  the 
inguinal  canal  will  produce  adhesion,  after  which  fluid  in  the  tunica 
vaginalis  will  be  absorbed  in  a  short  time.  In  case  of  the  failure  of  the 
truss  the  sac  can  be  injected  with  about  fifteen  drops  of  deliquesced  car- 


468  MISCELLANEOUS  AFFECTIONS. 

bolic  acid  just  at  the  peno-scrotal  junction.  As  soon  as  practicable  after 
this  injection  the  pressure  of  the  tumor  should  be  reapplied. 

Congenital  hydrocele  is  said  to  occur  in  from  4  to  7  per  cent,  of  all 
cases  of  hydrocele.     Exceptionally  this  form  of  hydrocele  is  bilateral. 

The  term  "simple  hydrocele,"  or  hydrocele  of  adults,  is  applied  to 
uncomplicated  cases  of  this  aifection.  Hydrocele  is  most  commonly  seen 
in  adults  and  toward  middle  life.  It  is  also  sometimes  seen  in  adolescents. 
The  following  table  of  1000  cases  of  hydrocele  observed  by  Martin  and 
reported  by  Dujat^  is  important  as  showing  the  years  of  life  in  which  the 
affection  was  observed : 

From  18  to  20  years 41  cases. 

"      21  "  25     "  173     " 

"      26  "  35     "  473     " 

"      36  "  45     "  257     " 

"      46  "  59     "  .  • 43     " 

"      60  "  70     "  13     " 

1000 

It  will  be  seen  that  nearly  one-half  of  all  the  cases  occurred  between  the 
twenty-sixth  and  thirty-fifth  years,  rather  more  than  a  quarter  between 
the  thirty-sixth  and  forty-fifth  years,  and  that  after  that  date  it  was  infre- 
quently found.  Hydrocele  therefore  occurs  in  the  years  when  the  sexual 
powers  are  at  their  best  and  the  testicular  circulation  is  most  active,  and 
when  individuals  are  most  commonly  attacked  by  gonorrhoea  and  syphilis 
and  liable  to  traumatisms  of  the  genitals.  Simple  hydrocele  is,  as  a  rule, 
unilateral  and  is  exceptionally  bilateral.  As  usually  found,  the  scrotal 
tumor  formed  by  the  hydrocele  is  pear-shaped  (see  Fig.  183),  with  its  base 
at  the  bottom  of  the  scrotum  and  its  apex  directed  toward  the  external 
abdominal  ring.  In  a  goodly  number  of  cases  the  shape  of  the  tumor  is 
distinctly  ovoid,  with  its  long  axis  directed  vertically  or  perhaps  a  little 
forward.  Less  commonly  the  tumor  is  rather  roundish  in  shape.  The 
size  of  the  tumor  varies  with  the  amount  of  eifusion,  which  may  be  several 
ounces  or  even  quarts.  As  a  rule,  from  eight  to  sixteen  ounces  of  fiuid 
can  ordinarily  be  drawn  from  cases  of  hydrocele. 

To  the  eye  the  scrotal  tumor  presents  a  quite  characteristic  clinical 
picture.  The  scrotal  wall  is  very  much  distended,  tense,  and  usually 
much  thinned,  and  the  scrotal  veins  are  very  distinct  and  usually  enlarged. 
By  palpation  a  very  firm  (see  Fig.  183),  resistant,  elastic  tumor  is  felt, 
which  may  give  a  sensation  of  slight  fluctuation.  In  some  cases  distinct 
fluctuation  may  be  made  out.  Pressure  does  not  in  any  way  render  the 
tumor  smaller,  though  the  finger-tip  can  cause  a  depression  for  a  moment. 

In  some  subjects,  particularly  fat  and  flabby  ones,  the  penis  is  drawn 
backward,  and  its  tegumentary  covering  is  largely  included  in  the  scrotal 
tumor,  which  hangs  quite  saliently  between  the  thighs. 

Simple  hydrocele  is,  as  a  rule,  not  the  seat  of  pain,  and  it  can  be 
manipulated  with  impunity  except  on  its  posterior  and  upper  surfiice  or 
that  part  in  which  the  testis  is  situated.  Pressure  here  usually  causes 
more  or  less  discomfort,  and  it  is  here  that  patients  state  that  pain  exists, 
either  from  the  pressure  of  a  suspensory  or  from  over-exertion. 

The  crucial  test  of  hydrocele  is  its  translucency,  and  this  may  be  deter- 

^  Considerations  snr  I'Hydrocele,  etc.,"  Gaz.  mkl.  de  Paris,  1838,  vol.  vi.  p.  561,  quoted 
by  Monod  and  Terrillon. 


HYDROCELE  AND  HEMATOCELE. 


469 


mined  by  what  is  known  as  the  "light  test."  The  simplest  application 
of  this  test  is  as  follows :  In  strong  sunlight  the  patient  is  made  to  stand 
before  the  surgeon,  who  sits  at  his  side :  he  then  shades  the  convexity 
of  the  tumor  Avith  the  outer  side  of  his  hand,  and  examines  the  organ. 
In  cases  where  the  scrotal  wall  and  the  tunica  vaginalis  are  thin  and  their 
fluid  transparent,  translucency  can  readily  be  made  out.  In  the  absence 
of  sunlight  a  candle,  a  gas-light,  or  the  electric  light  may  be  used.  The 
light  is  placed  on  the  opposite  side  of  the  scrotum,  and  the  surgeon  exam- 

FiG.  183. 


Hydrocele. 


ines  the  part  either  by  means  of  a  cylinder  of  paper  or  by  shading  his 
eye  with  the  hand.  Distinct  translucency  is  seen  in  the  anterior  portion 
of  the  tumor,  while  posteriorly  the  opaque  body  of  the  testis  may  be 
detected.  This  body,  when  thus  inspected,  usually  looks  rather  smaller 
than  one  expects  to  find  it.  In  somewhat  rare  cases  we  find  the  testis 
situated  anteriorly  and  at  the  upper  part  of  the  tumor,  the  tunica  vag- 
inalis being  placed  posteriorly.  Quite  exceptionally  the  testis  is  at  the 
bottom  of  the  tumor. 

In  old  hydrocele  such  is  the  thickness  of  the  sac  that  the  translucency 
is  quite  dim.  In  very  dense,  thick  sacs  there  is  no  translucency  what- 
ever. 

In  many  cases  it  is  utterly  impossible  to  clearly  define  the  outlines  of 
the  testis  by  palpation.     Its  position,  however,  may  then  be  ascertained 


470  MISCELLANEOUS  AFFECTIONS. 

by  pressure,  whicli,  when  made  on  the  organ,  causes  pain  or  discomfort. 
When  the  testis  can  be  made  out,  it  is  often  impossible  to  define  the  out- 
lines of  the  epididymis,  the  reason  being  that  with  the  distention  of  the 
tunica  vaginalis  the  parts  are  so  spread  out  that  the  epididymis  lies  flat  on 
the  tumor  and  presents  very  little  if  any  salience.  After  the  withdrawal 
of  the  fluid  the  testis  and  epididymis  regain  their  normal  relations. 

The  onset  of  hydrocele  is  usually  very  slow  and  without  any  symptoms. 
Its  further  course  is  also  slow  and  insidious,  so  that,  as  a  rule,  the  tumor 
has  reached  the  size  of  a  small  pear  before  its  presence  is  recognized  by 
the  patient.  In  general.  Curling's  statement  that  twelve  to  eighteen 
months  elapse  before  a  hydrocele  reaches  the  external  inguinal  ring  is 
correct.  There  are,  however,  cases  in  which  the  development  of  the 
tumor  is  more  rapid.  On  this  subject  the  following  table  of  miscella- 
neous cases,  arranged  by  Kocher,^  is  interesting,  as  shoAving  the  dates  at 
which  patients  claimed  they  came  for  treatment  after  the  development  of 
the  hydroceles : 

2  to  3  weeks     in    3  cases. 

1  month    "     3     " 

2  months  "     2     " 

3  "         "2     " 

4  "        "5    " 

5  "        "^     " 

18  cases. 

In  the  study  of  these  statistics  the  inaccuracy  of  patients'  memory  and 
their  lack  of  close  and  correct  observation  must  be  taken  into  account. 
It  certainly  is  very  rare  to  find  a  goodly-sized  primary  hydrocele  develop 
in  three  weeks  or  a  month,  except  in  southern  countries  and  in  the  East. 
In  some  very  exceptional  cases  it  may  refill  in  that  time.  The  further 
statistics  of  the  156  collected  cases  are  more  typical  of  the  true  course  of 
hydrocele.     They  are  as  follows  : 


ito 

1  " 

2  " 

1 
2 
3 

year 
years 

a 

in 

u 

40 
34 
13 

cases. 

3  " 

10 

u 

(t 

42 

a 

than 

10 

years 

in 

9 
138 

cases. 

It  is  stated  by  some  authors  that  spontaneous  cure  sometimes  occurs  in 
hydrocele.  Such  cases  are  very  rare  indeed.  In  literature  we  find  that 
Pott  claimed  that  hydrocele  disappeared  during  a  violent  attack  of  gout. 
Behrend  and  Gillis  respectively  observed  the  same  phenomenon  in  the 
course  of  small-pox  and  la  grippe.  It  is  to  be  hoped  that  if  in  the  future 
cases  illustrating  this  point  are  published,  all  the  details  will  be  freely 
given. 

The  fluid  of  hydrocele  usually  has  a  straw  color  and  is  highly  albumin- 
ous. It  has  been  found  of  a  dark-brown  and  even  black  color  from 
admixture  with  blood.  It  sometimes  contains  a  small  quantity  of  choles- 
terin,  and  in  some  few  instances  spermatozoa  have  been  found  in  it.  In 
some  cases  little  flakes  of  albumin  are  seen  floating  in  the  fluid. 

Quite  exceptionally  the  fluid  of  hydrocele  looks  like  milk,  from  its 

1  Op.  ci(.,  p.  76. 


HYDROCELE  AND  HJEMATOCELE.  All 

admixture  with  lymph.  This  condition  has  received  several  names,  as 
follows :  galactocele,  liporacele,  lymphocele,  chylocele,  and  hydrocele  lai- 
teuse  or  graisseuse.  This  form  of  hydrocele  is  observed  in  southern 
countries  and  in  the  East  Indies.  Dr.  W.  M.  Mastin,  in  an  elaborate 
essay  on  this  subject,  reaches  the  conclusion  that  the  filaria  sanguinis 
hominis  is  the  exciting  cause  of  this  chylous  fluid  of  hydrocele,  and  that  it 
reaches  the  cavity  of  the  tunica  vaginalis  as  a  result  of  rupture  of  the 
lymphatic  ducts. 

Several  accidents  and  complications  may  occur  in  the  course  of  hydro- 
cele. Rupture  as  the  result  of  blows  or  great  pressure  may  occur  and 
produce  much  oedema  of  the  scrotum.  If  careful  asepsis  is  observed,  these 
accidents  may  not  prove  very  troublesome  or  dangerous.  In  some  cases  a 
cure  has  been  noted.  In  others  the  fluid  has  been  absorbed  from  the 
scrotum,  and  later  on  the  hydrocele  reappeared. 

Inflammation  may  attack  the  walls  of  the  vaginal  sac,  which  is  the 
seat  of  hydrocele.  In  all  probability  this  is  the  result  of  traumatism. 
Purulent  inflammation  of  the  tunica  vaginalis  may  follow  tapping,  and 
there  can  be  no  doubt  that  the  trocar  in  these  cases  carries  the  pyogenic 
microbe  into  the  cavity.  In  the  inflammatory  process  the  walls  of  the 
tunica  vaginalis  may  become  very  much  thickened,  even  to  the  extent 
of  an  inch  or  more.  A  number  of  cases  have  been  reported  of  old  men 
in  whom  suppuration  of  the  sac  occurred  as  a  complication  of  hydrocele. 
It  does  not,  therefore,  follow  that  the  accident  is  peculiar  to  old  men. 
Without  doubt  the  infecting  agent  was  carried  by  the  trocar  or  needle. 
The  tissues  of  old  men  are  more  vulnerable  than  those  of  young  subjects, 
and  suppuration  is  therefore  more  promptly  produced.  Such  a  hydrocele 
then  becomes  nothing  less  than  an  abscess-cavity. 

As  a  result  of  blows  or  other  traumatisms  blood  may  be  efi"used  into 
the  vaginal  cavity,  in  which  event  the  hydrocele  is  transformed  into 
hsematocele. 

Encysted  Hydrocele  of  the  Testis. 

There  are  two  varieties  of  this  kind  of  hydrocele — ^^one  arising  from 
the  epididymis,  and  called  by  some  "spermatocele,"  and  the  other  from 
the  body  of  the  testicle.  Either  vai'iety  may  be  complicated  by  hydrocele 
of  the  tunica  vaginalis.  According  to  Gosselin,  Luschka,  and  Curling, 
these  cysts  are  of  two  kinds — subserous  and  parenchymatous,  or  small 
and  large. 

The  covering  or  walls  of  the  subserous  cysts,  which  are  superficial, 
are  composed  simply  of  stretched  serous  membrane,  while  the  walls  of  the 
parenchymatous,  which  are  developed  in  the  connective  tissue,  are  dense 
and  firm.  The  subserous  cysts  are  usually  multiple,  and  are  found  above 
and  around  the  head  of  the  epididymis  ;  they  are  generally  about  the  size 
of  a  pea.  They  contain  a  clear,  pellucid  fluid,  which  is  sometimes  of  a 
milky  hue  ;  spermatozoa  are  never  found  in  the  fluid.  These  cysts  some- 
times become  fused  together,  and  form  a  single  large  one  having  a  peduncu- 
lated base ;  they  never  have  any  connection  with  the  eff"erent  tubes  of 
the  testis,  and  rarely  cause  any  uneasiness.  Occasionally,  when  very 
old,  these  small  cysts  have  such  thick  walls  as  to  be  mistaken  for  solid 
tumors. 

The  large  cysts,  according  to  Curling,  are  usually  found  "below  the 


472  MISCELLANEOUS  AFFECTIONS. 

head  of  the  epididymis,  close  to  the  anterior  extremity  of  its  lower  border. 
They  are  formed  in  the  connective  tissue  beneath  the  investing  membrane 
of  the  epididymis  and  in  close  contact  with  the  efferent  tubes."  These 
have  received  the  name  of  encysted  hydrocele  of  the  epididymis.  The 
epididymis  is  flattened  and  displaced  laterally,  while  the  testis  is  found 
below,  in  front  of,  or  at  the  side  of  the  cyst,  very  rarely  behind  it.  Mr. 
Curling  gives  an  illustration  of  a  striking  case  of  this  form  of  cyst,  which 
was  distinctly  sacculated.  The  contained  fluid  is  slightly  albuminous, 
colorless,  and  sometimes  contains  an  abundance  of  molecules.  Curling 
states  that  this  form  of  cyst  is  liable  to  inflammation,  when  the  fluid 
becomes  albuminous  and  of  a  straw  color ;  the  cysts  may  even  become 
lined  with  a  false  membrane.  Spermatozoa  are  not  infrequently  found  in 
the  fluid.  Regarding  the  doubtful  origin  of  these  bodies,  Mr.  Paget  says 
"that  certain  cysts  seated  near  the  organ,  which  naturally  secretes  the 
material  for  semen,  may  possess  the  power  of  secreting  a  similar  fluid." 
Curling,  however,  does  not  accept  this  view.  In  his  opinion,  the  thin 
walls  of  the  sac  being  in  close  proximity  with  the  efferent  tubes,  which 
are  likewise  of  slight  texture,  a  rupture  occurs,  allowing  the  spermatozoa 
to  pass  into  the  cyst.  Being  merely  an  accident,  he  thinks  the  term 
spei^matic  hydrocele  is  improperly  applied  to  this  condition. 

Cysts  springing  only  from  the  body  of  the  testis  are  quite  rare.  They 
are  due  to  effusion  between  the  tunica  albuginea  and  the  deeper  layer  of 
the  tunica  vaginalis.  Occasionally  a  cyst  is  seated  partly  upon  the  epi- 
didymis and  partly  upon  the  testicle.  The  walls  of  a  recent  cyst  are 
thin  and  translucent ;  as  the  cyst  grows  older  its  walls  become  thick, 
dense,  and  fibrous,  sometimes  even  containing  spiculse  of  bone  and 
becoming  lined  with  false  membrane.  The  fluid  is  at  first  pellucid,  but 
after  a  time  it  assumes  a  yellow  or  even  a  deep-brown  color. 

Unusual  Forms  of  Hydrocele. — There  are  certain  anomalous  forms  of 
hydrocele  which  may  puzzle  the  young  surgeon. 

Rather  infrequently  we  find  a  scrotal  tumor,  due  to  hydrocele,  which 
presents  an  uneven  surface  and  is  more  compressible  in  some  parts  than 
others.  This  condition  is  due  to  exudative  or  adhesive  inflammation  of 
the  tunica  vaginalis,  which  produces  bands  of  fibrous  tissue  which  divide 
the  cavity  up  into  several  compartments.  Thus  is  produced  an  encysted 
hydrocele,  which  may  not  appear  translucent  when  the  light  test  is 
applied. 

In  still  rarer  instances  we  find  that  OAving  to  exudative  inflammation 
more  or  less  of  the  wall  of  the  tunica  vaginalis  is  thickened,  sometimes  in 
a  considerable  degree.  Upon  palpation  we  find  an  uneven  surface,  and  a 
marked  difference  is  experienced  between  the  thickened  plaque  and  the 
balance  of  the  unaltered  tunica  vaginalis.  Then,  again,  in  some  cases  of 
great  thickening  of  the  walls  there  are  areas  of  the  diameter  of  half  an 
inch  or  an  inch,  in  which  there  is  no  thickening  at  all,  and  on  inspection 
such  a  membrane  presents  an  appearance  similar  to  windows  in  a  wall. 

Circumscribed  hydrocele  is  also  somcAvhat  rarely  found.  In  these 
cases  a  large  portion  of  the  two  layers  of  the  tunica  vaginalis  has  become 
adherent,  and  a  dropsy  has  occurred  in  a  limited  portion,  which  produces 
a  swelling,  usually  round  or  oval,  which  is  attached  to  the  testes. 

Under  the  title  "hydrocele  bilocularis,"  or  hydrocele  eji  Mssac,  a 
peculiar  and  rare  form  of  the  affection  is  described.     (See  Fig.  184.)     In 


HYDROCELE  AND  HEMATOCELE. 


473 


this  form  the  hydrocele  tumor  is  in  the  scrotum,  extends  up  the  inguinal 
region  and  through  the  rings  by  a  narrow  neck,  and  is  continuous  with 
another  tumor  seated  within  the  abdominal  cavity  and  underneath  the 
parietal  peritoneum,  and  entirely  independent  of  it.  In  this  form  of 
hydrocele  the  vaginal  process  of  the  peritoneum  has  become  obliterated 
within  the  abdominal  cavity,  and  has  probably  not  undergone  obliteration 
toward  the.  testicle.     When  the  patient  stands  erect  the  scrotal  tumor  is 

Fig.  184. 


'■f^iMpI^^'' 


Hydrocele  bilocularis. 

large  and  tense,  and  when  in  the  horizontal  position  it  is  more  or  less 
flaccid,  owing  to  the  gravitation  of  the  fluid  into  the  abdominal  cavity. 
The  dimensions  of  this  form  of  hydrocele  are  sometimes  very  great. 
Rochard  reported  a  case  in  which  the  tumor  filled  part  of  the  abdominal 
cavity  and  extended  up  to  the  umbilicus  and  beyond  the  median  line.  In 
a  case  reported  by  Bazy  ^  these  dimensions  were  exceeded. 

Another  rare  and  anomalous  form  is  called  "diverticular  hydrocele," 
and  by  the  French  hydrocele  de  Beraud.^  In  this  form  there  are  two 
cavities,  the  one  around  the  testis,  and  the  other  outside  of  that  and  com- 
municating with  it  by  means  of  a  small  opening  or  neck.  This  hydro- 
cele begins  as  the  ordinary  form,  but,  owing  to  some  cause,  perhaps 
localized  thinning  of  the  sac-wall,  a  slight  bulging  occurs,  and  soon  a 
diverticulum  is  formed.  This  second  cavity  goes  on  increasing  until  it 
becomes  larger  than  the  original  sac.  The  orifice  of  communication  in 
these  cases  is  about  large  enough  to  admit  the  tip  of  the  fore  finger,  and 
by  its  firm  structure  it  remains  permanent.     The  translucency  is  marked 

^  Monod  and  Terrillon,  np.  cif.,  pp.  229  et  seq. 

^  "Remarqnes  snr  TAnatomie  pathologique  d'une  Forme  de  THydrocele,"  Arch.  gen. 
de  Medecine,  1856,  5th  Series,  vol.  vii.  p.  670. 


474  MISCELLANEOUS  AFFECTIONS. 

in  this  form  of  hydrocele,  owing  to  the  extreme  thinness  of  the  walls  of 
the  diverticulum. 

All  forms  of  hydrocele  may  be  complicated  with  hernia,  which  may  at 
first  make  the  diagnosis  more  difficult. 

Causes  of  Hydrocele. — Hydrocele  or  vaginalitis  frequently  follows 
gonorrhoeal  epididymitis  and  orchi-epididymitis.  Acute  hydrocele  with  a 
rather  limited  amount  of  effusion  is  a  constant  concomitant  of  gonorrhoeal 
testicular  inflammation.  When  hydrocele  is  of  gonorrhoeal  origin,  it  is 
thought  by  Panas^  and  V^tault^  to  be  due  to  fibrinous  effusion  into  the 
epididymis  by  which  the  efferent  vessels  are  compressed  to  such  a  degree 
as  to  produce  congestion  and  efi"usion  into  the  tunica  vaginalis.  Hydro- 
cele may  also  result  from  chronic  gonorrhoeal  orchitis.  It  is  very  common 
to  find  great  vascularity  of  the  visceral  layer  of  the  tunica  vaginalis  when 
that  cavity  is  opened  surgically  in  cases  of  chronically  inflamed  testis  with 
hydrocele  following  gonorrhoea.  In  the  same  class  of  cases  I  have  seen 
intense  congestion  and  thickening  of  the  epididymis  when  operating  for 
hydrocele.  My  studies,  therefore,  convince  me  that  chronic  inflammation 
of  the  epididymis  and  orchitis  with  or  without  epididymitis  following 
gonorrhoea  are  frequently  causative  factors  in  the  production  of  hydrocele. 

Hydrocele  has  been  known  to  follow  varicocele,  and  it  is  thought  by 
some  that  the  latter  condition  is  sometimes  the  determining  cause  of  the 
former. 

Hydrocele  may  occur  as  a  complication  of  general  dropsy,  but  it  is 
very  probable  that  in  that  event  there  was  some  antecedent  testicular 
injury  or  disturbance. 

Traumatism  undoubtedly  is  a  frequent  cause  of  hydrocele.  It  is  so 
common  to  find,  particularly  on  the  visceral  layer  of  the  tunica  vaginalis, 
patches  showing  antecedent  hemorrhage,  or  of  chronic  inflammation  and 
cicatrization,  that  in  the  absence  of  a  history  of  gonorrhoea  no  other  cause 
than  injury  can  be  assigned.  It  is  claimed  by  some  that  cysts  of  the  epi- 
didymis and  of  Morgagni's  hydatid  may  rupture  into  the  tunica  vaginalis, 
and  thus  cause  irritation,  which  is  followed  by  hydrocele.  This,  however, 
is  mere  hypothesis. 

Inguinal  hernia,  particularly  when  voluminous,  has  been  thought  to  be 
a  cause  of  hydrocele.  On  this  subject  the  essay  of  Bouisson^  may  be  of 
interest.  The  contention  that  a  diathetic  state  like  gout  or  rheumatism 
may,  as  claimed  by  Verneuil  and  Chollet,*  produce  hydrocele,  is  wholly 
wanting  in  scientific  proof.  Hydrocele  undoubtedly  results  in  every  case 
from  some  definite  disturbance  of  the  equilibrium  of  the  circulation,  the 
origin  of  which  is  not  always  apparent.  It  is  safe  to  say  that  the  dis- 
turbance in  the  circulation  exists  somewhere  in  the  testicle  or  the  cord, 
and  that  hydrocele  does  not  follow,  as  claimed  by  some,  per  se,  troubles  in 
the  bladder  and  urethra. 

Pathological  Anatomy. — In  some  recent  cases  of  hydrocele  no  thicken- 
ing of  the  serous  membrane  can  be  discovered,  and  in  many  it  is  even 
thinner  than  normal,  and  the  most  noticeable  feature  in  either  case  is 

^  "Sur  les  Causes  et  la  Nature  de  I'Hydrocele  vaginale  simple,"  Arch,  gen  de  Med., 
1872,  6th  Series,  vol.  xix.  p.  5. 

^  Considerations  etiologiques  sur  VHydrocUe  des  Adults,  Paris,  1872. 

^  "  De  I'Hydrocele  causee  par  une  Hernie  volumineuse.  Hydrocele  de  Gibbon,"  Mont- 
pellier  Medical,  Feb.,  1 867. 

*  "Eecherches  sur  I'Etiologie  de  I'Hydrocele,"  These  de  Paris,  1879. 


HYDROCELE  AND  HEMATOCELE.  475 

more  or  less  hypersemia,  the  vessels  being  numerous  and  prominent.  In 
further  advanced  cases  the  membrane  is  decidedly  thickened,  of  a  pearly- 
white  color,  and  streaked  by  numerous  vessels.  This  thickening  of  the 
membrane  may  be  comparable  to  that  of  blotting-paper  or  it  may  be  still 
more  excessive.  In  very  old  hydroceles  a  thickening  of  one  and  two 
lines,  and  even  more  than  that,  may  be  found.  In  many  cases  of  thick- 
ening the  serous  surface  is  still  smooth  and  glossy.  Evidences  of  fibrin- 
ous exudation,  local  or  general,  are  not  uncommonly  found.  Thus,  the 
membrane  may  be  simply  a  little  rough  and  more  than  ordinarily  opaque, 
or  it  may  be  covered  with  little  tufts  or  patches  of  false  membrane.  In 
fact,  all  the  features  of  exudative  and  adhesive  inflammation  of  serous 
membranes  may  be  found  in  the  tunica  vaginalis.  The  endothelium  is 
then  thrown  oif,  and  the  surface  of  the  membrane  becomes  covered  with 
a  membrane  of  plastic  lymph  looking  sometimes  like  velvet,  again  like 
lace,  and  sometimes  a  general  nutmeg-grater  roughness.  As  a  result  of 
this  adhesive  inflammation  the  visceral  and  parietal  layers  may  be  glued 
together  in  patches  of  greater  or  less  size. 

Where  pus-formation  occurs  there  is  always  more  or  less  plastic 
exudation,  coexistent  with  the  suppuration.  Kocher^  has  elaborated  a 
complex  pathological  classification  of  the  changes  which  take  place  in 
hydrocele,  and  has  expended  upon  it  a  wealth  of  Latin  terms.  The 
essential  facts,  however,  are  as  they  have  just  been  presented. 

The  diagnosis  of  hydrocele  is  usually  quite  easy.  Its  slow  develop- 
ment without  symptoms,  its  beginning  at  the  bottom  of  the  scrotum,  its 
pyriform  or  oval  shape,  are  presumptive  symptoms,  while  all  doubt  may 
be  removed  by  the  light  test  or  by  slight  aspiration  with  the  hypodermic 
needle.  In  hydrocele  the  tumor  presents  dulness  on  percussion  ;  there  is 
no  impetus  on  coughing  and  no  change  in  the  tumor  when  the  patient 
is  in  the  horizontal  position.  In  hernia,  particularly  incarcerated,  the 
tumor  comes  usually  suddenly  from  above,  where  it  is  largest,  and  is 
doughy,  and,  as  a  rule,  resonant,  on  percussion. 

The  translucency  of  hydrocele  ahvays  establishes  the  diagnosis  between 
it  and  solid  tumors  of  the  testes. 

Diagnosis. — Encysted  hydrocele  of  the  epididymis  is  usually  recognized 
from  the  position  and  number  of  the  cysts.  In  cases  of  doubt,  especially 
when  the  cysts  are  hard  and  firm,  the  introduction  of  a  hypodermic  needle 
will  determine  whether  they  contain  fluid.  The  difierence  in  shape  between 
these  large  cysts  and  hydrocele  of  the  tunica  vaginalis  is  an  important 
point,  while  the  position  of  the  testicle  at  the  bottom  of  the  tumor  con- 
firms the  suspicion  of  large  encysted  hydrocele. 

In  some  cases,  however,  on  account  of  abnormalities  in  position,  a 
positive  diagnosis  can  only  be  made  by  drawing  off"  some  of  the  fluid, 
which  is  generally  pellucid  or  milky  rather  than  straw-colored.  Trans- 
lucency and  fluctuation  are  additional  points  in  the  diagnosis. 

Treatment. — The  treatment  of  hydrocele  may  be  palliative  or  radical : 
by  the  former  we  merely  remove  the  fluid,  by  the  latter  we  hope  to  pre- 
vent its  re-formation.  The  seton,  acupuncture,  and  electrolysis  in  the 
treatment  of  hydrocele  are  now  practically  obsolete  procedures. 

For  various  reasons,  many  patients  prefer  to  have  their  hydroceles 
tapped  from  time  to  time,  rather  than  undergo  any  operation  more  radical. 

*  Op.  cii.,  pp.  54  et  seq. 


476  MISCELLANEOUS  AFFECTIONS. 

Tapping  of  hydrocele  is  a  very  simple  operation.  It  is  always  necessary 
to  wash  the  scrotal  wall  with  soap  and  water,  and  then  with  bichloride 
solution  (1 :  1000).  The  patient  stands  before  the  surgeon,  who,  having 
ascertained  by  palpation  or  the  light  test  the  position  of  the  testis,  holds 
the  scrotum  firm  and  tense  with  the  left  hand.  Then  he  pushes  firmly, 
rather  quickly  and  gently,  a  fine  asepticized  trocar  upward  as  well  as  for- 
ward. The  insertion  should  be  made  in  the  middle  of  the  most  promi- 
nent part  of  the  tumor,  and  care  should  be  taken  that  veins  are  avoided. 
If  we  aim  at  a  radical  cure  and  a  cutting  operation  is  out  of  the  question, 
we  may  inject  either  tincture  of  iodine  or  carbolic  acid  into  the  sac. 
For  this  operation  a  short  glass  syringe,  holding  two  or  three  drachms 
and  attachable  by  its  nozzle  to  a  fine  trocar,  may  be  used.  If  iodine  is 
selected  as  the  agent  to  produce  the  hoped-for  adhesive  inflammation 
which  shall  thoroughly  agglutinate  the  two  layers  of  the  tunica  vaginalis, 
about  two  to  four  drachms  of  the  tincture  may  be  thrown  into  the  vaginal 
cavity.  Care  must  be  taken  that  the  tip  of  the  trocar  does  not  slip  out 
from  between  the  two  layers  of  the  tunica  vaginalis.  After  the  injection 
the  part  should  be  well  kneaded  or  manipulated,  so  that  the  whole  of  the 
serous  membrane  is  acted  upon.  If  carbolic  acid  is  selected  for  use,  sixty 
to  ninety  drops  of  the  recently-deliquesced  acid  may  be  thrown  in  by 
means  of  the  syringe.  Both  of  these  fluids  may  be  left  in  the  vaginal 
cavity.  This  operation  should  be  done  at  the  patient's  home  or  at  a 
hospital.  The  immediate  result  may  be  a  slight  or  a  very  severe  reac- 
tion in  the  shape  of  heat,  swelling,  and  more  or  less  pain.  The  patient 
must  be  kept  in  the  recumbent  position,  and  cooling  lotions  or  applica- 
tions may  be  used  to  the  scrotum.  The  patient  may  go  about,  usually  in 
a  few  days,  but  he  may  be  confined  at  home  for  a  week  or  more. 

In  justice  to  the  patient,  it  is  well  to  make  him  clearly  understand 
that  this  injection  treatment  is  not  in  every  case  successful.  This  may 
be  said  in  spite  of  the  contention  of  some  enthusiasts  who  claim  uniform 
and  invariable  cure.  Failures  after  carbolic  acid  are  less  frequent  than 
after  tincture  of  iodine,  but  they  will  follow  in  a  goodly  proportion  of 
cases,  no  matter  how  carefully  and  thoroughly  the  injection  has  been 
made,  nor  how  skilful  is  the  operator.  It  is  needless  to  mention  other 
agents  for  injection,  since  they  are,  as  a  rule,  inert. 

The  injection  treatment  is  only  applicable  to  cases  of  rather  recent 
hydrocele,  of  not.  excessive  size,  and  in  which  the  epididymis  and  testes 
are  healthy.  When  the  tunica  vaginalis  is  much  thickened,  injections 
will  do  harm  rather  than  good. 

Treatment  hy  Incision. — Volkmann  proposed  a  method  which  is  gen- 
erally productive  of  cure,  the  failures  amounting  to  about  2  per  cent. 
His  procedure  is  as  follows :  The  scrotum  and  pubes  are  to  be  shaved 
and  well  Avashed  with  soap  and  water,  alcohol  and  ether,  and  then  flushed 
with  a  bichloride  solution  (1  :  1000).  A  vertical  incision  about  three 
inches  long  is  then  made  over  the  prominence  and  just  in  the  middle  of 
the  hydrocele.  The  dissection  is  slowly  made  until  the  brownish  or  bluish 
bag  of  water  is  visible,  all  vessels  being  secured  as  the  operation  proceeds. 
It  is  well  to  let  out  the  fluid  by  a  quick  stab  into  the  wall  with  a  straight 
bistoury,  and  then  to  complete  the  two-  or  three-inch  incision  with  blunt 
scissors.  The  cut  edges  of  the  tunica  vaginalis  are  then  stitched  to  the 
edges  of  the  scrotal  wound,  and  the  cavity  may  be  stufi^ed  Avith  gauze  or 


HYDROCELE  AND  HEMATOCELE.  477 

a  large  drainage-tube  may  be  inserted.  The  visceral  and  parietal  layers 
of  the  tunica  vaginalis  may  be  gently  swabbed  with  pure  deliquesced  car- 
bolic acid  just  after  stitching,  since  this  application  may  aid  in  the  pro- 
duction of  adhesive  inflammation.  It  certainly  never  does  any  harm. 
The  parts  are  to  be  dusted  with  iodoform  and  covered  with  gauze  and  a 
bandage.  Renewal  of  the  dressing  is  necessary  every  day  or  two,  and 
the  greatest  care  must  be  taken  that  the  wound  does  not  become  infected. 
Healing  occurs  in  two  to  three  weeks. 

Another  procedure  which  has  produced  good  results  in  my  hands  is  as 
follows :  The  patient  being  prepared  and  etherized,  the  incision  as  above 
detailed  is  made.  Then  all  of  the  parietal  layer  of  the  tunica  vaginalis 
is  cut  away  with  the  scissors,  except  what  is  necessary  to  cover  the  testis. 
The  serous  surface  is  then  swabbed  with  pure  carbolic  acid,  and  the  cut 
edges  of  the  remains  of  the  parietal  tunica  are  then  stitched  together  with 
fine  catgut,  leaving  a  little  opening  in  the  lower  part  for  drainage.  A 
small  drainage-tube  may  be  inserted  or  a  few  strands  of  horsehair.  The 
cut  edges  of  the  scrotum  are  treated  in  a  similar  manner.  The  wound  is 
dressed  as  described  in  the  previous  operation.  Healing  may  occur  in 
ten  days  or  two  weeks,  but  sometimes  it  is  delayed  a  little  longer.  It  is 
not  necessary  to  renew  the  dressings  so  often  after  this  operation. 

The  most  radical  operation  for  hydrocele  is  that  proposed  by  von 
Bergmann.  In  this  operation,  after  the  incision  into  the  sac,  the  tunica 
vaginalis  is  peeled  and  dissected  off  the  scrotum  and  cord  as  far  as  can  be 
reached.  It  is  then  cut  ofi"  as  close  to  the  testicle  as  possible.  A  drain- 
age-tube is  inserted,  and  the  edges  of  the  wound  are  stitched  together 
with  silk.  The  parts  are  then  dusted  with  iodoform  and  well  bandaged. 
Healing  occurs  in  from  ten  to  twenty  days,  during  which  the  patient 
remains  in  bed. 

Even  after  these  radical  cutting  operations  relapses  may,  though  quite 
rarely,  occur.  The  truth  is,  that  we  have  no  absolutely  infallible  cure 
for  hydrocele.  One  advantage,  often  of  much  importance,  attends  the 
cutting  operations :  it  is  that  we  are  able  to  freely  examine  the  testis  and 
the  epididymis.  After  thorough  healing  of  the  wound,  the  testis,  as  a 
rule,  will  not  be  found  adherent  or  immobile,  but,  on  the  contrary,  it  will 
float  free  in  the  ambient  connective  tissue. 

Treatment  of  Encysted  Hydrocele. — The  small  encysted  hydrocele 
seldom  requires  any  attention  unless  it  tends  to  increase  in  size  or  become 
painful,  when  the  fluid  may  be  drawn  off  with  a  hypodermic  needle  or  by 
acupuncture.  This  operation  sometimes  gives  permanent  relief,  but  may 
need  to  be  repeated.  Large  cysts  should  be  tapped  separately  and  in- 
jected. Sometimes  the  tapping  and  injection  of  a  single  cyst  cause  sub- 
sidence of  all  the  rest.  Although  the  seton  has  been  used  with  success, 
it  sometimes  causes  violent  inflammation  and  abscess.  Volkmann's  ope- 
ration may  be  employed  after  failure  of  tapping. 

Hydrocele  of  the  Spermatic  Cord. — There  are  two  varieties  of 
hydrocele  of  the  cord,  the  diffused  and  the  encysted. 

The  diffused  form  is  merely  a  serous  infiltration  into  the  loose  and 
abundant  connective  tissue  of  the  cord.  The  first  clear  description  of 
the  lesion  was  given  by  Pott :  "  In  general,  while  it  is  of  moderate  size, 
the  state  of  it  is  as  follows :  The  scrotal  bag  is  free  from  all  appearances 
of  disease,  except  that  when  the  skin  is  not  congested  it  seems  rather 


478  MISCELLANEOUS  AFFECTIONS. 

fuller,  and  hangs  rather  lower  on  that  side  than  on  the  other,  and,  if  sus- 
pended lightly  in  the  palm  of  the  hand,  feels  heavier ;  the  testicle  with  its 
epididymis  is  to  be  felt  perfectly  distinct  below  this  fulness,  neither  en- 
larged nor  in  any  manner  altered  from  its  natural  state ;  the  spermatic 
process  is  considerably  larger  than  it  ought  to  be,  and  feels  like  a  varix 
or  like  an  omental  hernia,  according  to  the  different  sizes  of  the  tumor ; 
it  has  a  pyramidal  kind  of  form,  broader  at  the  bottom  than  at  the  top ; 
by  gentle  and  continued  pressure  it  seems  gradually  to  recede  or  go  up, 
but  drops  down  again  immediately  upon  removing  the  pressure,  and  that 
as  freely  in  a  supine  as  in  an  erect  posture.  It  is  attended  with  a  very 
small  degree  of  pain  or  uneasiness,  which  uneasiness  is  not  felt  where  the 
tumefaction  is,  but  in  the  loins.  If  the  extravasation  be  confined  to  what 
is  called  the  spermatic  process,  the  opening  in  the  tendon  of  the  abdomi- 
nal muscle  is  not  at  all  dilated,  and  the  process  passing  through  it  may 
be  very  distinctly  felt ;  but  if  the  cellular  membrane  which  invests  the 
spermatic  vessels  within  the  abdomen  be  aifected,  the  tendinous  aperture 
is  enlarged,  and  the  increased  size  of  the  distended  membrane  passing 
through  it  produces  to  the  touch  a  sensation  not  very  unlike  that  of  an 
omental  rupture."  Curling  says  that  the  tumor  is  at  first  cylindrical, 
and  becomes  pyramidal  as  it  enlarges.  The  penis  in  this  affection  is 
never  retracted,  as  it  may  be  in  vaginal  hydrocele. 

This  form  of  hydrocele  may  be  mistaken  for  a  hernia.  The  latter 
often  passes  into  the  abdomen  when  the  patient  lies  down,  while  the 
former  is  but  slightly  if  at  all  displaced.  The  swelling  of  hydrocele 
is  firmer,  though  doughy,  and  fluctuating ;  a  hernia,  moreover,  unless  it 
be  omental,  is  resonant  on  percussion.  The  impulse  on  coughing  in  her- 
nia is  quite  different  from  the  very  slight  downward  movement  of  the 
enlarged  cord  in  hydrocele.  In  hernia  the  cord  can  always  be  traced  in 
normal  size  from  the  testis  to  the  ring.  Scarpa  called  attention  to  the 
resemblance  of  this  form  of  hydrocele  to  an  irreducible  epiplocele,  and  to 
the  necessity  of  caution  in  operating. 

The  treatment  consists  in  making  small  punctures  at  the  most  dependent 
part  of  the  tumor,  and  in  subsequently  maintaining  pressure.  Large  incis- 
ions are  unnecessary. 

Encysted  hydrocele  of  the  cord  occurs  most  commonly  in  infants.  It 
forms  slowly  and  without  pain,  and  may  reach  the  size  of  an  egg  before 
being  seen  by  the  surgeon.  It  is  distinctly  circumscribed,  round  or  oval, 
translucent,  firmly  attached  to  the  spermatic  cord,  movable  upon  firm 
traction,  and  not  involving  the  overlying  skin.  It  is  firm  in  consistence 
and  but  slightly  fluctuating. 

There  is  seldom  more  than  one  tumor,  but  we  sometimes  find  a  series 
of  tumors  extending  from  the  testis  to  the  external  abdominal  ring. 
When  occurring  in  infancy  the  lesion  may  result  from  imprisonment  of  a 
congenital  hydrocele  ;  in  adults,  however,  it  originates  in  the  same  manner 
as  do  the  hydroceles  of  the  epididymis.  The  cyst-wall  is  usually  thin  and 
fibrous,  but  in  chronic  cases  it  becomes  very  thick  and  tough.  The  fluid 
contents  of  the  cyst  are  colorless,  like  water,  or  viscid  and  mucoid,  and 
sometimes  spermatozoa  are  found. 

These  cysts  may  be  seated  at  any  part  of  the  cord ;  those  of  the  epi- 
didymis are  sometimes  Avrongly  considered  cysts  of  the  cord.  When  the 
latter  are  seated  near  the  external  abdominal  ring  the  diagnosis  may  be 


HYDROCELE  AND  HEMATOCELE.  479 

very  difficult,  otherwise  it  is  generally  easy.  The  character  and  situation 
of  the  tumor  and  its  mobility  with  the  cord  and  testis  are  usually  distinc- 
tive. The  danger  of  mistaking  hernia  for  encysted  hydrocele  may  be 
avoided  by  observing  the  uniform  size  of  the  latter,  its  circumscribed  con- 
dition, its  translucency,  and  the  absence  of  impulse  on  coughing  and  of  the 
gurgling  characteristic  of  rupture. 

In  children  this  aifection  usually  disappears  spontaneously.  The  process 
of  absorption  may  be  hastened,  if  desirable,  by  counter-irritation  Avith 
tincture  of  iodine.  Withdrawal  of  the  fluid  and  subsequent  pressure 
sometimes  produce  a  perfect  cure.  Acupuncture  has  been  found  of 
service,  while  incisions  and  the  seton  are  liable  to  cause  excessive  inflam- 
mation. In  very  obstinate  cases  injection  of  the  tincture  of  iodine  or 
carbolic  acid  may  be  resorted  to. 

Haematocele. 

The  term  hsematocele  is  applied  to  swellings  of  the  testis  or  of  the  cord, 
caused  by  effusion  of  blood.  Curling's  division  of  its  varieties  is  the 
best. 

HEMATOCELE  OF  THE  TESTIS. — Hsematoccle  of  the  testis  may  be 
either  vaginal,  in  which  the  effusion  takes  place  into  the  tunica  vaginalis, 
or  encysted,  when  blood  is  effused  into  cysts  of  the  testis.  Either  of  these 
forms  may  have  been  pi-eceded  by  hydrocele.  Although  some  authors 
have  doubted  the  occurrence  of  vaginal  hsematocele  independent  of  other 
disease  of  the  parts,  others  are  convinced  that  it  does  take  place  as  the 
result  of  puncture,  blows,  or  any  injury.  Under  such  conditions  it  may 
be  called  traumatic  haematocele  in  distinction  from  the  spontaneous  form, 
which  occurs  in  cases  of  blood-dyscrasia  and  vascular  degeneration  inducing 
rupture  of  the  vessels. 

Traumatic  hsematocele  is  usually  developed  very  rapidly;  the  testis 
becomes  enlarged,  hard,  and  painful,  and  the  scrotum  may  be  oedematous 
or  the  seat  of  blood-effusion.  There  are  usually  more  or  less  constitu- 
tional disturbance  and  pain  from  the  tension  of  the  parts.  The  effused 
blood  often  acts  as  a  foreign  body,  causing  suppurative  inflammation. 
Again,  the  blood  may  coagulate  as  it  does  in  aneurysm.  Thus  the  course 
of  the  affection  is  sometimes  severe,  and,  on  the  contrary,  when  the  effusion 
is  moderate  very  little  trouble  is  experienced. 

The  development  of  spontaneous  hsematocele  is  slow  and  unattended 
with  severe  symptoms. 

The  shape  of  the  tumor  in  vaginal  hsematocele  is  similar  to  that  of 
vaginal  hydrocele,  while  that  of  encysted  hsematocele  varies,  the  testicle 
in  the  latter  being  found  below  the  tumor.  Translucency  is  not  found  in 
any  form  of  hsematocele. 

The  diagnosis  of  traumatic  hsematocele  is  generally  clear,  the  history 
of  the  case  and  the  local  condition  indicating  its  nature.  The  spontaneous 
variety  is  often  mistaken  for  a  solid  tumor,  and  frequently  the  diagnosis 
can  be  reached  only  by  making  an  exploratory  puncture. 

Treatment. — The  patient  must  be  placed  upon  his  back,  the  scrotum 
thoroughly  washed,  elevated,  and  bathed  with  cooling  lotions.  Free  pur- 
gation is  often  beneficial,  and  anodynes  may  be  required  to  relieve  the 
pain.     In  mild  cases  improvement  begins  in  a  few  days,  and  but  little 


480  MISCELLANEOUS  AFFECTIONS. 

suiFering  is  experienced.  In  many  cases  the  effusion  continues,  and  the 
tension  must  finally  be  relieved  by  puncture.  The  contents  of  the  cavity 
should  be  completely  drawn  off  and  the  scrotum  be  well  suspended. 
Should  the  cavity  become  refilled,  the  operation  must  be  repeated.  In 
some  cases  after  entire  cessation  of  the  inflammation  iodine  may  be  injected 
as  in  hydrocele.  When  the  clots  are  very  firm,  it  may  be  necessary  to 
make  a  free  incision  and  thoroughly  cleanse  the  cavity  of  the  sac, 
antiseptic  precautions  being  observed  in  the  operation  and  in  the  sub- 
sequent treatment.     (See  operations  for  hydrocele.) 

HEMATOCELE  OF  THE  CoRD. — Hsematoccle  of  the  cord  is  very  rare, 
and  may  occur  in  a  diffused  or  in  an  ejieysted  form.  Our  knowledge 
of  this  lesion  is  largely  due  to  the  observations  of  Mr.  Pott. 

Diffused  hfematocele  occurs  quite  suddenly  from  rupture  of  a  spermatic 
vein  during  violent  exertion,  as  in  lifting  a  heavy  weight,  or  in  conse- 
quence of  a  blow  on  the  parts  or  during  the  act  of  copulation  (Maunder). 
The  swelling  is  usually  cylindrical,  extending  from  the  upper  part  of  the 
scrotum  to  the  external  ring,  and  may  attain  very  large  proportions.  The 
parts  lying  over  the  tumor  are  unaffected  unless  the  lesion  is  a  result  of 
contusion. 

The  symptoms  are  sometimes  slight  and  sometimes  severe.  On  palpa- 
tion the  tumor  is  found  to  be  firm,  but  doughy,  with  ill-defined  outlines. 
The  course  of  diffused  hsematocele  of  the  cord  is,  under  favorable  circum- 
stances, toward  gradual  subsidence  ;  in  some  instances  severe  inflamma- 
tory action  is  set  up.  Ultimately  the  cord  is  left  in  a  normal  condition  or 
perhaps  a  little  thickened. 

The  diagnosis  of  this  affection  usually  offers  no  difiiculty.  The  his- 
tory, position,  and  general  features  of  the  swelling  are  unmistakable.  An 
important  point  is  the  absence  of  impulse  on  coughing. 

Encysted  hsematocele  of  the  cord  is  very  rare,  and  is  due  to  effusion 
of  blood  into  a  cyst  in  consequence  of  injury. 

Treatment. — The  first  indications  are  to  prevent  inflammation  by  the 
use  of  the  ordinary  methods.  Subsequently  puncture  followed  by  pres- 
sure will  effect  a  cure. 


PART  II. 
THE  CHANCROID  OR  SOFT  CHANCRE. 


CHAPTER  XLIIL 

NATURE    OF   THE    CHANCROID. 

Such  is  the  general  acceptance  of  the  term  "chancroid"  or  "soft 
chancre  "  in  this  country,  in  contradistinction  to  the  hard  chancre  or 
initial  lesion  of  syphilis,  that  it  is  well  to  retain  it.  It  is  also  known 
as  the  simple  and  the  non-infecting  chancre,  the  local  contagious  ulcer 
of  the  genitals,  chancre  mulct,  chancre  mou,  ulcus  molle,  as  chancrelle 
by  Biday  and  his  followers,  and  as  chancre  by  the  Germans. 

While  matter  enough  to  make  volumes  has  been  written  upon  chan- 
croid in  the  past,  to-day  clear  and  intelligible  ideas  may  be  given  in 
sentences  where  pages  were  formerly  required.  There  is  no  more  strik- 
ing illustration  in  medicine  than  is  offered  in  the  history  of  chancroid 
of  diffuseness  and  uncertainty  of  statement  when  the  disease  was 
largely  the  subject  of  speculation  and  theory,  and  of  terseness  and 
lucidity  when  simple,  plain  facts  regarding  it,  unbiassed  and  unobscured 
by  theory,  are  given.  To-day  the  history  of  chancroid  may  be  amply 
given  in  a  modest  pamphlet,  while  years  ago  a  portly  volume  was 
necessary. 

Within  the  past  fifteen  years  more  particularly,  and  dating  back  as 
far  as  twenty-five  years,  observations  and  experiments  by  various  au- 
thorities have  been  made  with  a  view  of  determining  the  nature  of  the 
chancroid.  Slowly  and  surely  have  facts  accumulated,  so  that  to-day 
among  progressive  syphilographers  the  view  that  the  chancroidal  ulcer 
is  due  to  a  distinct  virus  is  generally  given  up.  (See  the  Introductory 
chapter.) 

Next  to  Bassereau's  era  of  light,  that  which  was  inaugurated  in 
1876,  in  which  Dr.  Bumstead  ^  and  myself  claimed  (I  state  the  fact  with 
all  modesty)  that  there  was  then  sufficient  proof  that  the  chancroid  is 
not  due  to  a  distinct  poison  or  virus,  and  that  it  may  be  developed 
under  certain  circumstances  de  novo,  is  in  my  judgment  the  most  im- 
portant in  the  history  of  syphilography.  From  that  eventful  day  in 
which,  at  the  International  Medical  Congress,  Dr.  Bumstead's  paper 
was  read  with  my  corroborative  results,  reached  independently  of  him, 
and  when  no  other  person  assented  to  the  view,  which  by  all  present 
was  regarded  as  false  and  almost  sacrilegious,  the  more  enlightened 
view  of  the  nature  of  the  chancroid  has  gradually  gained  ground.     We 

'  "The  Virus  of  Venereal  Sores,  its  unity  or  duality,"  Transactions  of  the  International 
Medical  Congress  (1876),  Philadelphia,  1877,  pp.  708  et  seq. 

31  481 


482  THE  CHANCROID   OR  SOFT  CHANCRE. 

felt  that  a  false  doctrine  like  the  following,  which  is  presented  by  an 
American  author,  should,  if  possible,  be  demolished:  "  Chancroid  is  an 
affection  perpetuated  only  by  contagion  ;  sexual  intercourse  is  not  essen- 
tial. Whenever  upon  the  human  body  a  chancroid  is  found,  there  has 
been  deposited  pus  from  another  chancroid  under  conditions  favorable 
to  its  absorption.  No  amount  of  sexual  excess,  no  degree  of  unclean- 
liness,  no  irritation,  traumatic  or  chemical,  however  prolonged,  no  sim- 
ple or  poisonous  ulceration  from  other  specific  sources  (syphilis,  cancer, 
glanders,  etc.), — nothing,  in  short,  can  produce  chancroids  except  chan- 
croid (chancroidal  bubo  included).  So  that,  as  Fournier  puts  it,  if  all 
patients  in  the  world  with  chancroid  would  avoid  contact  with  others 
until  their  malady  got  well,  the  disease  would  cease  from  off  the  face  of 
the  earth."  The  fallacy  of  these  sweeping  assertions  has  already  been 
brought  out  in  the  Introduction. 

The  chancroid  is  a  local  contagious  ulcer  of  the  genitals,  inflamma- 
tory in  its  nature  and  very  destructive  in  its  course.  It  never  under 
any  circumstances  leads  to  syphilis  nor  any  form  of  systemic  infection. 
Its  action  is  purely  local  to  the  parts  upon  which  it  develops  and  to  the 
lymphatic  vessels  and  ganglia  in  immediate  anatomical  association  with 
those  parts.  Under  certain  circumstances  chancroid  becomes  serpiginous, 
creeping  from  its  original  focus  and  attacking  and  destroying  parts  be- 
yond, or,  beginning  in  a  chancroid  bubo,  it  runs  a  chronic,  deeply  de- 
structive course  over  the  pudenda,  thighs,  and  abdominal  walls,  and  in 
very  severe  cases  ends  in  death.  Like  gonorrhoea,  chancroid  is  in  very 
many  cases,  particularly  among  the  lower,  ignorant,  and  uncleanly  classes, 
an  essentially  venereal  disease,  having  its  origin  in  sexual  contact  and 
its  lesions  being  sharply  limited  to  the  genitalia.  The  vehicle  of  con- 
tagion of  the  chancroid  in  clinical  practice  is  the  secretion  of  a  chan- 
croid, of  chancroidal  lymphangitis,  of  a  chancroidal  bubo,  or  of  a  ser- 
piginous chancroidal  ulcer.  Besides  these  secretions,  inflammatory  pus 
and  pus  resulting  from  active  irritation  of  syphilitic  lesions  are  also 
capable  of  producing  chancroidal  ulcers  de  novo,  the  person  from  whom 
the  contagion  is  derived  being  perhaps  free  from  actual  chancroids  at 
the  time. 

IiK)culation-experiments  have  shown  that  the  contagious  property  of 
chancroidal  pus  is  contained  in  the  corpuscles,  since  its  filtered  serum 
has  been  found  to  produce  no  reaction  upon  the  tissues.  Upon  this  fact 
the  hypothesis  has  been  based  that  chancroid  remains  a  local  disease, 
for  the  reason  that  its  pus-cells  are  confined  to  the  nearest  lymphatic 
ganglia  and  do  not  enter  the  circulation.  This  may  be  taken  as  a  fair 
specimen  of  the  indiscriminate  generalizations  which  have  been  indulged 
in  regarding  these  ulcers. 

A  marked  peculiarity  of  the  chancroid  is  its  amenability  to  repro- 
duction upon  its  bearer.  This  may  be  demonstrated  by  experimental 
inoculations  by  means  of  minute  superficial  incisions  or  abrasions,  and 
is  very  commonly  seen  in  auto-inoculations,  particularly  in  women. 
Our  knowledge  of  the  inoculative  power  of  the  chancroid,  and  of  the 
varying  vulnerability  of  the  skin  thereto,  largely  depends  upon  the  ex- 
perience of  those  who  years  ago  practised  syphilization  for  the  cure  of 
syphilis,  using  therefor  chancroidal  pus  and  pus  derived  from  irritated 
syphilitic  lesions.     It  was  proved  that  these  forms   of  pus   produced 


NATURE  OF  THE  CHANCROID.  483 

ulcers  having  all  the  characteristics  of  chancroids  in  a  long  series,  but 
that  in  time  their  power  seemed  to  wane,  since  only  aborted  pustules 
were  produced.  The  natural  inference  from  the  facts  as  observed  was 
that  auto-inoculations  with  chancroidal  pus  gradually  decreased  in  ac- 
tivity with  the  increased  repetition  of  the  process. 

This  decrease  in  the  activity  of  the  ulcerations  on  the  skin  is  essen- 
tially due  to  the  waning  power  and  final  decadence  of  the  pus-microbes. 
In  mucous  membranes,  however,  the  succulence  and  vascularity  of  the 
tissues  seem  to  stimulate  the  vitality  of  the  micro-organisms,  and  in 
these  structures  they  luxuriate  for  longer  periods.  As  a  rule,  tissues 
chronically  affected  by  chancroidal  ulceration  become  more  and  more 
immune  to  its  action,  and  are  less  and  less  affected  by  the  destructive 
process. 

After  a  period  of  quiescence  tissues  which  had  failed  to  respond  to 
the  irritant  action  again  became  susceptible  to  the  influence  of  chan- 
crous  pus.  The  practical  application  of  this  fact  is  that  a  man  or 
woman  may  have  an  indefinite  number  of  chancroids  during  life. 

Various  statements  have  been  made  as  to  the  durability  of  chancroidal 
pus  when  transferred  from  the  body.  Thus,  Ricord  says  that  he  kept 
it  in  sealed  tubes  for  seventeen  days,  and  then  found  it  active,  and 
Sperino  claims  that  by  means  of  a  lancet  upon  which  this  secretion  had 
dried  seven  months  later  he  produced  chancroids.  The  late  Prof.  Boeck 
of  Christiania,  whose  experience  in  chancroidal  inoculations  was  greater 
than  that  of  any  man  before  or  since  his  day,  assured  me  that  chan- 
croidal pus  lost  its  irritant  qualities  in  a  few  days  after  drying ;  and  I 
personally  saw  my  late  colleague,  Dr.  Bumstead,  fail  at  Charity  Hos- 
pital to  make  successful  inoculations  with  chancroidal  pus  which  had 
been  dried  on  glass  slips  for  twenty-four  hours.  These  facts  would  seem 
to  indicate  that  the  micro-organisms  of  chancroid  only  have  a  feeble 
vitality  when  removed  from  the  human  body. 

When  greatly  diluted  in  water  this  form  of  pus  loses  its  power, 
which  is  probably  destroyed  in  any  menstruum  in  which  its  corpuscles 
become  disintegrated. 

According  to  general  testimony,  chancroidal  ulcers  may  be  trans- 
mitted by  inoculation  to  the  lower  animals.  This  fact,  first  evolved 
during  the  period  of  obscurity  of  the  chancroid,  and  made  much  of  by 
the  dualists  in  their  arguments,  is  pertinent  in  emphasizing  the  point 
of  difference  between  it  and  syphilis,  which  is  not  communicable  to 
animals,  but,  in  the  present  status  of  this  question,  it  is  no  longer  essen- 
tial or  of  any  practical  value. 

Modes  of  Contagion. — Chancroidal  contagion  takes  place  most  com- 
monly, in  the  lower  classes,  by  actual  contact,  the  pus  being  transferred 
from  one  person  to  another  in  the  act  of  coitus  or  in  some  other  intimate 
mode  of  direct  transfer.  This  method  is  called  "direct  contagion." 
What  is  known  as  "mediate  contagion,"  in  which  the  secretion  is  trans- 
ferred by  means  of  the  fingers,  by  towels,  utensils,  and  instruments,, 
may  also  occur,   but  much  less  frequently. 

It  is  probable  that  chancroidal  inoculation  in  sexual  intercourse  in 
many  instances  takes  place  by  means  of  more  or  less  well-marked  ero- 
sions, abrasions,  tears,  and  rents  in  the  mucous  membrane,  and  even  on 
the  surface  of  herpetic  vesicles.     It  is  also  fair  to   assume  that  the 


484  THE  CHANCROID   OE  SOFT  CHANCRE. 

balano-preputial  mucous  membrane,  vith  its  delicate  epithelium  and  its 
rich  and  very  superficial  capillary  system,  especially  as  it  is  subject  to 
the  heat,  moisture,  and  maceration  incident  to  the  nature  and  structure 
of  the  parts,  may  be  eroded  by  the  irritating  pus  and  become  the  seat 
of  chancroids.  Clinical  observation  certainly  warrants  the  view  that 
this  secretion  may  lodge  in  the  ducts  of  the  sebaceous  follicles  of  the 
integument  of  the  penis,  and  there  produce  ulceration.  The  impunity 
with  which  surgeons  whose  fingers  are  intact  handle  chancroids  and 
their  sequelse  proves  that  the  epidermis  of  the  skin  is  to  an  extent  im- 
pervious to  the  action  of  its  pus.  It  is  important  to  remember,  how- 
ever, that  we  frequently  see  on  uncleanly  patients  chancroidal  pus 
escape  from  the  genitals  and  remain  a  more  or  less  long  time  upon  the 
integument,  and  there  produce  typical  ulcers  in  the  hair-follicles.  In 
this  case  also  it  is  fair  to  assume  that  contagion  has  taken  place  through 
the  irritant  action  of  the  pus  in  the  follicular  openings.  It  is  also  cer- 
tain that  prolonged  lodgement  of  chancroidal  pus  upon  the  fingers,  par- 
ticularly in  the  region  of  the  sulcus  of  the  nail,  may  be  followed  by 
ulceration. 

While  in  syphilis  mediate  contagion  is  very  common,  in  chancroid  it 
is  quite  rare.  Instances  in  which  patients  have  developed  chancroids 
by  means  of  their  fingers  or  nails  to  other  portions  of  the  body  through 
scratching  or  other  modes  of  transference  have  occurred  in  my  experi- 
ence as  well  as  in  that  of  others.  I  have  also  seen  chancroidal  contagion 
result  from  the  carelessness  of  a  surgeon  in  the  operation  of  circum- 
cision, and  a  simple  bubo  converted  into  one  of  the  chancroidal  variety 
by  the  surgeon  operating  upon  it  without  having  cleaned  his  bistoury 
with  which  he  had  just  incised  a  chancroidal  bubo. 

Chancroidal  pus  smeared  upon  a  water-closet  seat  may  possibly  be 
transferred  to  the  genitalia  or  perigenital  region  of  another,  though  I 
have  never  seen  or  heard  of  such  an  accident. 

Occasionally  we  see  men  suffering  from  chancroid  who  have  cohabited 
with  women  upon  whose  genitals  no  ulceration  can  be  discovered ;  and 
the  explanation  of  the  case  formerly  very  generally  accepted  was  that  in 
the  vagina  chancroidal  pus  had  been  deposited  by  one  man  and  taken  up 
in  coitus  by  a  second  one,  who  became  contaminated,  while  the  woman 
thus  freed  from  the  pus  escaped.  The  case  related  by  Ricord  in  which 
during  a  husband's  short  absence  his  friend,  suffering  from  chancroids, 
had  connection  with  his  wife,  who  shortly  after  cohabited  with  her  hus- 
band, who  contracted  chancroids,  while  she  escaped,  is  so  full  in  detail  as 
to  be  convincing.  As  confirmatory  of  this  coincidence  the  case  of  Puche 
is  interesting.  A  man  on  his  wedding-day  had  coitus  with  a  woman  suf- 
fering from  chancroid,  and  later  on  with  his  wife.  Having  neglected 
washing  his  long  foreskin  after  the  impure  coitus,  the  chancroidal  pus  was 
transferred  to  his  wife's  genitals,  and  she  contracted  chancroids,  while  he 
escaped.  Further,  the  possibility  that  the  vagina  may  thus  be  the  means 
of  mediate  contagion,  the  woman  escaping,  has  been  very  clearly  proved 
by  the  experiments  of  Cullerier  and  Tarnowsky.  These  observers  depos- 
ited chancroidal  pus  in  the  vaginas  of  several  women  and  allowed  it  to 
remain  there  for  a  period  of  less  than  an  hour  before  it  was  washed  away. 
None  of  these  Avomen  contracted  chancroids.  They  made  inoculations  on 
the  integument  with  this  pus  in  order  to  determine  its  activity,  and  were 


NATURE  OF  THE  CHANCROID.  485 

successful.  The  practical  inference  from  the  fact  is  that  the  epithelial 
lining  of  the  vagina,  being  quite  thick  and  horny,  is  resistant  to  the 
action  of  chancroidal  pus,  and  that  if  removed  within  a  few  hours,  either 
by  the  friction  of  coitus  or  by  irrigation,  contagion  will  not  take  place. 

Frequency. — The  collated  experience  of  those  who  see  large  numbers 
of  cases  of  venereal  diseases  goes  to  prove  that  the  frequency  of  occur- 
rence of  chancroid  is  largely  dependent  upon  the  class  of  cases  observed. 
Years  ago  I  examined  at  short  intervals  large  numbers  of  pwg/?«  j^wiZfc^e 
in  our  down-town  wards,  and  among  them  found  many  cases  of  chancroid, 
while  in  a  more  select  grade  of  the  profession  up  town,  where  I  also  had 
opportunities  of  examination,  I  found  a  large  proportion  of  hard  chancres 
and  few  chancroids.  In  like  manner,  at  Charity  Hospital  I  have  seen 
more  chancroids  than  hard  chancres,  while  in  private  practice  the  reverse 
obtains.  This  experience  is  in  direct  accord  with  that  of  Fournier,  who 
says  "that  the  simple  chancre,  which  is  common  in  the  lower  classes, 
becomes  rarer  and  rarer  relatively  to  the  syphilitic  chancre  in  proportion 
as  we  rise  in  the  social  scale."  Fournier  explains  this  condition  by 
assuming  that  men  of  the  lower  classes  mostly  cohabit  with  old  prosti- 
tutes long  ago  syphilitic,  and  then  only  subject  to  chancroid,  while  among 
the  upper  classes  younger  women,  who  are  just  acquiring  or  have  just 
acquired  their  experience  in  syphilis,  are  the  ones  in  demand. 

When  we  come  to  consider  farther  on  the  orio;in  of  the  chancroid,  we 
shall  find  that  it  is  derived,  not  only  from  actual  lesions,  but  also  from 
inflammatory  pus  in  syphilitic  and  non-syphilitic  subjects;  and  it  will  be 
shown  that  the  matter  of  cleanliness  plays  a  most  important  part  in  its 
propagation. 

Mauriac  ^  has  shown  that  in  Paris  durinor  the  reign  of  the  Commune 
the  ratio  of  chancroids  was  much  increased,  and  that  in  the  years  succeed- 
ing the  Franco-Prussian  War  it  was  much  diminished.  The  logical  ex- 
planation of  this  is  that  during  the  unbridled  license  of  the  Commune 
vice  and  uncleanliness  went  hand  in  hand,  but  later  on,  when  law  and 
order  prevailed,  a  more  moral  and  sanitary  status  existed.  Thus,  during 
the  past  twenty  years  I  have  seen  in  dispensary  and  in  hospital  practice 
what  we  may  term  little  epidemics  of  chancroid  follow  the  influx  of 
foreign  immigrants,  particularly  Italians  and  Hungarians. 

In  the  light  of  our  present  knowledge  it  may  be  positively  afiirmed 
that  chancroid  is  not  caused  by  a  distinct  specific  virus,  as  was  formerly 
so  truculently  claimed. 

The  basis  of  our  knowledge  of  the  nature  of  the  chancroidal  ulcer  has 
already  been  fully  detailed  in  the  Introductory  chapter.  It  is  there 
shown  that  it  does  not  have  a  special  specific  virus,  and  that  the  ulcer 
may  be  readily  generated  de  novo  at  the  will  of  the  experimenter  from 
various  and  the  most  varied  sources.  Observation  and  investigation  have 
shown  that  while  the  chancroid  may  be — and  very  commonly  is — derived 
from  a  previous  chancroid,  a  chancroidal  bubo,  or  chancroidal  lymphangi- 
tis, it  may  also  originate  in  the  pus  derived  from  irritated  lesions  of 
syphilis  and  from  irritated  simple  lesions  in  syphilitic  subjects,  and  also 
in  simple  pus,  particularly  when  originating  in  active  or  intensely  irritated 
lesions. 

^  Rarele  aduelle  du  Chancre  simple,  Paris,  1876. 


486  THE  CHANCROID   OB  SOFT  CHANCRE. 


CHAPTER    XLIV. 

ETIOLOGY  OF  THE  CHANCROID  AS  OBSERVED   IN  CLINICAL 

PRACTICE. 

In  the  older  works  the  origin  of  chancroid  is  always  associated  with 
•sexual  contact,  and  nothing  is  said  of  the  development  of  the  disease  de 
■novo.  The  truth  is,  that  clinical  observers  were  held  in  thraldom  by  the 
doctrine  of  the  absolute  specificity  of  the  chancroid,  and  they  undoubtedly 
failed  to  rightly  interpret  cases  in  which  men  presented  true  chancroids, 
yet  who  had  not  been  infected  in  the  sexual  act. 

In  very  many  cases,  undoubtedly,  chancroids  are  derived  during  sexual 
intercourse,  one  party  being  affected  with  this  active  form  of  ulceration. 
This  form  of  transmission  of  the  disease  is  well  and  generally  known.  It 
is  transmission  by  direct  descent.  But  it  must  be  clearly  understood  that 
chancroids  may  be  found  on  the  penis  of  a  man,  and  that  examination  of 
the  woman  with  whom  he  cohabited  may  show  her  to  be  free  from  these 
lesions.  In  other  words,  it  is  not  safe  to  say  to  a  man  suffering  from 
chancroids  that  the  woman  with  whom  he  cohabited  undoubtedly  had 
chancroids.  This  point  is  strikingly  brought  out  by  the  case  of  a  young 
man  free  from  all  disease  who,  after  prolonged  embraces,  with  much  alco- 
holic stimulation,  with  his  mistress,  was  attacked  by  several  preputial 
chancroids.  The  woman,  otherwise  healthy,  had  just  recovered  from 
peritonitis,  and  had  an  ulcerated  fissure  of  the  os  uteri,  which  gave  forth 
much  pus.  In  this  case  a  discharge  that  had  previously  come  from  a 
subacute  form  of  inflammation  was,  in  consequence  of  the  peritonitis  and 
excess,  transformed  into  a  more  active  form  of  pus.  Every  source  of 
■error  in  this  case  was  carefully  eliminated. 

This  and  many  similar  cases  have  convinced  me  beyond  all  doubt  that 
many  cases  of  chancroid  are  developed  through  non-syphilitic  women  in 
whom,  owing  to  various  causes,  an  exacerbation  has  taken  place  in  some 
lesion  of  the  genitals  that  previously  was  innocuous,  and  which  then  gave 
forth  an  active  form  of  pus.  It  folloAVS,  therefore,  that  we  should  be 
guarded  in  the  cases  of  suspected  wives  and  mistresses  as  to  what  we  say 
to  husbands  or  lovers  that  are  unlucky  enough  to  become  affected  with 
ulcers  of  the  genitals  in  intercourse  with  the  former.  Otherwise  much 
harm  may  be  done  and  innocent  women  may  be  cruelly  wronged. 

It  is  far  from  uncommon  to  observe  chancroids  in  a  man  contracted  in 
intercourse  with  a  syphilitic  woman  who  has  no  specific  lesion  of  the 
genitals,  but  who  suffers  from  a  purulent  vaginal  secretion.  In  these 
cases  the  simple  inflammation  of  the  syphilitic  woman  gives  issue  to  pus 
rich  in  pyogenic  microbes.  This,  again,  is  an  illustration  of  the  state- 
ment that  men  may  gain  chancroids  from  women  whose  genitals  are  free 
from  these  lesions.  I  have  many  times,  by  means  of  confrontations,  con- 
clusively convinced  myself  of  this  mode  of  origin  of  chancroids. 

Then,  again,  I  have  seen  many  instances,  in  the  lower  class  of 
patients,  in  which  men  have  cohabited  with  impunity  Avith  women  the 
victims  of  an  old  and  extinct  syphilis,  but  who  suffered  from  chronic 


ETIOLOGY  OF  THE  CHANCROID.  487 

chancroids.  In  these  cases  the  ulcers  had  become  old  and  inactive,  and 
they  had  ceased  to  secrete  a  dangerous  pus. 

Now,  then,  I  come  to  a  portion  of  this  subject  concerning  which  there 
is  a  widespread  want  of  knowledge  in  the  minds  of  medical  men. 

Chancroid  being  classed  as  a  venereal  disease,  the  physician  instinct- 
ively thinks  that  a  given  ulcer  that  is  presented  to  him  must  of  necessity 
have  originated  in  sexual  contact.  In  many  cases  this  supposition  is  not 
correct,  for  chancroids  may,  as  we  have  seen,  originate  in  some  subjects 
de  novo.  In  other  words,  it  is  not  very  uncommon  to  see  chancroids  in 
men  who  have  had  no  sexual  exposure  whatever,  such  lesions  being  perhaps 
due  to  some  inherent  peculiarities  of  their  tissues,  to  some  diathetic  con- 
dition or  to  debility,  or  to  some  contamination  with  particles  of  dirt  that 
have  lodged  upon  their  genital  organ.  This  mode  of  origin  of  the  chan- 
croid has  been  conclusively  demonstrated  to  me  by  very  many  cases  in 
which  herpetic  lesions  became  transformed  into  actively  destructive  chan- 
croids. Such  cases  are  far  from  rare,  and  if  the  practitioner  will  care- 
fully interrogate  the  patients  that  come  to  him  suffering  from  chancroids, 
he  will  in  many  instances  find  that  there  has  been  no  exposure  vrithin  the 
time  required  for  the  development  of  these  lesions,  and  he  will  convince 
himself  beyond  all  doubt  that  the  ulcerative  lesions  are  due  to  some 
unknown  source  of  contamination  of  herpetic  vesicles,  of  chafes,  abrasions, 
or  fissures.  I  have  among  my  notes  many  cases  illustrating  the  origin 
of  chancroid  in  all  of  these  lesions  and  traumatisms.  The  chancroid  in 
these  cases  is  simply  an  evidence  of  wound-infection,  and  is  really  a  septic 
ulcer. 

Many  years  ago,  when  the  doctrine  prevailed  that  a  man  or  woman 
having  upon  his  or  her  genitals  or  elsewhere  a  chancroid  must  of  neces- 
sity have  contracted  that  ulcer  from  some  other  person  afl9iicted  with 
chancroid,  a  gentleman,  aged  twenty-nine,  came  to  me  whose  case  and 
history  much  puzzled  me.  He  had  had  gonorrhoea  several  times,  but  had 
never  been  infected  with  syphilis.  He  was  fat  and  plethoric,  and  claimed 
that  he  had  never  been  sick  for  a  day  in  his  life  (sulfering  from  clap  ex- 
cepted). He  showed  on  the  inner  side  of  the  prepuce  a  lesion  one-third 
of  an  inch  in  diameter  that  without  hesitation  I  pronounced  to  be  a  chan- 
croid. The  soft,  yellowish,  worm-eaten  surface  and  base,  the  undermined 
edges,  the  peculiar  secretion,  and  the  halo  of  inflammatory  redness  pro- 
duced a  picture  so  characteristic  and  typical  that  my  assertion  was  em- 
phatic. But  the  gentleman  insisted  that  he  had  not  had  any  intercourse 
for  a  month,  and  that  he  had  been  informed  that  chancroids  appeared 
within  a  very  few  days  after  coitus.  My  reply  was  that  he  had  a  chan- 
croid, and  that  in  some  unexplained  manner  he  had  been  contaminated 
with  chancroidal  pus.  He  claimed  that  this  was  impossible,  and  said  that 
under  similar  circumstances  he  had  had  precisely  similar  ulcers,  which, 
by  a  number  of  eminent  surgeons  and  syphilographers  in  some  of  the 
largest  cities  of  America  and  Europe  had  in  each  instance  been  unqual- 
ifiedly pronounced  to  be  chancroids.  For  a  number  of  years  this  man 
came  to  me  with  these  ulcers.  In  some  instances  they  appeared  so  soon 
after  coitus  that  chancroidal  infection  seemed  probable  as  a  cause,  while 
in  others  no  sexual  intercourse  had  been  indulged  in  for  several  weeks 
prior  to  their  appearance.  Repeated  careful  questioning  convinced  me 
that  this  gentleman  was  the  victim  of  persistently  recurring  herpes  pro- 


488  THE  CHANCROID   OR  SOFT  CHANCRE. 

genitalis,  and  for  a  long  time  it  was  a  mystery  to  me  why  in  some  in- 
stances the  vesicles  dried  and  their  surfaces  healed  promptly,  and  in 
others  they  became  transformed  into  unhealthy  ulcers  that  could  not  be 
distinguished  from  classical  chancroids. 

Whether  in  this  case  there  was  a  tissue-peculiarity  I  am  unable  to  say. 
The  patient  was  seemingly  in  robust  health,  yet  it  seemed  to  be  his  lot  to 
suffer  (as  I  know  now)  from  the  ravages  of  pyogenic  microbes  which,  in 
some  unexplained  manner,  so  persistently  attacked  his  excoriated  vesicles. 

The  following  case  is  even  more  remarkable  and  worthy  of  study :  A 
gentleman,  thirty  years  old,  thin  and  rather  pale,  but  who  had  never  had 
any  serious  sickness,  has  suffered  from  herpes  progenitalis  three  or  four 
times  a  year  for  about  ten  years.  He  had  severe  attacks  of  gonorrhoea 
in  his  twenty-fourth  and  twenty-sixth  years.  He  had  never  had  syphilis. 
He  came  under  my  observation  in  1886,  having  a  deep  sloughing  ulcer  in 
the  left  groin  and  a  similar  ulcer  on  the  thigh  just  below  the  groin.  These 
lesions  were  the  sequelae  of  two  virulent  buboes.  On  the  anterior  surface 
of  the  corresponding  thigh  were  three  little  ulcers,  in  all  respects  like 
chancroids,  and  several  hair-follicles  were  the  seat  of  a  deep  hypergemia. 
According  to  the  patient's  statement,  the  lesions  upon  the  thigh  were 
caused  by  the  matter  that  had  escaped  from  the  buboes,  he  in  travelling 
being  unable  to  dress  his  ulcers  or  keep  himself  clean.  As  the  case  is 
thus  far  reported  it  would  pass  for  a  well-marked  illustration  of  virulent 
buboes,  complicated  by  the  chancroidal  ulcers  of  the  thigh,  which  were 
produced  by  accidental  auto-inoculation. 

Let  us  now  consider  the  history  of  the  case.  The  patient  was  a  very 
intelligent  and  scrupulously  clean  man,  who,  by  reading  and  from  con- 
versation with  medical  men,  had  gained  a  good  general  idea  of  chancre 
and  its  consequences,  and  of  chancroid  and  its  sequelae.  His  account 
of  his  case  was  as  follows :  He  had,  as  stated,  for  a  number  of  years  been 
much  troubled  with  herpes  progenitalis,  which  appeared  before  he  had 
suffered  from  gonorrhoea.  Each  attack  came  on  Avith  smarting,  burning 
pain.  In  some  instances  the  vesicles  were  seated  on  the  skin  of  the  penis, 
in  others  on  the  inner  surface  of  the  prepuce,  and  in  others,  again,  near 
the  frgenum  and  the  meatus  urinarius.  In  the  early  attacks  the  vesicles, 
under  simple  treatment,  healed  in  about  a  week.  As  years  went  on  he 
observed  that  sometimes  the  vesicles  assumed  an  unhealthy  appearance, 
became  much  ulcerated,  and  were  very  rebellious  to  careful  treatment. 
Being  observant  as  to  the  results  of  coitus,  he  convinced  himself  that  his 
attacks  of  herpes  were  never  the  effects  of  that  act,  and  that  in  none  of 
his  sexual  contacts  had  he  been  the  victim  of  infection.  The  facts  con- 
cerning what  took  place  prior  to  this  development  of  the  virulent  buboes 
already  spoken  of  are  these :  The  patient  had  not  had  sexual  intercourse 
for  three  months,  and  was  suddenly  attacked  with  a  crop  of  herpetic  vesi- 
cles seated  in  the  left  fossa  of  the  frsenum,  which  rapidly  developed  into  a 
large  ulcer,  which  a  surgeon  pronounced  to  be  a  chancroid,  and  which  he 
maintained  could  only  have  been  contracted  in  coitus.  This  ulcer  gave 
rise  to  the  virulent  process  in  the  groin  and  thigh  which  eventuated  in 
the  buboes  and  the  chancroids. 

Here,  then,  was  a  case  in  which  an  undoubted  history  of  herpes  pre- 
putialis  was  given,  in  which  infection  in  sexual  intercourse  was  entirely 
out  of  the  question,  but  in  which  the  vesicles,  from  some  unknown  cause, 


ETIOLOGY  OF  THE  CHANCROID.  489 

became  transformed  into  an  ulcer  typically  chancroidal  in  appearance, 
which  was  followed  by  suppurating  buboes. 

In  1890  this  gentleman  came  to  me  again  under  the  following  circum- 
stances :  Three  weeks  previously,  not  having  had  coitus  in  four  months, 
he  had  again  been  attacked  with  perputial  herpes  near  the  right  of  the 
frpenum.  Being  deeply  engrossed  in  business,  he  contented  himself  with 
washing  the  parts  and  applying  a  mild  lotion  on  cotton.  The  vesicles 
developed  into  a  typical  chancroidal  ulcer,  and  the  ganglia  in  the  right 
groin  became  swollen  and  painful  and  went  on  to  suppuration. 

It  may  be  that  this  gentleman's  tissues  afforded  an  especially  good 
culture-ground  for  pyogenic  microbes,  for  his  lesions  were  certainly  very 
active  and  destructive,  considering  that  he  did  not  suffer  from  syphilis. 

It  is  very  important  to  understand  the  relation  of  an  active  syphilitic 
infection  to  excoriations,  chafes,  abrasions,  and  fissures  about  the  genitals, 
male  and  female.  In  the  first  and  second  years  of  syphilis  more  espe- 
cially, and  in  some  instances  at  later  periods,  we  find  that  in  many  cases 
the  simple  lesions  just  enumerated  become  transformed  into  ulcers  having 
every  feature  and  characteristic  peculiar  to  chancroids.  Cases  presenting 
these  features  are  frequently  very  puzzling,  and  it  is  important  that  their 
nature  should  be  clearly  understood. 

The  citation  of  a  case  is  therefore  warrantable :  A  gentleman,  aged 
twenty-eight,  had  been  syphilitic  less  than  a  year,  and,  though  commenced 
rather  late,  specific  treatment  was  doing  well  for  him.  He  presented  four 
typical  chancroids  on  the  inner  aspect  of  the  prepuce,  which  appeared 
twelve  days  after  intercourse  with  a  woman  who,  under  examination,  was 
found  to  have  a  simple  leucorrhoea.  The  gentleman  had  for  years,  at 
irregular  intervals,  suffered  from  herpes  progenitalis,  which  had  always 
healed  promptly  under  simple  treatment.  He  Avas  therefore  much 
impressed  with  the  fact  that  in  two  such  attacks  which  occurred  since 
his  infection  with  syphilis  the  excoriations  had  developed  into  unhealthy- 
looking  and  destructive  ulcers,  which  were  difficult  to  cure. 

In  this  case  we  find  a  condition  very  frequently  observed  in  syphilitics. 
Simple  inflammatory  lesions  of  the  genitals  become  converted  into  typical 
chancroids — or,  as  we  may  say,  wound-infections  or  septic  ulcers — undoubt- 
edly as  the  result  of  contamination  with  pyogenic  microbes,  the  source  of 
which  is  a  mystery.  Lesions  thus  produced  often  display  great  virulence 
in  consequence  of  the  activity  of  the  local  infective  process  (staphylococ- 
cus and  streptococcus  infection),  which  seems  to  reach  its  acme  in  syphilitic 
tissues,  particularly  when  the  infection  is  not  very  old.  Pus  taken  from 
these  chancroids  in  syphilitic  subjects  will,  as  a  rule,  be  seen  to  possess 
great  potentiality  in  the  extent  and  persistence  of  the  ulcers  and  in  the 
power  that  it  possesses  of  producing  by  inoculation  similar  lesions  for 
many  generations. 

In  some  of  these  cases  of  chancroid  that  develop  de  novo  in  syphilitic 
subjects  contamination  of  the  inguinal  ganglia  takes  place  by  direct 
lymphatic  absorption.  As  a  result  Ave  have  two  forms  of  bubo — the 
irritative,  which  may  be  aborted ;  and  the  inflammatory,  which  leads  to 
abscess.  It  is  very  probable  that  in  the  tissues  of  syphilitic  subjects  the 
pyogenic  microbes  find  a  most  favorable  nidus.  The  inflammatory  process 
to  Avhich  they  give  rise  is  often  very  active,  and  the  resulting  pus,  rich  in 
microbes  and  their  poisons  or  tissue-products,  is  very  virulent  and  destruc- 


490  THE  CHANCROID   OB  SOFT  CHANCRE. 

tive.  Observation  during  a  long  period  of  years  has  convinced  me  that 
chancroids  derived  from  syphilitic  pus  (the  diathesis  being  quite  active) 
are  commonly  more  destructive  than  their  congeners  that  are  caused  by 
the  various  forms  of  simple  pus. 

It  is  well  to  emphasize  the  fact  that  in  old  syphilitics,  male  and  female, 
in  whom  the  diathesis  has  seemingly  run  itself  out,  lesions  of  continuity 
about  the  genitals  are  liable  to  assume  the  features  and  characteristics  of 
chancroids.  A  recollection  of  this  fact  will  often  render  an  obscure  case 
clear. 

It  now  only  remains  to  speak  briefly  of  the  influence  of  syphilis  in 
producing  chancroids  in  women.  The  tissues  of  the  genitals  of  syphilitic 
women,  like  those  of  men  similarly  afilicted,  are  liable  to  the  development 
of  chancroidal  ulcers  de  novo  upon  all  forms  of  lesion  of  continuity,  such 
as  herpetic  vesicles,  abrasions,  chafes,  etc.  In  proportion  as  the  disease  is 
active  and  the  general  nutrition  is  lowered  these  ulcers  will  be  found  to 
be  more  active  and  destructive — in  short,  more  typically  chancroidal.  I 
will  briefly  report  two  cases  as  illustrative  of  this  statement : 

1.  A  young  woman  of  flabby  build,  syphilitic  a  year,  in  consequence 
of  vulvar  pruritus  following  menstruation  scratched  the  surface  of  the 
right  protruding  nympha  until  it  was  raw.  She  had  absolutely  refrained 
from  coitus  for  a  month,  and  had  not  been  near  any  one  suffering  from 
chancroids.  Ten  days  after  this  paroxysm  of  scratching  I  saw  her  with 
a  large  typical  chancroid  upon  the  wounded  nympha,  and  a  bubo  that, 
Avhen  opened  a  week  later,  presented  every  evidence  of  destructive  action. 

2.  A  young  woman,  fifteen  months  syphilitic,  treated  irregularly, 
noticed  a  group  of  herpetic  vesicles  to  the  right  of  the  clitoris.  She  had 
had  similar  lesions  in  years  gone  by.  She  had  not  indulged  in  sexual 
intercourse  for  several  months.  This  group  of  vesicles  promptly  became 
transformed  info  a  typical  chancroid  as  large  as  a  ten-cent  piece.  Very 
shortly  pain  in  the  right  groin  pointed  to  ganglionic  contamination,  and 
later  on  I  opened  a  typical  bubo. 

In  the  light  of  what  has  already  been  said  in  the  Introduction  as  to  the 
development  of  chancroids  in  syphilitic  subjects  I  need  make  no  further 
comment  on  these  cases,  for  they  are  simply  illustrations  of  wound-infec- 
tion. They  speak  for  themselves,  and  I  can  vouch  for  the  correctness  of 
the  facts.  Any  physician  who  sees  many  cases  of  venereal  disease  will 
certainly  call  to  mind  similar  ones,  some  of  which  may  have  been  obscure 
to  him. 

In  old  prostitutes,  the  subjects  of  ancient  and  perhaps  extinct  syphilis, 
we  find  chronic  chancroids  that  linger  in  an  indolent  and  aphlegmasic 
condition  for  years  and  years,  frequently  giving  their  bearers  very  little 
concern,  but  presenting  great  rebelliousness  to  treatment.  They  are  relics 
of  active  ulceration,  and  it  is  probable  that  the  microbes  which  have 
caused  them  have  become  weak  and  attenuated,  and  hence  are  powerless 
for  active  invasion. 

In  this  clinical  summary  I  have  endeavored  to  present  a  general  out- 
line of  the  mode  and  peculiarities  of  development  of  chancroids  appearing 
after  sexual  contact,  and  de  novo  without  sexual  contact,  and  also  by  acci- 
dental pus-contamination.  The  subject  has  occupied  my  mind  for  many 
years,  and  I  believe  that  it  is  here  presented  in  an  accurate  manner.  I 
think  that  I  have  adduced  evidence  v/hich  proves  beyond  controversy  that 


BACTERIOLOGY  OF  THE  CHANCROID.  491 

the  assertions  that  a  chancroid  is  always  of  necessity  the  result  of  chan- 
croidal pus,  and  that  if  all  the  patients  in  the  world  suffering  with 
chancroid  would  avoid  contact  with  others  until  their  malady  got  well 
the  disease  would  cease  from  off  the  face  of  the  earth,  are  utterly  false, 
and  not  at  all  in  keeping  with  the  present  condition  of  our  know- 
ledge. 

To  sum  up :  What  we  call  chancroid  is  the  product  of  many  varieties 
of  pus  derived  from  non-syphilitic  and  syphilitic  subjects.  It  is  therefore 
a  hybrid,  heterogeneous  lesion,  in  all  cases  a  septic  ulcer,  and  in  many 
instances  simply  an  active  form  of  wound-infection.  This  septic  ulcer  in 
some  cases  originates  de  novo  from  the  contact  of  pyogenic  microbes  with  a 
raw  surface,  herpetic  or  eczematous  excoriation,  a  chafe,  etc.,  sexual  contact 
then  having  nothing  to  do  with  its  development.  As  a  general  rule,  this 
local  infective  process  is  more  active  in  syphilitic  than  in  non-syphilitic 
subjects.  It  follows,  therefore,  that  so  long  as  pyogenic  microbes  and 
tissue-predisposition  exist  chancroids  will  be  found  upon  the  mucous 
membranes  and  integument  of  the  human  race. 


CHAPTEK    XLV. 
BACTERIOLOGY  OF  THE  CHANCROID. 

Within  the  past  ten  years  several  observers  have  endeavored  to  prove 
that  in  the  chancroidal  pus  and  in  mucous  membranes  the  seat  of  chan- 
croidal ulcerations  they  have  found  a  specific  micro-organism. 

Ferrari,^  Mannino,^  and  De  Luca  ^  each  described  a  micro-organism 
which  they  thought  was  the  virus  animatum  of  chancroid,  but  their 
descriptions  and  observations  were  faulty  and  lacking  in  many  essen- 
tial particulars,  so  they  failed  to  carry  conviction  to  the  medical 
mind. 

The  essay  which  has  carried  the  most  weight  in  this  question  is  that 
of  Ducrey,^  who  has  constantly  found  a  microbe  in  chancroidal  pus.  This 
observer  failed  in  his  efforts  to  cultivate  this  microbe,  but  he  noticed  that 
in  a  series  of  inoculations  on  the  human  subject  many  microbes  gradually 
disappeared,  but  this  particular  one  remained  constant  and  abundant  in 
the  pus  and  retained  its  virulent  action.  Consequently,  he  claims  that 
this  is  the  pathogenic  agent  in  soft  chancre. 

These  observations  and  conclusions  of  Ducrey  have  been  confirmed  by 

'  "La  Pathologia  dell'  Adenite  ulcerosa,"  Gazz.  degli  Oupitali,  June,  1885. 

^  "  Nouvelles  Recherches  sur  la  Pathogenie  du  Bubou  qui  accompagne  le  Chancre 
mou,"  Annales  de  Derm,  et  de  Syph.,  1885,  pp.  486  et  seq. 

^  "II  Micrococco  del  I'TJlcer'a  molle,"  Gazz.  degli  OspUcdi,  1886,  pp.  38  et  seq. 

*  "  R^cherches  experimentales  sur  la  Nature  intime  du  Principe  contagieux  du  Chan- 
cre mou,"  Comptes  Rendus  du  Congris  Internal,  de  Derm,  el  de  Syph.,  Paris,  1889,  pp.  229 
€t  seq. 


492 


THE  CHANCROID   OB  SOFT  CHANCRE. 


Krefting,^  Unna,^  Quinquaud  and  Nicolle,^  Audry/  Petersen,^  Nicolle,^ 
and  by  Dubreuilh  and  LasnetJ  The  latter  authors  claim  that  they  have 
confirmed  the  results  of  Ducrey's  series  of  inoculations  and  of  Unna's 
methods  of  staining  the  specimens,  and  have  assured  themselves  of  the 
identity  of  the  bacilli  described  by  these  investigators. 

The  streptobacillus  of  soft  chancre  was  found  in  the  pus  first  by 
Ducrey,  and  later  in  the  tissues  by  Unna.  It  is  a  rod-like  bacillus  of 
variable  size  and  with  rounded  ends.  The  dimensions  vary  from  1.5  to 
2  /i  in  length  and  from  0.3  to  1  //  in  breadth.  This  micro-organism 
is  found  singly,  but  it  shows  a  tendency  to  form  chains  and  to  become 
agglomerated  in  masses.  In  the  pus  it  occurs  singly,  but  more  frequently 
in  chains.     In  the  tissues  it  is  found  almost  entirely  in  chain-form.     It 

Fig.  185. 


Section  of  a  chancroid,  showing  the  streptobacillus  of  Ducrey-IInna  in  the  tissues.  The  chains 
are  composed  of  minute  rods  arranged  linearly,  mostly  in  two  or  three  parallel  rows,  and  they 
give  off  branches  in  their  course.  Single  rows  of  the  bacilli  are  also  found.  They  lie  between 
ithe  cells,  not  in  them,  and  are  situated  especially  in  the  superficial  layers  of  the  tissues, 
beeper  down  in  the  section  they  are  not  seen.s 

has  been  found  in  all  soft  chancres  examined  by  Unna,  but  has  not  as 
yet  been  cultivated.  It  stains  with  carbolic-fuchsin,  and  with  gentian 
violet,  anilin-water  solution,  and  is  decolorized  by  Gram's  method — a  cha- 
racteristic by  which  it  may  be  difi"erentiated  from  other  organisms  occur- 
ring in  chancroidal  pus. 

In  a  recent  communication'  Ducrey  made  the   bold  statement  that 

^  "Ueber  die  fiir  Ulcus  molle  specifische  Mikrobe,"  Arch,  fur  Derm,  und  Syph.,  1892, 
Erganzungsheft  2,  pp.  41  et  seq. 

^  "Der  Streptobacillus  des  Weichen  Schankers,"  Monatscheft  fiir  Prakt.  Dermal.,  vol. 
xiv.,  1892,  pp.  485  et  seq. 

*  "  Sur  le  Microbe  du  Chancre  mou,"  Bull,  de  la  Socieie  frauQ.  de  Derm,  et  de  Syph., 

1892,  pp.  343  et  seq. 

*  "  Eact^riologie  clinique  du  Chancre  simple,  etc.,"  Gaz.  hebdom.  de  Med.,  1893,  2d 
Series,  vol.  xl.  pp.  101  et  seq. 

^  "  Ueber  Bacillenbefunde  beim  Ulcus  molle,"   Centralhl.  fiir  Bakter.  und  Parasitenk., 

1893,  vol.  xiii.  pp.  743  et  seq. 

^  "  ^echerches  sur  le  Chancre  mou,"  Tlihe  de  Paris,"  1893. 

^  "  Etude  bact^riologique  sur  le  Chancre  mou,  etc.,"  Arch.  din.  de  Bordeaux,  Oct.  and 
Nov.,  1893. 

^  This  drawing  was  kindly  made  for  me  by  Dr.  George  T.  Elliot  from  a  section  made 
and  stained  by  Dr.  Unna. 

^  "  Congres  Internat.  de  Mddecine  de  Kome,"  A7inales  de  Derm,  et  de  Syph.,  1895,  p.  50. 


CLINICAL  HISTORY  OF  THE  CHANCROID.  493 

the  soft  chancre  is  a  pathological  entity,  and  that  its  specific  micro- 
organism is  the  one  already  described.  To  this  Finger^  replied  that 
if  this  Ducrey-Unna  bacillus  is  the  morbific  agent  of  soft  chancre,  it  is 
nothing  more  than  a  pyogenic  microbe  which  produces,  like  the  staphy- 
lococcus, a  circumscribed  and  intense  suppuration. 

These  observers,  who  devote  so  much  time  to  the  microscopic  study  of 
the  soft  chancre,  are  silent  about  its  multifarious  origin.  Chancroid  bears 
the  same  relation  to  mucous  membranes  that  impetigo  and  ecthyma  do  to 
the  general  integument.  Knowing  as  we  do  that  chancroid  may  arise  from 
so  many  diiferent  pyogenic  processes,  that  it  can  be  readily  produced  at 
pleasure  by  any  one  who  will  take  the  trouble  to  make  the  necessary 
experiments  and  inoculations,  that  it  frequently  arises  de  novo  when  the 
genital  parts  are  subjected  to  irritation,  dirt,  and  uncleanliness, — it  is 
utterly  absurd  to  call  it  a  specific  process  and  due  to  a  special  specific 
cause.  If  this  streptobacillus  is  a  pus-producing  agent,  it  may  be  that 
it  follows  in  the  wake  of  the  well-known  pyogenic  microbes,  after  the 
manner  of  mixed  infections.  It  must  be  distinctly  borne  in  mind  that 
when  chancroidal  pus  is  examined  with  high  powers  and  oil-immersion  by 
means  of  the  microscope,  it  is  invariably  found  to  contain  staphylococci, 
streptococci,  indifferent  cocci,  and  bacilli.  The  science  of  bacteriology  is 
not  yet  far  enough  advanced,  nor  are  its  results  sufficiently  accurate  and 
extensive  in  a  diagnostic  point  of  view,  to  warrant  the  statements  which 
have  been  made  concerning  this  streptobacillus. 


CHAPTER    XLVI. 

CLINICAL  HISTORY  OF  THE  CHANCROID. 

Appearances  of  the  Chancroid. — Chancroidal  ulcers  have  no  period 
of  incubation,  since  the  destructive  action  of  the  pus  or  of  the  pyogenic 
microbes  begins  at  once,  and  the  resulting  lesion  is  apparent  as  soon  as 
the  morbid  action  penetrates  beneath  the  epithelium.  Thus,  when  this 
layer  is  thick  the  appearance  of  the  chancroid  may  be  delayed,  and  very 
often  some  time  elapses  during  Avhich  the  pus  is  entering  a  follicle.  Con- 
stitutional conditions  in  many  cases  influence  the  rapidity  of  development. 
Chancroids  on  mucous  surfaces  develop  much  more  quickly  than  upon  the 
integument.  Abrasions,  excoriations,  and  fissures  in  the  mucous  mem- 
brane aitord  favorable  doors  of  entry,  and  upon  them  chancroids  develop 
with  great  promptness.  As  a  rule,  inflammatory  action  is  very  apparent 
within  twenty-four  hours  after  the  implantation  of  the  pus  on  mucous 
membranes,  and  within  forty-eight  hours  in  general  the  pustular  nature 
of  the  lesion  can  be  readily  made  out.  In  other  cases  the  progress  may 
be  slower,  and  three  or  four  days  may  elapse  before  the  chancroid  pustule 

^  "  Congres  Intemat.  de  Mddecine  de  Eome,"  Annates  de  Derm,  et  de  Syph.,  1895,  p.  50. 


494  THE  CHANCROID   OB  SOFT  CHANCRE. 

is  fully  formed.  These  statements  are  based  on  the  results  of  experi- 
mental inoculation,  and  are  in  the  main  correct.  The  statements  of 
patients  sometimes  place  the  appearance  of  chancroids  after  connection  at 
much  longer  intervals,  but  they  are  so  liable  to  errors  of  observation,  and 
often  are  so  careless  of  their  persons,  that  very  little  credit  can  be  placed 
in  them.  The  surgeon  very  often  can  form  a  more  correct  idea  from  the 
size  and  number  of  the  lesions  than  he  can  from  the  patient's  story. 

By  the  aid  of  experimental  inoculations  and  of  clinical  observation 
we  are  able  to  give  a  very  clear  description  of  the  early  appearances 
and  course  of  the  chancroid.  In  its  course  there  are  three  stages,  the 
active,  the  stationary,  and  the  reparative. 

Upon  mucous  membranes  the  very  first  sign  of  a  chancroid  is  a 
minute  yellow  spot  surrounded  by  a  halo  of  intense  redness,  which 
shades  off  into  the  surrounding  pink  color.  If  not  ruptured,  the  yellow 
central  spot  grows  larger  and  higher,  and  very  soon  a  typical  conical- 
shaped  pustule  is  formed.  Upon  the  integument  the  same  yellow  spot 
and  red  halo  are  present,  and  the  pustular  condition  may  be  present  or 
may  be  replaced  by  an  ulceration. 

In  most  cases  on  mucous  membranes  chancroids  very  early  lose  their 
epithelial  dome,  which  constitutes  the  pustule,  and  the  typical  ulcer  is 
then  seen. 

The  outline  of  a  chancroid  is  usually  either  round  or  oval,  according 
to  the  conformation  of  the  parts  upon  which  it  is  seated ;  but  when  de- 
veloped upon  a  fissure  or  abrasion  it  may  be  linear  or  irregular.  Irreg- 
ularity of  outline  also  results  from  the  coalescence  of  a  number  of 
chancroids.  '  On  the  prepuce  and  in  the  sulcus  they  are  circular ;  about 
the  frsenum  they  frequently  are  oval ;  when  developed  partly  on  the 
glans  and  partly  on  the  prepuce  they  are  irregular,  for  the  reason  that 
the  ulcerative  process  is  more  active  on  the  former  than  on  the  latter. 
Chancroids  at  the  orifice  of  the  prepuce  and  at  the  anus  have  a  tendency 
to  follow  the  radiating  fissures  peculiar  to  these  parts.  A  comprehensive 
idea  of  the  clinical  feature  of  chancroids  may  be  gained  by  a  survey  of 
Plate  II. 

Fig.  1  shows  incipient  chancroids  on  the  inner  lamella  of  the  pre- 
puce, while  in  Fig.  2  a  well-developed  chancroid  of  the  integument  is 
portrayed. 

Whatever  the  shape  of  the  chancroid,  the  edges  are  sharply  cut  and 
abrupt,  as  if  punched  out.  The  whole  thickness  of  the  epithelium  is 
destroyed,  and  it  can  be  seen  that  though  cleanly  cut,  as  is  the  resulting 
lesion,  the  edges  of  it  are  slightly  undermined  in  some  cases  to  such  an 
extent  that  the  tip  of  a  probe  can  be  carried  circumferentially  around 
the  ulcer  and  under  it.  This  feature  of  undermined  edge  is  due  to  the 
fact  that  the  soft  subepithelial  tissues  are  less  resistant  than  the  more 
horny  epithelium.  In  addition  to  the  undermined  condition,  the  edges 
are  frequently  minutely  uneven  or  jagged,  as  best  seen  by  a  magnifying- 
glass,  showing  that  the  destructive  action  takes  place  by  minute  radiating 
processes.  Around  the  edge  of  the  chancroid  is  an  areola  of  redness 
which  varies  in  depth  and  width  according  to  the  stage  of  the  inflamma- 
tion. This  red  halo  extends  pari  passu  with  the  ulcer.  The  floor  of 
the  latter  is  peculiarly  uneven  and  worm-eaten  in  appearance,  and  in 
its  early  stage  covered  with  a  light  yellowish  pellicle  composed  of  dis- 


PLATE 


..,^«*#^'' 


Chancroids. 


CLINICAL  HISTORY  OF  THE  CHANCROID.  495 

organized  tissues  and  pus.  With  the  growth  of  the  ulcer  this  film  be- 
comes thicker  and  forms  a  bright  or  golden-yellow  pseudo-membranous 
layer,  which  is  shown  with  admirable  fidelity  in  Figs.  1,  2,  3,  and  4  of 
Plate  II.  This  membranous  pellicle  covering  the  chancroid  is  thrown 
into  little  uneven  maramillations,  which  correspond  to  the  minute  rugosi- 
ties which  cover  the  surface  of  the  ulcer. 

The  secretion  of  chancroids  is  in  the  active  stage  quite  abundant, 
and,  while  purulent,  the  pus  difi"ers  from  that  of  gonorrhoea.  It  is 
thinner  in  quality  and  usually  of  a  brownish  or  rusty-brown  tint,  due 
to  the  admixture  of  small  quantities  of  blood.  This  chancroidal  pus 
under  the  microscope  is  found  to  consist  of  pus-globules,  red  corpuscles, 
and  the  detritus  of  tissues. 

The  underlying  bed,  as  it  may  be  called,  of  chancroids  should  always 
be  attentively  studied.  It  usually  consists  of  ordinary  inflammatory 
oedema,  and  is  felt  between  the  thumb  and  finger  as  a  mass  firm  in  con- 
sistence midway  between  ordinary  oedema  and  a  furuncle.  It  is  yield- 
ing to  firm  pressure,  though  not  doughy,  but  has  not  the  dense  consist- 
ency of  the  true  hard  chancre.  The  oedematous  infiltration  of  the 
chancroid  is  not  very  sharply  limited,  but  becomes  gradually  lost  in  the 
surrounding  tissues. 

In  the  typical  hard  chancre  the  induration,  on  the  other  hand,  is 
condensed  and  sharply  circumscribed.  This  symptom,  to  a  certain  de- 
gree important  in  the  diagnosis  of  the  chancroid,  is  often  much  obscured 
by  injudicious  cauterization,  particularly  when  the  solid  stick  of  nitrate 
of  silver  is  vigorously  used,  and  also  when  chromic  acid,  pure  sulphuric 
acid,  and  indeed  any  very  caustic  application,  is  made.  A  similar  mis- 
leading hardness  is  very  often  felt  after  active  cauterization  of  herpetic 
vesicles,  abrasions,  fissures,  and  vegetations. 

The  duration  of  the  period  of  activity  of  chancroid  is  so  variable 
that  it  is  really  indefinite.  It  is  influenced  largely  by  the  intelligence 
and  eflficiency  of  the  treatment,  the  care  and  attention  of  the  patient, 
and  by  his  general  condition  and  modes  of  life.  Alcoholic  indulgence 
is  a  prolific  cause  of  chronicity  and  activity  of  chancroidal  ulceration, 
and  plethora  tends  to  increase  it.  A  very  active  life,  much  walking, 
and  physical  exercise  likewise  tend  to  perpetuate  the  existence  of  these 
sores. 

In  general,  chancroids  exist  in  an  active  condition  from  two  to  four 
weeks,  but  they  may  be  arrested  sooner  by  treatment  or  they  may  thus 
continue  for  indefinite  periods.  The  amount  of  destruction  of  tissues 
varies  in  difi"erent  cases,  in  different  localities,  and  in  varying  conditions. 
On  the  integument  the  ulceration  is  slow,  and  there  is  not  the  marked 
tendency  to  extension  that  there  is  on  mucous  membranes.  In  some 
instances  the  ulceration  extends  quite  superficially  over  considerable 
surface.  Then,  again,  the  ulceration  grows  in  extent  by  the  fusion  of  a 
number  of  chancroids,  as  depicted  in  Fig.  6  of  Plate  II.,  in  which  it 
will  be  seen  that  a  large  portion  of  the  surface  of  the  integument  of  the 
penis  has  been  invaded.  In  Fig.  4  an  active  chancroid  is  seen  compli- 
cated by  the  development  of  another  chancroid  in  the  course  of  the 
lymphatics,  called  bubonulus — a  feature  first  described  by  Nisbet. 

The  so-called  stationary  and  chronic  period  of  chancroids  exists  in 
many  cases,  owing  to  the  apathy  and  inattention  of  the  patient ;  and 


496  THE  CHANCROID   OR  SOFT  CHANCRE. 

these  circumstances  have  proved  to  us  that  after  a  varying  time  the  in- 
tensity of  the  ulceration  in  chancroids  passes  into  a  stage  of  quiescence, 
in  which  there  is  no  marked  tendency  to  destruction,  and  on  the  other 
hand  none  to  repair.  A  chronic  chancroid,  such  as  is  shown  in  Fig. 
5  of  Plate  II.,  all  irritating  influences  being  at  a  minimum,  might  thus 
remain  for  several  Aveeks  or  months.  This  aphlegmasic  condition  may 
readily  give  place  to  exacerbation  of  the  destructive  action. 

The  stage  of  repair  of  chancroids  is  indicated  by  a  number  of  changes 
in  all  of  the  features  of  the  ulcer.  Perhaps  the  most  noticeable  one  is 
a  diminution  of  the  inflammatory  areola  and  a  subsidence  of  the  under- 
lying oedematous  infiltration.  Then  the  grayish-yellow  well-marked 
pseudo-membranous  layer  begins  to  disappear,  and  as  it  does  healthy 
pink  granulations  spring  up  over  more  or  less  of  the  surface  and  the 
unhealthy  pus  begins  to  become  laudable.  The  undermined  edges  lose 
their  deep  redness  and  gradually  disappear,  and  the  ulcer  becomes 
saucer-shaped.  Coincidently  with  this,  healthy  granulations  make  their 
Avay  over  the  whole  surface  and  push  upward,  gradually  becoming  even 
with  the  parts  around.  Then,  a  delicate  filamentous  ring  of  epithelium 
begins  at  the  site  of  the  undermined  edge,  and  gradually  increases  in 
width,  at  the  same  time  closing  over  the  site  of  former  ulceration,  until, 
in  the  end,  full  cicatrization  is  accomplished.  In  cases  where  the  sores 
have  been  quite  large  points  of  cicatrization  spring  up  in  the  centre, 
enlarge,  fuse  together,  and  meet  the  circumferential  healing  ring.  These 
minute  surface-spots  of  healing  are  well  described  by  my  late  colleague. 
Dr.  Bumstead,  as  follows :  "  Macerated  by  the  discharge,  it  (the  spot) 
has  a  whitish  look  and  resembles  a  fragment  of  lint  which  has  not  been 
removed  at  the  last  dressing ;  but  at  subsequent  visits  of  the  patient  it  is 
found  to  be  still  present,  gradually  increasing  iri  size  until  it  becomes 
continuous  at  some  portion  of  its  periphery  with  the  margin  of  the  sore, 
and  it  thus  contributes  toward  the  final  closure  of  the  wound," 

A  remarkable  feature  of  the  chancroidal  ulcer  is  its  tendency,  even  in 
the  reparative  stage,  to  retrogress  and  assume  all  of  the  attributes  of 
activity.  In  such  cases,  however,  there  is  usually  some  Avell-defined  cause 
for  the  exacerbation,  such  as  carelessness,  and  particularly  uncleanliness, 
sexual  intercourse,  or  alcoholic  excesses.  A  sore  which  has  seemingly 
become  of  simple  nature  rapidly  takes  on  all  of  the  chancroidal  features, 
even  to  great  destructiveness.  This  possible  accident  should  always  be 
remembered  by  the  surgeon  in  holding  his  patient  well  in  hand,  even 
when  the  latter  regards  himself  as  virtually  well.  The  possibility  of  con- 
tagion in  the  advanced  reparative  stage  of  chancroid  should  always  be 
impressed  upon  the  patient.  With  thorough  cicatrization  the  chancroid 
is  annihilated  ;  without  fresh  contagion  there  is  no  relapse,  such  as  we 
often  see  in  true   chancre. 

Scars  left  by  chancroids  vary  according  to  the  size,  depth,  and  situa- 
tion of  the  ulcers,  and  are  trifling  or  severe  in  proportion  to  the  extent  of 
the  destructive  process.  They  may  be  superficial,  thin,  and  smooth,  or 
they  may  be  thick  and  deep,  uneven,  and  traversed  by  fibrous  bands  of 
various  sizes.  At  the  margin  of  the  prepuce  following  a  chancroid  they 
are  usually  hard  and  fibrous  and  produce  more  or  less  phimosis. 
When  superficial,  but  extensive,  as  when  following  a  chancroid  on  the 
glans,  they  are  thin  and  smooth.     Extensive  chancroids  of  the  balano- 


CLINICAL  HISTORY  OF  THE  CHANCROID. 


497 


preputial  furrow  are  usually  followed  by  much  destruction  and  an  uneven 
fibrous  cicatrix,  often  adherent  to  the  corpora  cavernosa.  Chancroids 
of  the  frgenum  may  result  in  a  Avell-marked  scar  and  more  or  less  deform- 
ity. Chancroids  producing  phimosis  and  paraphimosis  are  followed  by 
much  destruction  of  tissue  and  by  firm  fibrous  scars  of  varying  shapes. 
Seat  of  the  Chancroid. — In  the  male  the  chancroid  is  most  commonly 
found  in  the  sulcus  behind  the  glans ;  on  the  inner  surface  of  the  pre- 
puce ;  on  and  near  the  fourchette,  particularly  on  the  fossae  on  each  side 
of  it ;  on  the  lips  of  the  meatus  and  within  the  urethra ;  upon  the  sheath 
of  the   penis;   on  the   glans;    and,  usually  by  auto-inoculation,  on  the 

Fig.  186. 


Chancroid  of  the  labia  minora,  of  the  contiguous  integument,  and  of  the  margin  of  the  anus. 

scrotum  and  thighs,  pubes  and  anus.  They  occur  on  the  finger  by  con- 
tagion from  genital  sores,  and  upon  the  face  by  means  of  the  fingers,  and 
Avithin  the  anus  from  pederasty.  In  women  they  are  found  at  the  introi- 
tus  vaginae ;  on  the  fourchette  and  vestibule  and  on  the  clitoris ;  on  the 
labia  minora ;  within  the  vagina  (rather  rarely) ;  on  the  os  uteri ;  on  the 
labia  majora,  and  by  auto-inoculation  on  the  integument  of  the  latter 

32 


498  THE  CHANCROID    OR  SOFT  CHANCRE. 

bodies ;  upon  the  perineum,  inner  surface  of  the  thighs ;  on  the  hvpogas- 
trium,  and  around  the  margin  of,  and  within,  the  anus. 

Upon  the  external  and  integumental  surface  of  the  labia  majora  chan- 
croids often  assume  the  appearance  of  pustules  or  abscesses  in  consequence 
of  the  pus  having  inoculated  one  or  more  of  the  follicles  (follicular  chan- 
croids) ;  and  there  is  frequently  more  or  less  oedema  of  the  subcutaneous 
cellular  tissue,  as  evinced  by  the  swelling  and  hardness  of  the  labia. 
When  the  pustule  breaks  the  underlying  ulcer,  if  exposed  to  the  air, 
becomes  covered  with  a  scab  and  resembles  ecthyma.     (See  Fig.  186.) 

Chancroids  are  also  common  on  other  portions  of  the  vulva  and  on  the 
internal  surface  of  the  labia  majora,  where  they  occasion  pain  and  dif- 
ficulty in  walking.  Vulvar  ulcers  become  much  inflamed  from  the  irri- 
tation of  the  urine  and  vaginal  discharges,  which  likewise  renders  them 
difficult  to  cure.  Those  situated  at  the  meatus  often  penetrate  the  urethra 
for  some  distance,  giving  the  orifice  an  infundibuliform  shape,  or,  by 
destroying  the  posterior  wall  of  the  canal,  throw  its  opening  backward 
into  the  vagina.  When  attacked  by  phagedena  the  loss  of  tissue  may 
result  in  great  deformity  and  inconvenience. 

Varying  Features  of  Chancroidal  Ulcers. — The  most  simple  form  of 
chancroid  is  very  shallow  (see  Fig.  1,  Plate  II.) ;  the  undermining  of  the 
edges  is  very  slight,  and  the  worm-eaten  unevenness  of  the  base  very 
delicate.  This  condition  may  really  be  but  the  early  stage  of  the  ulcer, 
and  appropriate  treatment  very  soon  brings  about  the  reparative  stage. 

A  form  called  by  Clerc  the  "  exulcerous  chancroid"  is  occasionally 
seen.  The  sore  is  shallow  and  saucer-shaped,  and  the  punched-out, 
sharply-cut  edges  are  wanting.  The  floor  is  rather  smooth  and  covered 
with  a  grayish-yellow  film,  and  from  it  much  pus  escapes.  (See  ulcer  just 
behind  the  corona  in  Fig.  4.)  The  two  foregoing  varieties  are  stages  of 
development  rather  than  different  forms. 

Upon  surfaces  where  mucous  membranes  and  integument  meet,  and 
upon  the  mucous  membrane  lining  the  labia  majora,  and  on  the  skin  in 
the  region  of  the  genitals,  rounded  conical  elevations  surmounted  with  a 
minute  pustule  are  sometimes  seen.  The  pustule  increases  in  size,  and 
forms  an  ulcer  which  presents  a  crater-like  appearance,  as  sometimes  seen 
in  acne  indurata.  This  lesion  is  called  the  follicular  or  acneform  chan- 
croid, and  results  from  the  destructive  action  of  the  pus,  beginning  in  the 
hair-  or  sebaceous  follicles  and  accompanied  by  much  inflammatory  swell- 
ing. It  is  shown  in  Fig.  186  on  the  upper  part  of  the  left  labium  magus. 
(Comparison  of  the  outlines  furnished  by  this  figure  with  the  colored 
figures  will  give  a  clear  idea  of  chancroids  in  women.) 

What  is  termed  the  ecthymatous  chancroid  is  always  met  Avith  upon 
the  integument,  particularly  upon  the  penis  and.  those  parts  of  the  geni- 
tals of  both  sexes  which  are  not  macerated  with  perspiration  or  which  are 
not  in  coaptation.  This  variety  of  chancroid  resembles  in  many  of  its 
features  chancroidal  ulcers  produced  by  inoculation.  It  begins  as  a  small 
red  spot,  commonly  around  a  hair-follicle,  which  increases  rather  slowly, 
with  a  small,  more  or  less  perfectly  formed,  pustule  in  its  centre.  As  the 
redness  extends  the  pustule  flattens  down  into  a  blackish-green  crust,  and 
thus  may  attain  an  area  of  nearly  half  an  inch  before  its  nature  is  sus- 
pected by  the  patient.  Removal  of  the  crust  reveals  a  typical  chancroidal 
ulcer,  with  the  exception  that  the  sharply-punched  out  and  undermined 


CLINICAL  HISTORY  OF  THE  CHANCROID. 


499 


Fig  le: 


edges  are  thicker,  as  thej  are  composed  of  epidermis ;  the  floor  is  deeper, 
corresponding  to  the  thickness  of  the  skin,  and  the  base  more  markedly 
uneven  and  worm-eaten.  The  ulcer  is  usually  slow  in  its  course,  and 
secretes  a  moderate  amount  of  pus,  which  constantly  dries  into  a  crust. 
Upon  the  integument  of  the  penis  or  on  the  outer  surface  of  the  labia 
majora,  where  it  quite  frequently  occurs,  this  chancroid  is  sometimes 
accompanied  Avith  lymphangitis  and  adenitis.  It  is  well  shown  after  the 
removal  of  crusts  in  Fig.  186. 

In  some  cases  of  chancroids,  particularly  when  they  are  seated  upon 
the  prepuce  near  the  sulcus  glandis  and  upon  the  labia  minora,  or  on  any 
part,  in  short,  in  which,  owing  to  its  conformation,  irritation  is  apt  to  be 
severe,  the  bed,  as  we  may  call  the  underlying  tissues,  is  sometimes  the 
seat  of  more  than  usual  oedema  and  cell-infiltration.  The  result  is,  that 
the  chancroid  is  elevated  above  the  surrounding  plane,  and  it  is  then 
called  the  ulcus  elevatum.  In  like  manner,  there  is  a  syphilitic  elevated 
ulcer.  The  salience  of  the  ulcus  elevatum  is  by  some  authors  incorrectly 
said  to  be  due  to  exuberant  granulations,  whereas  inspection  will  show 
the  typical  chancroidal  surface,  with  usually  less  undermining  of  the  edges 
of  the  ulcer.  A  very  good  idea  of  the  ulcus  elevatum  may  be  obtained 
from  inspection  of  Fig.  3,  Plate  II.  (lower  and  right-hand  lesion)  and  the 
larger  oval  lesion  on  the  right  labium  minus  in  Fig.  186. 

These  ulcers,  showing  a  tendency  to  extend  rather  superficially  over 
more  or  less  surface,  are  called  sei-jng- 
inous  chancroids.  In  my  judgment, 
this  formidable  adjective  is  rather  too 
loosely  used,  particularly  by  French 
writers.  For  instance,  the  coalesced 
and  moderately  active  chancroids  de- 
picted in  Fig.  6  of  Plate  II.  might  be 
called  "serpiginous"  when  there  is 
really  no  evidence  of  very  unusual 
destruction.  The  term  should  be  ap- 
plied to  cases  which  show  progressive 
extension,  where  the  lesion  creeps  over 
much  surface.  Such  cases  perhaps 
deserve  this  designation.  In  America 
we,  for  the  most  part,  reserve  the  term 
"serpiginous  chancroid"  to  a  chronic, 
more  or  less  deeply  destructive,  ulcer 
which  usually  has  its  beginning  in  a 
chancroidal  bubo.  These  ulcers,  hap- 
pily rare,  have  a  deep,  irregular,  fun- 
gating  surface  covered  with  a  rather 
thick,  uneven,  variegated,  brownish- 
red  and  grayish-green  slough  or  mem- 
brane and  a  sanious  pus,  and  having  thick,  bluish-red,  undermined,  and 
often  everted  edges,  extend  irregularly  over  the  abdomen  and  thighs  to 
the  parts  beyond,  destrojnng  more  or  less  of  the  Avhole  thickness  of  the 
skin.  They  are  most  rebellious  to  treatment,  lasting  months,  years,  and 
a  lifetime,  and  often  they  lead  to  death  from  exhaustion  or  from  perfora- 
tion of  the  abdominal  walls  and  peritonitis.     (See  Fig.  187.) 


Serpiginous  chancroid  of  abdominal  walls. 


500  THE  CHAl^CROID   OR  SOFT  CHANCRE. 

What  is  termed  phagedenic  chancroid  is  an  example  of  the  most 
serious  complication  of  the  local  contagious  ulcer.  Phagedena  is  a 
rather  infrequent  complication  of  both  chancroid  and  hard  chancre, 
and,  in  my  experience,  occurs  more  frequently  in  the  course  of  an 
initial  lesion  than  in  that  of  the  chancroid.  For  its  production  no 
special  virus  is  required.  It  originates  in  local  causes,  such  as  neglect 
of  treatment  and  improper  treatment  of  chancroids,  or  where  they  are 
so  situated  that  it  is  difficult  to  thoroughly  irrigate  them,  as  in  chancroidal 
phimosis.  Poverty,  insufficient  food,  alcohol,  and  a  crowded  condition, 
such  as  sometimes  occurs  in  hospitals,  in  camps,  and  in  emigrant-ships,  are 
predisposing  causes  to  it.  It  is  seen  in  two  forms — the  sloughing  or  gan- 
grenous and  the  serpiginous.  In  sloughing  chancroid  the  ulcer  becomes 
swollen  and  surrounded  by  a  deep  bluish-red  areola,  and  its  floor  becomes 
a  gangrenous  slough  which  secretes  a  foul  brown  sanies.  In  this  condi- 
tion it  increases  in  area  and  in  depth. 

Serpiginous  phagedena  is  similar  in  its  appearance,  but  has  a  tendency 
to  extend  more  superficially.  These  cases  are  always  attended  by  severe 
local  pains  and  a  general  and  severe  constitutional  condition.  The  patient 
looks  anxious  and  haggard,  has  no  appetite,  emaciates  rapidly,  and  in 
unfavorable  instances  dies.  The  course  of  the  affection  is  sometimes 
rather  slow,  and  in  others  very  rapid.  In  some  cases  a  diphtheritic  mem- 
brane forms  over  the  sore,  while  the  destructive  action  goes  on  beneath. 

The  course  of  chancroidal  phagedena  presents  many  features  which 
point  to  a  further  bacterial  infection  complicating  the  chancroidal  ulcer- 
ation. 

Chaxcroidal  Lymphaxgitis. — Inflammation  of  the  lymphatics  is  a 
not  very  frequent  complication  of  the  chancroid.  It  is  sometimes  seen  as 
heat,  redness,  pain,  and  a  cord-like  condition  of  these  vessels  on  either 
side  of  the  penis,  corresponding  to  the  chancre.  This  condition  may  end 
in  inflammation  of  the  inguinal  ganglia  and  its  own  subsidence,  or  it  may 
go  on  to  the  formation  of  chancroids  along  the  sides  of  the  penis,  and  even 
at  its  root,  low  down  on  the  pubes,  as  seen  in  Fig.  4,  Plate  11.  In  some 
cases,  besides  chancroidal  ulcers  along  the  lymphatics,  there  is  a  similar 
form  of  bubo. 

Chaxcroids  of  the  Meatus. — These  chancroids  are  not  very  com- 
mon, and  when  present  involve  one  or  both  sides  of  the  orifice.  They 
may  extend  downward  and  involve  the  whole  fossa  navicularis.  I  have 
never  seen  a  true  case  of  chancroid  in  which  the  lesion  was  seated  beyond 
the  navicular  portion  of  the  urethra,  and,  although  many  cases  have  been 
reported,  there  is  a  strong  probability  that  in  some  an  error  of  diagnosis 
was  made. 

Chancroids  of  the  vagina  are  very  rare,  except  in  old  syphilitic  subjects. 

Chancroids  of  the  os  uteri  are  also  exceedingly  rare,  and  when  present 
resemble  those  seen  in  the  vulva. 

Chaxcroids  of  the  Axus  axd  Rectum. — Chancroids  of  the  anus 
and  rectum  may  occur  in  either  sex  from  unnatural  coitus,  but  are  more 
frequent  in  women,  owing  to  the  facility  with  which  these  parts  are  soiled 
with  the  secretion  of  sores  situated  upon  the  vulva.  When  seated  upon 
the  margin  of  the  anus  they  may  readily  be  mistaken  for  fissures.  They 
are  attended  by  much  pain,  especially  during  the  passage  of  the  fieces, 
which  should  always  be  rendered  liquid  before  going  to  stool  by  a  muci- 


CLINICAL  HISTORY  OF  THE  CHANCROID.  501 

laginous  injection.  It  is  sometimes  advisable  after  clearing  out  the 
bowels  to  thoroughly  cauterize  the  sore  and  to  confine  the  patient  to  bed 
and  a  low  diet,  and  administer  opiates  for  the  purpose  of  preventing  any- 
further  stools  until  cicatrization  has  taken  place. 

Chancroids  contracted  in  pederasty  (and  the  same  is  true  of  chancres)  are 
usually  found  upon  the  same  side  in  both  male  and  female — upon  the  right 
or  left  side  of  the  penis  in  the  one,  and  upon  the  corresponding  side  of  the 
rectum  in  the  other.  This,  of  course,  is  the  reverse  of  what  holds  good 
in  natural  coitus,  in  which  a  sore  upon  one  side  of  the  penis  or  vulva  is 
most  apt  to  be  inoculated  upon  the  opposite  side  of  the  other  sex. 

Chancroids  of  the  folds  of  the  anus,  even  when  cured,  may  terminate 
in  fissures  which  are  very  difficult  to  heal,  in  consequence  of  the  frequent 
passage  of  the  faeces  and  the  spasmodic  contraction  of  the  sphincter  ani. 
In  such  cases  the  only  certain  means  of  relief  is  to  be  found  in  the  for- 
cible dilatation  or  rupture  of  the  sphincter  as  employed  in  ordinary  cases 
of  fissure  of  the  anus. 

Chancroids  of  the  anus  and  rectum  not  unfrequently  escape  observa- 
tion from  the  natural  reluctance  of  patients,  especially  women,  to  have 
this  part  of  the  body  examined  ;  and,  indeed,  the  surgeon  himself  is  often 
content  with  an  inspection  of  the  external  orifice  of  the  alimentary  canal 
when  a  digital  examination  would  reveal  the  presence  of  a  chancroid  in 
the  rectum. 

Chronic  chancroids  in  Avomen  ^  are  commonly  seen  in  old  broken-down 
syphilitic  prostitutes.  The  ulcers  are  usually  found  in  the  vulva  and  may 
extend  into  the  vagina.  They  are  aphlegmatic  ulcers  seated  on  a  thick- 
ened hyperplastic  base  and  covered  with  a  dense  film  formed  of  micro- 
organisms, pus,  and  debris  of  tissues. 

Chancroids  upon  the  Integument  of  the  Penis — The  majority 
of  venereal  ulcerations  following  suspicious  connection  and  seated  upon 
the  integument  of  the  penis  are  chancres  and  not  chancroids ;  therefore 
the  surgeon  should  be  very  careful  in  his  diagnosis  of  ulcers  in  this  region. 
The  rule,  however,  is  far  from  being  invai'iable,  for  I  have  met  with  many 
cases  of  simple  chancres  situated  between  the  preputial  orifice  and  the 
root  of  the  penis,  and  even  upon  the  pubes.  Chancroids  upon  the  integu- 
ment of  the  penis  often  originate  in  a  follicle,  and  Avhen  first  noticed 
resemble  a  pustule  or  small  abscess  (follicular  chancroids).  Not  infre- 
quently they  extend  to  the  loose  cellular  tissue  and  undermine  the  skin 
around  a  small  external  opening,  through  which  the  pus  can  be  made  to 
well  up  on  pressure. 

Chancroids  of  the  Fr^num. — Chancroids  of  the  frsenum  are  espe- 
cially painful,  persistent,  and  liable  to  hemorrhage.  They  may  commence 
either  upon  the  free  margin  or  at  the  base  of  the  bridle.  In  the  former 
case  a  rent  or  fissure,  the  result  of  violence  during  coitus,  has  probably 
been  inoculated,  and  the  resultant  chancroid  gradually  eats  away  the  whole 
frffinum  and  hollows  out  a  narrow  longitudinal  groove  upon  the  under  sur- 
face of  the  glans,  giving  great  annoyance,  long  persisting,  and  resisting 
ordinary  modes  of  treatment.  Again,  they  may  proceed  from  chancroids 
in  the  neighborhood,  which  exhibit  a  remarkable  tendency  to  involve  the 

^  The  reader  is  referred  to  a  systematic  essay  on  the  subject  entitled  "  Chronic  Inflam- 
mation, Infiltration,  and  Ulceration  of  the  External  Genitals  of  Women,"  by  R.  W.  Tay- 
lor, M.  D.,  ^V.  Y.  Med.  Journal,  Jan.  4,  1890. 


502  THE  CHANCROID   OR  SOFT  CHANCRE. 

frsenum,  if  situated  near  it.  In  this  case  the  base  of  the  frsenum  is  first 
attacked,  and  often  becomes  perforated  from  side  to  side ;  this  chancroidal 
opening  gradually  enlarges,  extends  to  the  free  margin,  and,  as  in  the 
former  case,  probably  destroys  the  whole  bridle.  The  frgenum  is  copiously 
supplied  with  blood  and  exceedingly  sensitive ;  hence,  ulcers  of  this  part 
are  very  liable  to  bleed  and  give  rise  to  much  suffering.  Their  persistency 
and  destructive  tendency  are  due  to  the  frequent  rupture  of  the  longi- 
tudinal fibres  of  the  frgenum,  occasioned  by  the  constant  motion  to  which 
it  is  exposed  in  walking,  handling  the  penis  during  micturition,  in  erec- 
tions, etc.  Minute  rents  are  thus  caused  in  the  sore,  which  become  inocu- 
lated and  increased  in  depth  ;  an  ulcerative  action  goes  on  until  the  whole 
bridle  is  destroyed,  including  the  portion  buried  in  the  under  surface  of 
the  glans ;  and  hence  the  fossa  already  referred  to.  Occasionally  they 
extend  to  the  urethra  and  give  rise  to  a  urinary  fistula.  In  the  treatment 
of  these  ulcers  the  patient  should  be  directed  to  avoid  all  motion  of  the 
part  which  will  stretch  the  frsenum ;  the  glans  should  not  be  uncovered 
except  to  dress  the  sore,  and  even  then  no  further  than  is  absolutely  neces- 
sary to  insert  the  dressing. 

SuBPREPUTiAL  CHANCROIDS. — Chancroids  beneath  the  prepuce  are 
usually  multiple,  cause  much  inflammatory  oedema,  and  exhibit  a  marked 
tendency  to  extensive  ulceration.  In  proportion  as  the  prepuce  is  long 
and  tight  at  its  orifice  there  is  a  tendency  to  the  production  of  chan- 
croidal phimosis.  In  many  cases  chancroidal  ulcers  form  at  the  pre- 
putial orifices  of  the  fissures,  which  may  be  present  there  as  a  result  of 
efforts  to  retract  the  prepuce.  (For  further  particulars  see  section  on 
Chancroidal  Phimosis.) 


CHAPTER    XLVII. 

CEPHALIC  AND  EXTRAGENITAL  CHANCROIDS. 

In  the  early  days  of  the  discussions  between  the  unicists  and  dualists 
the  latter  made  what  they  considered  a  strong  point  in  claiming  that  the 
virus  of  syphilis  acted  upon  the  tissues  of  the  head,  face,  and  mouth,  and 
that  the  secretion  of  the  chancroid  was  powerless  to  penetrate  those  parts. 
This  sweeping  statement  led  to  extensive  investigation  to  ascertain  whether 
the  alleged  exemption  was  founded  on  fact.  Fournier  ^  took  a  prominent 
part  in  this  labor,  and,  from  a  diligent  search  through  medical  works  and 
inquiry  of  those  who  made  a  special  study  of  venereal  diseases,  was  able 
to  collect  150  cases  of  venereal  ulcers  upon  the  head  and  face,  all  of  which, 
however,  with  the  exception  of  5,  were  chancres.  These  five  exceptional 
cases,  in  which  the  ulcer  Avas  supposed  to  be  a  chancroid,  had  been  observed 
by  MM.  Ricord,  Venot,  Devergie,  Bassereau,  and  Diday  ;  but  Ricord  con- 
fessed that  his  case,  an  ulceration  at  the  base  of  one  of  the  superior  incisor 

^  "  Etude  sur  le  Chancre  cephalique,"  Union  medicale,  Feb.  and  March,  1858. 


CEPHALIC  AND  EXTRAGENITAL  CHANCROIDS.  503 

teetli  (figured  in  his  Iconographie,  pi.  xxi.),  was  unreliable,  and  the  other 
four  were  thought  to  be  imperfectly  reported  ;  and  thus  there  could  remain 
no  doubt  of  the  rarity  of  the  chancroid  upon  the  region  in  question. 

It  has  been  since  ascertained  that  the  chancroid  can  be  developed 
upon  the  head  and  fice  by  artificial  inoculation.  Nadau  des  Islets^  and 
Rollet "  have  inoculated  its  virus  with  success  upon  different  parts  of  the 
head  in  20  instances;  Bassereau^  and  Prof.  Huebbenet*  of  Kiefi"  upon 
the  lips  and  cheeks  in  5  ;  Robert ''  upon  the  temple,  nose,  and  lips  in  3; 
and  in  all  the  sore  so  produced  was  entirely  free  from  induration  and  was 
not  followed  by  secondary  symptoms.  Horteloup  ^  alludes  to  an  inoculation 
with  chancroidal  on  the  forehead  in  which  five  days  elapsed  before  the 
appearance  of  the  characteristic  pustule. 

Still  further,  at  least  two  instances  of  the  occurrence  of  chancroids 
upon  the  cephalic  region  have  been  met  with  in  clinical  experience,  in 
Avhich  every  precaution  appears  to  have  been  taken  to  establish  the  diag- 
nosis. The  first  is  reported  by  Fournier  himself  from  the  notes  of  M. 
Puche  of  the  Hopital  du  Midi :  the  sore  was  situated  upon  the  lower  lip, 
and  artificial  inoculation  of  its  secretion  upon  the  patient's  abdomen,  as 
well  as  an  accidental  inoculation  upon  the  patient's  thumb,  proved  suc- 
cessful ;  no  general  symptoms  showed  themselves  within  seventy-four  days 
from  the  appearance  of  the  ulcer,  during  which  period  the  patient  was 
kept  under  observation.^  In  the  second  case,  observed  by  M.  Profeta,^ 
a  serpiginous  chancroid  of  two  years'  duration  was  situated  upon  the  face, 
and  its  secretion  was  inoculated  in  five  places  by  Profeta  upon  himself, 
with  the  efi"ect  of  producing  five  chancroids,  which  have  not  been  followed 
by  any  symptoms  of  syphilis  during  eighteen  months  that  have  since 
elapsed. 

Besides  these  cases  there  are  four  others  in  literature  which  merit 
mention,  and  still  others  which  have  their  weak  points. 

Diday  ^  reported  the  case  (his  second)  of  a  young  girl  having  genital 
chancroids  and  similar  ulcers  in  the  mouth.  Rollet  concurred  in  Diday's 
diagnosis.     The  case,  however,  is  not  perfectly  satisfactory  to  me. 

Labarthe's  ^^  case  was  that  of  a  man  who  had  chancroid  and  bubo,  who 
wounded  his  loAver  lip  with  the  pin  which  held  his  dressing,  and  as  a 
result  a  chancroid  developed. 

My  own  case  '^  was  that  of  a  laborer  who  had  chancroids  on  the  penis, 
and  who  fell  and  received  a  lacerated  wound  of  the  eyebrow.  By  acci- 
dent he  smeared  this  wound  with  the  pus  from  his  chancroids,  and  a 
typical  ulcer  developed.  I  made  successful  inoculation  with  the  pus  from 
the  supraorbital  ulcer. 

^  "De  rinoculation  du  Chancre  mou  a  la  R^ion  cephalique,"  Thlse  de  Paris,  1858. 

^  Gaz.  med.  de  Lynn,  Dec,  1857. 

^  Buzenet,  "  Du  ( 'liancre  de  la  Bouche,"  Tk^se  de  Paris,  1858,  p.  41. 

*  Union  vied.,  Paris,  20  .Mai,  1858. 

*  Nouveau  traite  dea  Mai.  veneriennes,  Paris,  1861,  p.  380. 

^  "  Note  sur  la  Chancre  simple,  etc.,"  Annales  de  Derm,  et  de  Syph.,  1880,  p.  62. 
'  N.  Diet,  de  Med.  d  de  Chir.-prnt.,  Paris,  t.  vii.  p.  76. 

*  Gaz.  med.  de  Lyon,  9  Juin,  1867,  p.  275. 

'"Observation  de  Chancrelle  de  la  Bouche,"  Annales  de  Derm,  et  de  Si/ph.,  No.  2, 
1873. 

'"  Le  Chancre  simple  chez  I' Homme,  etc.,  Paris,  1873,  pp.  61  et  seq. 

'^  "A  Case  of  Cephalic  Chancroidal  Ulceration  resulting  from  Accidental  Inoculation," 
Arch,  of  Scientific  and  Practical  Medicine,  1873,  No.  5,  pp.  405  et  seq. 


504  THE  CHANCROID   OR  SOFT  CHANCRE. 

Pellizzari  ^  also  reports  the  case  of  a  man  who  accidentally  inoculated 
his  face,  producing  a  chancroid.  Inoculation  of  the  pus  of  this  acci- 
dental ulcer  was  followed  by  positive  results. 

Jeanselme^  reports  the  case  of  a  man  who  in  all  probability  inoculated 
his  chin  with  the  pus  of  a  chancroid  on  the  penis.  Inoculation-experi- 
ments of  the  pus  from  the  penis  and  chin  were  successful,  and  the  author 
further  says  that  he  found  the  pathognomonic  bacillus  of  the  soft  chancre. 

It  will  thus  be  seen  that  the  occurrence  of  the  chancroid  about  the 
head,  face,  and  mouth  is  very  exceptional,  and  that  the  old-time  conten- 
tion that  chancre  and  chancrous  lesions  of  these  parts  are  almost  always 
followed  by  syphilis  has  not  been  proved  wholly  false. 

Pospelow  ^  reports,  with  a  colored  picture,  the  case  of  a  woman  who 
had  genital  chancroids,  with  a  typical  chancroid  on  the  nipple,  in  which 
she  undoubtedly  inoculated  herself  by  transference  of  the  pus  from  the 
genitals  to  the  breast. 

Nov^-Josserand  *  reports  four  cases — two  men  and  two  women — whose 
fingers  became  infected  with  chancroidal  pus  from  ulcers  of  the  genitals. 
These  cases,  while  not  common,  are  not  so  very  rare.  I  have  seen  several 
such. 

Mauriac^  details  a  case  of  soft  chancre  of  the  little  fincrer  in  which 
there  was  a  typical  axillary  bubo. 

Cases  are  sometimes  seen  in  which  several  regions  are  synchronously 
the  seat  of  chancroids.  Thus,  Coquet  ^  reports  a  case  in  which  a  man 
had  one  typical  genital  ulcer,  several  chancroids  of  the  scrotum  and  anal 
region,  and  eight  ulcers  on  the  scalp.  The  lesions  near  the  genitals  were 
the  result  of  more  or  less  direct  inoculation,  while  those  on  the  head  were 
produced  by  scratching  and  the  transference  of  pus  by  the  fingers. 

In  a  case  reported  by  Legrain ''  a  man  with  chancroids  and  bubo  pro- 
duced on  his  legs  and  arms  near  the  axillge  several  crops  of  chancroidal 
ulcers,  about  fifty  in  number,  which  were  caused  by  scratching  with 
soiled  fingers. 

'  "  Delia  Transmissione  accidentale  della  Sifilide,"  Giom.  Ital.  delle  Mai.  ven.  e  della 
Pelle,  1882,  pp.  193  et  seq. 

^  "  Contribution  a  TEtude  du  Chancre  mou  cephalique,  etc.,  Gaz.  hebdom.  de  Med.  et. 
de  Chir.,  Dec.  9,  1893,  p.  581. 

^  "  Ulcus  molle  mammae,"  Internat.  Atlas  of  Rare  Skin  Diseases,  1889,  Part  2. 

*  Province  medicale,  July  4,  1891. 

*  Journ.  de  Med.  et  de  Chir. -prat.,  1891,  p.  580. 

^  Annales  de  la  Polidiniqve  de  Bordeaux,  May,  1893. 
''  Annales  de  Derm,  et  de  Syph.,  1892,  pp.  931  et  seq. 


DIAGNOSIS,  PROGNOSIS,  AND  TREATMENT.  505 

CHAPTER    XLVIII. 
DIAGNOSIS,  PROGNOSIS,  AND  TREATMENT. 

In  various  stages  the  chancroid  may  be  mistaken  for  herpes  progen- 
italis,  exulcerated  balanitis,  ulcerated  fissures  and  abrasions,  hard  chan- 
cres, mucous  patches,  ulcerating  syphilides,  and  epithelioma. 

When  a  number  of  herpetic  vesicles  are  grouped  on  the  genitals, with 
their  polycyclic  outline,  their  shallow  and  not  much  ulcerated  surface,  with 
the  history  of  antecedent  pains,  their  diagnosis  is  easy.  In  cases  in 
which  there  is  much  inflammation  a  doubt  may  exist,  but  while  ulcerous 
herpes  may  extend  deeper  into  the  tissues,  it  does  not,  as  a  rule,  like  chan- 
croid, extend  peripherally  by  ulceration.  Herpetic  vesicles  coalesce 
because  they  are  so  closely  grouped ;  chancroids  coalesce  by  peripheral 
extension  and  fusion  with  each  other.  A  single  herpetic  vesicle  may  be 
mistaken  for  a  chancroid,  but  observation  of  its  course  for  a  day  or  two 
will  settle  the  question  of  its  nature.  The  crucial  test  of  auto-inoculation 
of  the  secretions  will  in  the  case  of  chancroid  be  followed  by  a  similar 
lesion,  whereas  failure  would  follow  in  the  case  of  herpes  progeni talis.  It 
must  be  remembered,  however,  that  in  uncleanly  persons,  in  those  whose 
vesicles  have  been  injudiciously  cauterized,  in  persons  of  poor  fibre,  in 
plethoric  subjects,  and  those  given  to  drink  herpes  progenitalis  often 
takes  on  features  identical  with  those  of  chancroids.  Indeed,  they  may 
be  the  starting-point  of  chancroids. 

Exulcerated  balanitis  is  commonly  very  readily  recognized.  Its  lesions 
begin  in  patches  much  larger  than  chancroidal  ulcers,  usually  with  a  his- 
tory of  inattention  to  cleanliness  or  of  phimosis,  and  their  edges  are  not 
undermined,  nor  are  their  surfaces  ulcerated  or  worm-eaten,  but  rather 
smooth  and  velvety. 

Very  frequently,  patients,  particularly  men,  are  much  exercised  over 
traumatic  fissures  and  abrasions.  When  much  inflammation  is  present 
a  reserved  diagnosis  may  be  made,  but  cooling  applications  will  cure  the 
simple  lesion,  whereas  the  chancroid  will  be  only  slightly  improved. 
Water  dressings  and  time  will  make  the  diagnosis  between  a  simple 
lesion,  a  chancroid,  or  a  hard  chancre,  the  last  of  Avhich  these  seemingly 
simple  lesions  often  prove  to  be.  This  fact  cannot  be  kept  too  promi- 
nently in  mind. 

Mucous  patches  may  in  a  measure  resemble  chancroids  if  very  much 
irritated,  but  it  is  an  exceeding  rarity  to  see  them  present  and  of  the 
appearance  of  the  chancroid.  Usually  their  mode  of  development,  size, 
situation,  their  well-marked  salience,  their  configuration,  peculiar  color, 
and  their  coexistence  with  a  history  of  syphilis  or  with  syphilitic  lesions 
point  out  their  specific  nature.  It  must  be  remembered  tbat  about  the 
genitals  of  both  sexes  mucous  patches  and  condylomata  lata  are  often 
much  irritated  and  give  issue  to  an  irritant  pus  wliich  is  auto-inoculable. 

In  old  syphilitics,  both  male  and  female,  particularly  those  who  are 
cachectic  or  broken  down  by  dissipation,  ulcers  having  all  the  characters 
of  chancroids,  but  of  greater  depth,  are  not  uncommonly  seen.  They  have  a 
soft  base,  are  very  often  multiple,  particularly  in  women,  very  sluggish  in 


506  THE  CHANCROID   OR  SOFT  CHANCRE. 

their  course,  usually  unaccompanied  by  ganglionic  reaction,  but  attended 
by  a  profuse  purulent  secretion.  In  some  instances  I  have  seen  their  pus 
produce  other  similar  ulcers  by  auto-inoculation,  and  I  have  seen  several 
cases  in  which  their  secretion  produced  undoubted  chancroids  in  coitus. 
These  ulcers  in  women  are  commonly  attended  with  much  oedema  and 
cell-infiltration,  and  may  exist  months  and  years.  They  in  somewhat 
rare  cases  become  phagedenic.  In  men,  though  occasionally  very  chronic, 
they  are  less  formidable. 

It  is  scarcely  conceivable  that  chancroid  can  be  mistaken  for  epithe- 
lioma, yet  my  colleague,  Dr.  Bumstead,  saw  in  consultation  a  case  in 
which  this  accident  occurred.  When  it  is  considered  that  cancer  and 
epithelioma  do  not  begin  as  ulcers,  but  as  small  nodules  and  warty 
growths,  particularly  on  parts  the  seat  of  antecedent  chronic  irritation,  the 
diagnosis  seems  very  easy. 

Prognosis. — In  the  majority  of  cases  the  prognosis  of  chancroids  is 
good.  When  intelligent  and  efficient  treatment  is  instituted  early,  the 
aff"ection  is  soon  cured.  Carelessness  of  the  patient,  dissipated  habits, 
and  excessive  physical  exercise  render  a  prognosis  less  positive  and 
assuring. 

When  phimosis  or  paraphimosis  is  present  the  outlook  is  more  grave, 
since,  unless  the  patient  can  be  put  under  perfect  control  on  his  back,  the 
progress  of  the  case  will  be  inevitably  bad,  and  may  result  in  more  or 
less  loss  of  tissue  or  deformity  of  the  penis,  may  be  complicated  by  severe 
hemorrhage,  or  result  in  phagedena  or  gangrene.  Lymphangitis  and 
buboes  may  be  produced,  Avhich  may  lay  a  patient  up  for  a  long  time, 
besides  entailing  upon  him  much  suffering  and  misery.  In  such  cases 
the  immunity  to  systemic  infection  enjoyed  by  the  patient  is  a  source  of 
much  comfort  to  him.  Chancroids  of  the  meatus  and  urethra  under 
unfjivorable  circumstances  result  in  stricture. 

In  women  the  prognosis  of  chancroids  is  less  favorable,  even  in  mild 
cases,  than  in  men.  The  difficulties  of  properly  treating  them,  unless 
they  will  remain  in  bed  under  the  care  of  a  nurse  or  in  a  hospital,  are 
very  great.  The  conformation  of  their  parts,  the  presence  of  normal  and 
abnormal  secretions,  the  setbacks  caused  by  menstruation,  and  the  diffi- 
culty of  retaining  properly  the  dressings, — all  tend  to  prolong  the  course 
of  the  ulcers.     Further,  women  as  a  rule  are  not  docile  patients. 

Young  surgeons  are  prone  to  fear  phagedena  and  gangrene  in  the 
course  of  chancroids.  These  formidable  complications  are  usually  not  to 
be  feared  early  in  the  course  of  these  lesions.  I  have  in  private  practice 
never  seen  them  begin  in  an  uncomplicated  young  chancroid,  though  in 
armies,  jails,  and  emigrant  vessels,  and  among  the  squalid  poor  and 
drunkards,  they  often  begin  quite  early.  There  is  usually,  in  these  cases, 
a  history  of  injudicious  treatment,  particularly  in  the  way  of  improper 
cauterization,  an  absence  of  treatment,  and  inattention  on  the  part  of  the 
patient,  or  of  inaccessibility  of  the  ulcers  in  consequence  of  complications, 
such  as  phimosis  or  paraphimosis.  The  presence  of  complications  should 
always  render  the  prognosis  more  guarded,  particularly  in  persons  of  poor 
fibre  and  in  those  given  to  drink. 

Treatment. — The  most  sensible  and  efficient  prophylactic  measure  is 
thorough  cleansino;  of  the  genitals  in  every  fold  and  recess.  In  the  treat- 
ment  of  chancroid  it  is  important  to  know  what  not  to  do — namely,  not 


DIAGNOSIS,   PROGNOSIS,   AND    TREATMENT.  507 

to  give  mercury  and  treat  the  ease  as  one  of  syphilis,  which  is  the  custom 
of  many  practitioners ;  not  to  emjyloy  the  curette  as  a?i  abortive  or  cura- 
tive means  in  the  verg  early  stages  of  the  ulceration  ;  not  to  cauterize  inju- 
diciously and  iiidiscriminately  ;not  to  use  ointments  and  fatty  preparations  ; 
and  never  resort  to  excision.  Nothing  but  harm  can  follow  any  of  these 
procedures. 

Cauterization  of  chancroids  has  for  its  object  their  destruction  and 
their  transformation  into  simple  lesions.  To-day  this  treatment  is  not 
largely  followed,  owing  to  the  tendency  which  has  increased  within  the 
past  fifteen  years,  to  limit  it  to  certain  cases.  The  agents  now  mostly 
used  are  nitric  acid  and  carbolic  acid.  Carbosulphuric  paste,  Vienna 
paste,  Canquoin's  paste,  acid  nitrate  of  mercury,  chloride  of  zinc,^  and 
solutions  of  caustic  potassa  are  deservedly  passing  into  oblivion. 

It  is  of  prime  importance  that  patients  suffering  from  chancroids  should 
be  as  quiet  as  possible — that  they  should  rest  at  every  opportunity,  should 
not  attempt  severe  muscular  exercise,  nor  walk,  jump,  dance,  nor  ride  on 
horseback.  Care  should  be  taken  that  friction  and  pressure  of  the  penis 
be  avoided.  Alcoholics  should  be  uncompromisingly  interdicted,  and 
plain  digestible  food  taken. 

The  most  rigid  attention  to  cleanliness  and  to  keeping  the  parts  very 
dry  are  necessary  during  the  existence  of  chancroids. 

Destructive  cauterization  is  only  applicable  for  chancroids  in  the  early 
stage  and  before  the  ulcers  become  complicated  by  much  oedema.  Before 
using  it — in  fact,  before  making  any  application  to  chancroids — the  ulcers 
and  the  surrounding  parts  should  be  thoroughly  cleansed  with  soap  and 
water,  and  then  well  irrigated  with  a  very  warm  or  hot  solution  of  bichloride 
of  mercury  (1  :  2000).  No  chancroid  should  be  thus  treated  which  cannot 
be  thoroughly  exposed  and  afterward  carefully  dressed.  The  technique  of 
applying  the  acid — and  in  most  cases  liquid  carbolic  acid  answers  every 
purpose — is  very  simple.  The  surface  of  the  ulcer  must  be  carefully  dried, 
and  then  the  acid  thoroughly  applied  by  means  of  a  bit  of  absorbent 
cotton  wound  around  the  end  of  a  wooden  toothpick.  Care  must  be 
taken  that  the  undermined  edge  is  thoroughly  touched,  but  that  none  of 
the  liquid  escapes  on  the  surrounding  parts.  Some  authors  recommend 
that  the  application  of  carbolic  acid  shall  be  preliminary  to  that  of  nitric 
acid,  the  former  playing  the  role  of  an  analgesic.  In  the  vast  majority  of 
cases  within  the  lines  already  indicated  this  double  cauterization  is  wholly 
unnecessary.  Such  is  the  evanescent  character  of  the  pain  produced  by 
carbolic  acid,  which  is  soon  followed  by  a  sensation  of  coolness  and  numb- 
ness, that  patients  make  scarcely  any  complaint  from  its  use. 

When  the  chancroidal  film  at  the  floor  of  the  ulcer  is  rather  thick,  it 
may  be  necessary  to  use  the  stronger  caustic  nitric  acid,  which  may  be 
done  in  the  manner  just  indicated ;  but  it  is  always  well  to  first  apply  a 
10  per  cent,  solution  of  muriate  of  cocaine.  By  this  means  the  patient 
suffers  no  pain,  and  the  surgeon  may  be  more  thorough  in  his  application. 
There  is  no  necessity  for  the  use  of  a  long  glass  stopper  or  of  a  glass  rod 

^  Balzer  and  Souplet  have  recently  revived  the  use  of  chloride  of  zinc  in  the  treat- 
ment of  chancroids  {Evil,  medical,  1891,  No.  8,  p.  899).  They  use  a  paste  known  as 
Socin's  paste,  made  in  the  following  proportions :  (])hloride  of  zinc,  5  to  6  parts ;  oxide  of 
zinc  and  watei-,  of  eacli  60  parts.  This  is  essentially  Canquoin's  paste,  which  I  think  has 
not  been  used  in  America  for  years.  It  was  an  uncertain  remedy,  and  often  produced 
severe  irritation. 


508  THE  CHANCROID   OR  SOFT  CHANCRE. 

in  applying  nitric  acid,  since  it  can  be  done  much  more  perfectly  with  the 
absorbent  cotton  on  the  end  of  a  wooden  toothpick.  It  is  usually  well 
for  a  few  hours  after  these  caustic  applications  to  apply  water  dressing  or 
lead-water  on  lint. 

The  actual  cautery  and  Paquelin's  thermo-cautery  are  very  efficient 
destructive  agents,  but  their  use  is  greatly  restricted  m  consequence  of 
the  dread  inspired  in  the  mind  of  the  patient  by  them.  Though  the  parts 
may  be  thoroughly  benumbed  by  cocaine,  few  persons  can  avoid  shrinking 
when  they  see  the  incandescent  wire  or  cauterizer. 

A  word  of  warning  is  necessary  against  the  use  of  the  stick  nitrate  of 
silver,  which,  unfortunately,  is  largely  used  by  the  laity  and  many  physi- 
cians, not  only  for  chancroids,  but  also  for  simple  fissures,  erosions,  and 
herpetic  vesicles.  This  agent  irritates,  while  it  does  not  destroy  ;  it  inten- 
sifies the  patient's  sufferings,  obscures  the  nature  of  the  lesion,  rendering 
diagnosis  impossible,  and  produces  so  much  inflammatory  oedema  in  the 
lesion  and  around  it  that  it  is  frequently  mistaken  for  a  hard  chancre. 
Its  use  is  to  be  emphatically  condemned. 

In  this  connection  it  is  well  to  emphasize  the  fact  that  mercurial  oint- 
ment is  especially  baneful  to  chancroids,  particularly  in  their  active  stage, 
during  which  any  fatty  application  is  productive  only  of  mischief. 

Treatment  Subsequent  to  Cauterization. — Such  is  the  superficial  action 
of  carbolic  acid  when  delicately  applied  that  under  proper  conditions  no 
inflammatory  reaction  is  to  be  feared.  With  nitric  acid,  on  the  contrary, 
unless  temporary  water  or  lead-water  dressings  are  used,  there  is  a  danger 
of  producing  subchancroidal  and  circumferential  oedema  and  cell-infiltra- 
tion. This  is  a  complication  much  to  be  avoided,  since  it  inevitably 
retards  the  cure.  It  is  also  very  necessary  in  any  case  where  several 
chancroids — or  even  one  large  one — have  been  cauterized  that  the  patient 
should  remain  in  the  recumbent  position  from  a  half  to  a  whole  day. 

For  chancroids  upon  the  glans  and  prepuce  and  in  the  vulva  the 
interposition  of  pledgets  of  lint  or  of  absorbent  cotton  is  necessary. 
Whatever  application  is  used,  it  should  be  changed  at  short  intervals  and 
directly  destroyed,  preferably  by  fire.  Care  must  be  exercised  that  the 
parts  be  not  wounded  in  changing  dressings.  In  addition,  patients  should 
be  instructed  to  very  carefully  wash  the  parts,  using  a  little  bunch  of 
absorbent  cotton  Avith  soap  and  warm  water,  and  then  thoroughly  immerse 
them  in  a  sublimate  solution  (1  :  2000).  For  women  too  much  insistence 
upon  cleanliness  is  not  possible,  since  they,  even  the  most  cleanly  of  them, 
are  liable  to  be  derelict.  Thev  should  be  instructed  to  thoroughlv  and 
copiously  irrigate  the  vagina  several  times  daily  with  a  mild  and  hot 
alkaline  solution  (borax  or  supercarbonate  of  soda,  sss,  to  water,  5lxij), 
followed  by  a  hot  solution  of  sublimate  (1  :  5000). 

The  most  efficient  all-round  application  to  chancroids  is  iodoform,  since 
it  is  an  undoubted  promoter  of  healthy  granulations  and  a  local  sedative. 
It  should  only  be  employed  in  the  form  of  an  impalpable  powder,  either 
pure  or  in  combination  with  some  bland  and  absorbent  powder,  such  as 
subnitrate  of  bismuth,  starch,  magnesia,  boracic  acid,  or  powdered  sugar 
of  milk.  Its  odor  is  its  great  drawback,  but  even  in  private  practice  the 
expedients  of  the  patient  or  surgeon  may  be  such  that  its  use  does  not 
compromise  the  former.  Various  essential  oils  are  mixed  with  it,  but, 
after  all,  coumarin,  the  active  principle  of  Tonka  beans,  is  yet  the  best 


BIAGXOSIS,   PBOGXOSIS,  AXD   TREAT MEXT.  509 

disguise.  Powdered  roasted  coffee  also  is  good.  "When  used  in  powder 
form  the  ulcerated  surface  should  be  fully  but  not  copiously  dusted  with 
it,  and  over  it  a  thickness  of  perfumed  lint  or  absorbent  cotton  may  be 
placed.  It  may  be  employed  suspended  in  sulphuric  ether  (oSS-3;j  to  3J) 
or  in  similar  proportions  in  glycerin,  3ij,  aq.  3vj.  I  have  been  unfavor- 
ably impressed  by  its  use  when  combined  Avith  vaseline  and  other  fatty 
bases. 

It  is  important  to  remember  that  the  action  of  iodoform  is  that  of  pro- 
ducing; healthy  crranulations,  and  that  when  this  has  been  effected  its  use 
should  be  suspended,  since  upon  granulating  surfaces  it  often  acts  by  even 
impeding  healing.  Further,  from  these  surfaces  it  is  liable  to  be  absorbed 
and  produce  toxic  effects  upon  the  skin  and  system  at  large.  The  con- 
clusion, therefore,  warranted  is  that  the  use  of  iodoform  should  he  sus- 
pended ichen  chancroids  take  on  a  granulating  surface. 

It  has  been  claimed  that  iodol.  a  preparation  containing  a  large  per- 
centage of  iodine,  is  equally  as  efficient  as  iodoform,  and  has  the  advan- 
tage of  being  odorless.  Unfortunately,  our  hopes  have  not  been  realized, 
since  this  agent  is  frequently  found  wanting  in  test  cases.  When  there 
is  a  moderate  amount  of  ulceration  its  action  is  fairly  as  good  as  that  of 
many  old  remedies. 

Europhen  was  used  by  Estay  ^  in  the  Hopital  du  Midi  in  the  treatment 
of  chancroids,  and  was  found  to  be  mildly  caustic  and  to  have  healing 
qualities.  It  is  claimed  that,  as  this  drug  contains  28  per  cent,  of  iodine, 
it  is  better  than  iodoform,  and  that  it  has  no  odor. 

In  like  manner,  the  subiodide  of  bismuth  was  vaunted  as  the  substi- 
tute for  iodoform.  In  my  hands  chancroids  have  crept  on.  leaving  this 
substance  as  a  deep  red  crust  over  the  ulcer,  while  it  Avas  very  annoying 
to  the  patient  by  reason  of  the  staining  of  his  under-linen. 

Within  the  past  ten  years  I  have  used  with  some  advantage  salicylic 
acid,  which  is  odorless  and  does  not  stain  the  linen.  It,  however,  is  not 
invariably  reliable  like  iodoform.  For  ordinary  chancroids  and  ulcerated 
herpes  progenitalis  five  grains  of  the  acid  suspended  in  an  ounce  of  water 
is  a  good  lotion.  Combined  with  subnitrate  of  bismuth.  1  :  4  or  1  :  8, 
salicylic  acid  may  be  used  even  when  chancroids  are  active. 

Recent  experiments  with  resorcin  and  pyrogallol  has  convinced  me  that 
they  are  not  equally  as  reliable  as  iodoform.  In  many  cases  they  act 
fairly  well,  but  they  are  powerless  in  arresting  serpiginous  chancroids. 

In  the  cicatrizing  or  reparative  stage  of  chancroids,  not  earlier,  much 
progress  is  often  made  by  judicious  applications  of  a  solution  of  nitrate  of 
silver,  10  :  20  grains  to  the  ounce,  made  every  few  days.  The  parts  are 
prepared  by  careful  irrigation,  then  they  are  dried,  and  the  solution  is 
carefully  and  sparingly  applied. 

It  may  be  not  amiss  to  mention  Du  Castel's  ^  treatment  of  these  ulcers. 
This  surgeon  recommends  the  following  as  a  topical  application  :  Alcohol, 
10  ;  acid,  carbolic,  1.  After  this  mild  cauterization  the  parts  are  covered 
with  powdered  salol  or  aristol. 

Aristol  is  sometimes  very  beneficial  in  the  treatment  of  chancroids,  but 
it  cannot  be  depended  upon  in  rebellious  cases,  as  iodoform  can.     It  is 

1  Thlie  de  Pans,  1893. 

^  "  Le  Traitement  du  Chancre  simple,"  Eev.  gen.  de  Clin,  et  de  Therapeut.,  1891,  Nos.  16 
and  17. 


510  THE  CHANCROID    OR  SOFT  CHANCRE. 

very  necessary  to  irrigate  the  ulcers  ^Yith  the  bichloride  solution  (1  ;  2000), 
and  then  dry  them  before  the  aristol  is  applied. 

Formalin,  used  pure  or  in  dilution  with  Avater  40  and  10  per  cent.,  has 
been  used  with  much  success  by  Gaylord  ^  in  both  chancroids  and  chan- 
croidal buboes.  It  is  said  to  cause  quite  severe  pain,  but  to  be  produc- 
tive of  prompt  healing 

The  following  lotions  are  also  useful  in  many  cases ; 

'Sf.  Zinci  sulph.,  gr.  viij  ; 

Spts.  lavand.  comp.,  Sij  ; 

Aquse,  ^iv. — M. 

I^.  Argenti  nitrat.,  gr.  j  ; 

Aquae,  5iv. — M. 

I^.  Liq.  sodse  chlorinatae,  3ij  ; 

Aquae,  |iv. — M. 

I^.  Acid,  boracic,  Siss  ; 

Aquae,  5iv. — M. 

!^.  Vini  aromat.,  sij  ; 

Aquae,  |iij . — M. 

The  seat  of  chancroids  materially  modifies  the  method  of  treatment. 
For  those  lesions  under  the  prepuce  dry  powders  may  be  used,  and  great 
care  must  be  taken  to  avoid  oedema,  for  that  brings  in  its  train  phimosis 
and  paraphimosis,  two  very  annoying  and  serious  complications.  On  the 
integument  it  is  often  difficult  to  keep  dry  powders  on  the  ulcers,  in 
which  case  watery  applications  may  be  used,  or  powders  covered  over 
with  lint,   cotton,  or  gauze  moistened  in  water. 

At  the  fraenum  chancroids  are  prone  to  become  the  seat  of  oedema,  to 
hemorrhage,  to  eat  through  the  base  of  the  bridle  itself  Therefore  they 
require  especial  care,  particularly  as  oedema  at  this  region  is  always  fol- 
lowed by  phimosis,  even  if  the  prepuce  is  ample. 

Chancroids  at  the  margin  of  or  within  the  urethra  must  also  be  care- 
fully treated,  and  it  is  well  to  avoid  cauterization,  since  it  is  so  liable  to 
produce  oedema,  to  cause  the  ulcers  to  become  more  active,  and  even  re- 
sult in  stricture. 

If  the  chancroids  are  just  at  the  lips  of  the  meatus,  they  should  be 
Avell  irrigated  with  a  hot  bichloride  solution  (1 :  2000)  or  carbolic  acid 
and  water  (1  :  250-500).  After  drying  the  parts  should  be  covered  with 
iodoform  or  aristol,  and  then  well  bandaged  with  a  mass  of  absorbent 
cotton  carefully  retained. 

If  the  chancroids  are  about  an  inch  down  the  urethra,  the  parts 
should  be  first  irrigated  with  the  solutions  just  mentioned.  Then  a  No. 
12  French  catheter,  cut  ofi"  at  a  length  of  four  inches  and  lubricated 
with  glycerin,  should  be  passed  into  the  urethra  beyond  the  ulcers,  and 
then  by  attachment  with  an  irrigator  fully  a  quart  of  the  antiseptic  solu- 

1  Medical  Newa,  Oct.  27,  1894. 


DIAGNOSIS,   PEO GNOSIS,   AND   TREATMENT.  511 

tions  mentioned  should  be   retrojected.      Then  iodoform  or  aristol  is  in- 
sufflated into  the  urethra,  which  is  packed  with  absorbent  cotton. 

Chancroids  under  the  prepuce  must  be  treated  after  the  manner  of 
phimosis,  plus  that  of  destructive  ulceration.  Subpreputial  injections  of 
hot  (1 :  2000)  sublimate  solution  or  of  carbolic  acid  and  water  (1 :  150) 
should  be  used  very  often  by  means  of  my  fiat  syringe  nozzle,  taking 
care  to  get  the  irrigating  liquid  well  behind  the  glans.  Then  iodoform 
suspended  in  glycerin  and  water  should  be  introduced.  It  is  better  in 
all  cases  to  anticipate  gangrene,  and  if  the  progress  in  treatment  is  not 
perfectly  satisfactory  to  make  two  lateral  incisions  into  the  prepuce  as  far 
back  as  the  glans,  which  will  place  all  of  the  affected  parts  at  the  disposal 
of  the  surgeon.  Fears  of  inoculation  of  the  incisions  need  give  the  sur- 
geon no  disquietude.     (See  chapter  on  Phimosis.) 

In  paraphimosis  complicated  with  chancroids  it  is  well  to  refrain  from 
cutting  if  possible ;  but  if  the  constriction  tends  to  produce  strangula- 
tion, the  encircling  band  at  the  bottom  of  the  sulcus  must  be  cut  as  di- 
rected in  the  section  on  Paraphimosis. 

Chancroids  in  women  demand  the  utmost  attention  to  cleanliness, 
very  much  prudence  and  care  in  cauterization,  and  thorough  and  fre- 
quent dressings.  Their  surfaces  should  be  kept  free  from  all  discharges, 
and  all  coapting  parts  should  be  separated.  In  like  manner,  chancroids 
of  the  anus  must  not  be  injudiciously  cauterized  ;  they  should  be  care- 
fully dressed,  the  parts  being  separated.  Attention  should  be  paid  that 
the  stools  be  rendered  liquid  in  consistence. 

Since  the  era  of  violent  and  indiscriminate  cauterization  has  departed 
and  iodoform  has  come  into  use,  the  ravages  of  serpiginous  chancroids, 
phagedena,  and  gangrene  are  much  less  common  and  less  severe  than 
formerly. 

The  treatment  of  serpiginous  chancroids  should  be  both  local  and 
general.  Wherever  there  is  debility,  it  is  to  be  combated  with  nutritious 
food,  tonics,  and,  if  necessary,  stimulants.  Locally,  after  prolonged 
immersions  of  the  parts  in  water  as  hot  as  can  be  borne  and  irrigations 
with  1 :  2000  hot  sublimate  solutions,  the  surface  may  be  touched  with 
nitric  acid  or  bromide  and  glycerin  (1 :  8),  care  being  taken  that  the 
ulcerating  furrow  at  the  edge  be  thoroughly  touched.  The  whole  may  be 
temporarily  covered  with  lint  or  absorbent  cotton  moistened  with  dilute 
Labarraque's  solution,  1 :  10  of  water.  After  this  iodoform  may  be  ap- 
plied quite  freely,  and  the  whole  surface  covered  with  absorbent  or 
iodoform  gauze,  over  which  is  a  layer  of  gutta-percha  tissue.  While  this 
treatment  is  usually  successful,  cases  do  occur  which  tax  the  resources  of 
the  surgeon  and  call  in  play  all  manner  of  therapeutical  expedients  in  the 
way  of  remedies  and  methods  of  application.  In  some  cases  the  sys- 
tematic use  of  the  curette,  particularly  at  the  margin  of  the  ulcer,  pro- 
duces good  results. 

Phagedenic  chancroids,  commonly  seen  in  neglected  cases,  in  ulcera- 
tion in  inaccessible  places,  and  tliose  injudiciously  cauterized,  and 
occurring  mostly  in  unhealthy  subjects,  require  the  most  careful  atten- 
tion to  diet,  hygiene,  and  surroundings.  The  vital  powers  must  be  sus- 
tained by  tonics  and  stimulants,  and  opium  must  be  given  to  relieve  the 
pain  and  quiet  the  nervous  anxiety  of  the  sufferer.  The  next  essential 
is  to  determine  whether  syphilis  is  a  factor  in  the  process,  since  in  pro- 


512  THE  CHANCROID   OR  SOFT  CHANCRE. 

portion  as  that  diathesis  is  active  in  such  cases,  so  is  mercury  beneficial ; 
whereas  it  is  positively  injurious  in  simple  phagedenic  chancroids.  I 
have  never  seen  any  benefit  result  from  the  use  of  the  potassio-tartrate 
of  iron,  which  Ricord  used  to  call  the  "  born  enemy  of  phagedena."  In 
this  complication  of  the  chancroid  the  dermal  curette  may  be  employed 
with  benefit  to  remove  debris  of  tissue,  sloughs,  and  pultaceous  matter 
from  the  surface  and  edges.  Then  the  whole  surface  may  be  thoroughly 
but  carefully  touched  with  nitric  acid,  with  the  bromine  solution  (1 :  3) 
of  glycerin,  or  with  the  actual  cautery,  care  being  exercised  that  the  sur- 
rounding parts  are  not  injured.  Phagedena  complicating  chancroidal 
phimosis  necessitates  incisions  sufiiciently  extensive  to  allow  the  parts  to 
be  reached.  In  addition  to  this  direct  medication,  the  most  important 
measure  is  the  immersion  of  the  parts  or  of  the  whole  body  in  a  hot  sitz- 
bath  (98°  to  102°  Fahr.)  for  from  eight  to  twelve  hours  a  day,  care  being 
taken  that  the  comfort  of  the  patient  is  attended  to  in  every  particular. 
I  have  seen  in  my  hospital  practice  the  most  salutary  results  from  this 
treatment  in  very  unpromising  cases  in  which  the  destructive  action 
ceased  and  reparative  action  began  in  from  two  to  thirteen  days. 

Where  the  phagedena  attacks  the  distal  portion  of  the  penis,  irriga- 
tions of  hot  Avater,  of  hot  sublimate  solution  (1  :  2000)  by  means  of  a 
spray  syringe  for  several  hours  a  day,  have  proved  very  efficacious  in  my 
hands.  When  healthy  granulations  appear  the  surfaces  may  be  dressed 
with  balsam  of  Peru  and  covered  with  absorbent  gauze. 

Since  Aubert^  in  1884  demonstrated  the  fact  that  when  subjected  to 
much  heat  chancroidal  ulcers  promptly  lost  their  destructive  tendency, 
many  observers  have  advocated  this  agent,  but  only  in  a  half-hearted 
way.  Within  recent  years  Welander^  has  claimed  striking  results  from 
the  application  of  heat  by  means  of  hot  water  (50°  to  52°  C.)  passing 
through  thin  lead  tubes,  which  are  held  in  apposition  to  the  ulcers. 
Arnozan  and  Vigneron^  and  J.  Fournier  *  claim  excellent  results  from  the 
use  of  hot-water  applications  (as  high  as  120°  F.)  to  chancroids,  and 
also  to  the  buboes  which  follow  them. 

The  truth  of  this  matter  is  about  as  follows  :  Hot  water  of  as  high  a 
temperature  as  can  be  borne  is  very  curative  in  cases  of  obstinate  chan- 
croids, but  it  is  rendered  much  more  potential  by  the  addition  of  bichlo- 
ride of  mercury  (1  :  2000)  and  of  carbolic  acid  (1 :  250  or  500).  The 
solutions  may  be  held  either  in  a  fountain  syringe  or  a  two-quart  rubber 
irrigator,  supplied  with  a  long,  thin  soft-rubljer  tube,  to  which  is  attached 
the  little  nozzle  which  looks  like  a  miniature  watering-pot  spout,  which 
accompanies  most  soft-rubber  syringes.  Thus  equipped,  the  surgeon  is 
prepared  for  any  case,  whether  phagedenic  or  gangrenous. 

^  "  De  I'Attenuation  du  Virus  du  Chancre  mou  par  la  Chaleur,"  Annates  de  Derm, 
et  de  Syph.,  1883,  pp.  736  et  seq. 

^"traitement  du  Chancre  mou  par  la  Chaleur,"  ibid.,  1892,  p.  1194. 

3  "  Du  Traitement  de  la  Chancrelle  et  du  Bubon  chancrelleux  par  le  Applications 
locales  d'Eau  chaude,"  Journ.  de  Medicine  de  Bordeaux,  vols.  xx.  and  xxi.,  July  and 
August,  1891. 

*  "  De  la  Virulence  du  Chancre  simple,  etc.,"   These  de  Bordeaux,  1 892. 


BUBOES.  513 


CHAPTER   XLIX. 
BUBOES. 

By  the  term  "bubo"  we  understand  an  inflammation  of  a  hyper- 
plastic or  suppurative  character,  or  both  conditions  combined,  in  the 
ganglia  of  the  inguinal  or  crural  regions. 

While,  in  general,  it  is  -well  to  retain  the  classical  division  of  buboes 
into  the  simple  and  virulent  forms,  it  is  necessary,  for  clearness  of 
description,  to  consider  quite  fully  the  causes  which  give  rise  to  these 
glandular  swellings  and  abscesses. 

Pathology  has  conclusively  proved  that  whenever  gland-tissue  be- 
comes inflamed  it  is  always  as  the  result  of  some  poison  or  toxine  or 
of  some  micro-organism,  pyogenic  or  non-pyogenic,  carried  by  the 
lymphatic  vessels  from  some  inflammatory  focus.  In  like  manner,  in 
malignant  diseases,  particularly  epithelioma  of  the  penis,  some  unknown 
but  irritant  secretion  is  carried  to  the  contiguous  ganglia,  and  there  it 
causes  a  malignant  process  and  sometimes  a  suppurative  condition.  We 
are  unable  to  say  which  is  the  exact  agent  in  the  causation  of  the  gland- 
ular hyperplasia  due  to  syphilis. 

When  we  recognize  the  fact  that  every  bubo  depends  on  a  distinctly 
irritative  or  inflammatory  cause,  we  can  reject  as  being  unscientific  the 
terms  "sympathetic  bubo  "  and  "bubon  d'embl^e."  These  terms  imply 
ignorance.  If  in  a  given  case  of  bubo  we  cannot  ascertain  the  exact 
site  and  nature  of  the  extragenital  morbid  focus  in  which  the  poison  was 
elaborated,  Ave  can  be  absolutely  certain  that  such  poison,  either  as  a 
toxine  or  as  micro-organisms,  existed  and  gave  rise  to  the  morbid  process 
which  in  old  times  was  spoken  of  as  sympathetic  or  as  bubon  d'emblee. 

So  much  for  the  pathogenic  cause :  now  let  us  consider  its  action. 
Perhaps  the  poisonous  secretion  is  small  in  amount  and  not  very  active ; 
the  effect  upon  the  ganglia  then  will  be  mild.  This  is  the  condition  so 
frequently  observed  in  gonorrhoea!  adenitis.  But  in  some  cases  this 
poison  is  active,  and  then  suppuration  occurs. 

Undoubtedly,  many  mild  inflammatory  swellings  of  the  inguinal 
ganglia  are  the  results  of  trifling  irritation  and  suppurating  processes 
on  the  toes,  legs,  scrotum,  penis,  and  anal  region.  It  may  be  that  these 
local  lesions  are  very  mild  and  ephemeral,  but  in  their  short  life  they 
give  off  sufiicient  poisonous  secretion  to  cause  more  or  less  inflammatory 
reaction  in  the  crural  and  inguinal  ganglia.  Now,  there  may  be  in  the 
regions  just  mentioned  more  severe  inflammatory  processes,  in  which 
the  potentiality  of  the  poisoning  dose  is  greater,  and  as  a  consequence 
there  is  true  suppuration  in  the  ganglia  of  the  groin.  Undoubtedly,  a 
large  proportion  of  the  suppurating  buboes  which  we  see  in  dispensary 
and  hospital  practice  is  caused  by  genital  and  extragenital  inflammatory 
lesions  of  which  the  patient  can  give  us  little  if  any  information. 

While  we  can  speak  with  much  positiveness  of  the  existence  of 
tubercular  adenitis  in  the  neck,  Ave  knoAv  little  of  an  analogous  inguinal 
adenitis.  It  is  perfectly  conceivable  that  if  a  tubercular  focus  exists  in 
the  regions  in  Avhich  the  lymphatics  Avhich  centre  in  the  groin  take  their 

33 


514  THE  CHANCROID   OR  SOFT  CHANCRE. 

origin,  these  vessels  may  carry  to  these  ganglia  tubercular  infection. 
On  this  subject  our  knowledge  is  very  meagre.  I  may  even  say  that 
we  know  nothing  definite  concerning  it.  This  naturally  leads  us  to 
allude  to  strumous  buboes  of  the  groin.  These  buboes  are  simply  hyper- 
plastic ganglia  in  which  a  low  grade  of  suppurative  process  goes  on  and 
involves  the  overlying  skin  in  a  chronic  unhealthy  or  phlegmasic  inflam- 
mation, which  causes  for  long  periods  only  slight  destruction  of  tissues 
and  moderate  suppuration  composed  of  an  unhealthy  form  of  pus.  This 
is  all  that  we  can  positvely  say  of  the  strumous  bubo.  It  is  not  essen- 
tially a  sharply-marked  morbid  process,  but  a  chronic  unhealthy  adenitis, 
which  has  been  started  in  the  same  way  that  the  majority  of  suppurating 
buboes  do. 

We  now  come  to  the  so-called  virulent  bubo,  which  is  a  more  active 
and  destructive  form  than  any  we  have  thus  far  considered.  As  late  as 
the  year  1884  it  was  received  as  gospel  truth  that  the  virulent  bubo  was 
caused  by  the  virus  of  the  chancroid,  and  great  was  the  consternation 
in  the  camp  of  the  dualists  when  Straus  ^  bluntly  made  the  assertion 
that  in  the  pus  of  forty-two  cases  of  chancroidal  bubo  he  had  found  no 
micro-organism,  and  when  he  inoculated  this  pus  aseptically  as  taken 
from  the  bubo  his  experiments  invariably  failed.  Straus  convinced 
himself  (and  I  know  of  no  advocate  of  dualism  who  has  assailed  his 
position)  that  whenever  this  bubo  becomes  virulent  and  destructive  it  is 
because  it  has  been  contaminated  with  chancroidal  pus  after  it  has  been 
opened.  Now,  I  am  prepared  to  go  a  little  farther  than  Straus — and  I 
speak  from  observation  and  experience — when  I  say  that  in  some  cases 
in  which  there  has  been  absolutely  no  dhancrous  pus-contamination  of 
the  abscess,  dirt,  uncleanliness,  and  carelessness  have  caused  the  sup- 
purating process  to  become  virulent  and  to  assume  all  the  features  and 
qualities  of  a  typical  chancroidal  abscess. 

Spietschka^  has  gone  over  this  subject,  and,  like  Straus,  concludes 
that  the  pus  of  buboes  resulting  from  chancroid  is  absolutely  free  from 
all  micro-organisms.  Although  the  pus  of  chancroidal  buboes  may  not 
contain  micro-organisms,  the  clinical  fact  remains  that  this  form  of  bubo 
shows  evidence  of  a  more  active  and  destructive  suppuration  than  do  the 
simple  forms. 

Since  we  have  a  fairly  good  scientific  idea  of  the  materies  morbi  of 
buboes,  we  can  venture  upon  a  classification  which  Avill  work  Avell  in  clin- 
ical study  and  will  serve  as  a  basis  for  precise  surgical  procedures. 

The  buboes  due  to  epithelioma  and  syphilis  will  not  be  considered 
here,  since  they  are  treated  of  in  their  proper  places. 

In  general,  it  is  well  to  retain  the  terms  simple  and  virulent  bubo, 
and  to  bear  in  mind,  at  the  same  time,  that  the  only  difference  between 
them  is  that  due  to  the  mild  potentiality  of  the  poison  in  the  simple  form, 
and  to  the  concentration  and  activity  of  the  morbid  secretion  which  pro- 
duces the  second  form. 

Inguinal  buboes  are  found  in  practice  in  the  following  forms  and  con- 
ditions :   1,  simple  hyperplasia  of  one  or  more  ganglia — mono-  and  poly- 

^  "  Sur  la  Virulence  du  Bubon  qui  accompagne  le  Chancre  mou,"  Annales  de  Derm,  et 
de  Sijph.,  1885,  pp.  9  et  beq. 

^  ''  Beitriige  zur  Aetiologie  des  Schanker  Bubo  nebst  untersuchungen  iiber  das  Ulcus 
molle,"  Arch,  fiir  Derm,  und  Syph.,  1894,  vol.  xviii.  pp.  25  et  seq. 


BUBOES.  515 

ganglionic  adenitis,  which  may  be  acute  or  chronic ;  2,  suppuration  of 
one,  more,  or  many  ganglia  and  of  the  ambient  connective  tissue,  while 
some  ganglia  still  remain  in  a  hyperplastic  condition ;  3,  suppuration  of 
the  whole  mass  of  ganglia  and  the  formation  of  an  abscess-cavity  ;  4,  a 
chronic  and  mild  combined  hyperplasia  and  suppuration  of  the  ganglia 
and  of  the  connective  tissue  and  skin,  which  becomes  of  a  dull  bluish  or 
purplish  color  and  the  seat  of  sinuses  and  fistulse :  this  is  the  so-called 
strumous  bubo ;  and,  5,  the  chancroidal  or  virulent  bubo,  which  may 
follow  a  chancroid  or  develop  from  an  ordinary  suppurating  bubo  which 
has  been  contaminated  by  dirt  (pus-microbes  perhaps). 

Simple  hyperplasia  shows  itself  by  enlargement  of  the  inguinal  gan- 
glia and  swelling  of  the  parts,  which  may  be  of  normal  color  or  of  a  more 
or  less  deep  red.     Pain  may  or  may  not  be  present. 

When  one  or  more  ganglia  are  the  seat  of  suppuration,  and  others  of 
hyperplasia,  a  red  and  painful  swelling  is  found  in  the  groin,  and  digital 
examination  shows  a  combination  of  fluctuation,  doughy  sensation,  and 
nodulation.  This  mixed  form  of  bubo  may  be  as  large  as  an  egg  or  even 
larger.  The  true  suppurating  bubo  shows  itself  by  a  round  or  oval  red 
and  painful  swelling  which  is  much  elevated  and  has  an  area  of  one  to 
four  inches  or  even  larger,  its  long  axis  usually  corresponding  to  the  fold 
of  the  groin. 

The  so-called  strumous  bubo  shows  itself  as  a  circumscribed  or  irregu- 
lar inguinal  swelling  of  a  dull  purplish  color,  considerably  raised  above 
the  normal  level  of  the  parts  and  perforated  by  holes  which  show  both 
undermining  of  the  integument  and  the  existence  of  sinuses  leading  down 
to  inflamed  ganglia.  The  clinical  picture  is  very  striking,  and  gives 
evidence  of  a  chronic,  sluggish,  inactive  cell-increase  and  suppuration,  the 
pus  of  which  is  thin,  sanious,  and  unhealthy.  Patients  having  this  form 
of  bubo  are  usually  persons  of  poor  health  and  those  broken  down  by 
excesses  or  as  a  result  of  poverty. 

The  chancroidal  bubo  gives  evidence  from  the  first  of  an  actively 
destructive  process.  The  groin  becomes  red  and  sAvollen,  and  a  percept- 
ible tumor  is  soon  developed.  The  skin  becomes  red,  tense,  and  the 
seat  of  much  pain.  Redness  gives  place  to  a  brownish-red  tint,  and  then 
the  swelling,  which  is  considerably  salient,  presents  decided  fluctuation. 
The  abscess  either  bursts  from  ulceration  of  the  skin  or  it  is  incised. 
The  roof  of  this  cavity,  which  consists  of  thinned  and  inflamed  skin,  then 
quite  promptly  melts  away  and  the  typical  chancroidal  bubo-cavity  is 
left.  This  cavity  is  usually  quite  deep ;  its  base  is  anfractuous,  covered 
with  sloughy  tissue  of  a  dirty-brown  color,  over  which  is  a  layer  of 
unhealthy  pus.  The  edges  of  this  ulcer  (since  it  really  is  one)  are  of  a 
deep  red,  thickened,  and  decidedly  undermined. 

Treatment  of  Buboes. — Simple  hyperplasia  of  inguinal  ganglia  may 
disappear  by  resolution.  In  some  cases  the  daily  application  of  tincture 
of  iodine,  combined  with  pressure,  will  eff"ect  a  cure.  Whenever  the 
patient  is  particularly  anxious  for  the  speedy  resolution  of  the  swellings 
cantharidal  collodion  may  be  painted  over  them.  This  treatment,  aided 
by  the  recumbent  position,  is  sometimes  very  effective. 

Where  there  are  many  ganglia  the  seats  of  a  low  inflammatory 
process  which  has  not  yet  progressed  to  suppuration,  resolution  may  be 
induced  by  injections  of  carbolic  acid,  according  to  the  method  of  Dr. 


516  THE  CHANCROID   OB  SOFT  CHANCRE. 

M.  K.  Taylor/  who  advocates  the  use  of  interstitial  carbolic-acid  injec- 
tions in  buboes  and  inflamed  lymphatic  ganglia  generally.  He  injects 
from  ten  to  forty  minims  of  a  watery  solution  of  the  agent  of  a  strength 
of  from  eight  to  ten  grains  to  the  ounce.  When  used  before  the  forma- 
tion of  pus  he  claims  that  he  has  not  failed  to  arrest  the  morbid  process. 
When  pus  has  formed  he  evacuates  the  abscess  by  aspiration  and  throws 
in  the  carbolic  solution.  When  the  abscess-cavity  is  small  he  evacuates 
the  Avhole  of  the  contained  pus ;  if  large,  only  a  part,  and  then  throws 
in  sufficient  of  the  fluid  to  take  its  place.  When  spontaneous  opening 
has  occurred,  the  cavity  has  to  be  washed  out  with  the  same  fluid  and 
compression  applied.  Care  is  to  be  used  to  reach  the  centre  of  the 
tumor,  and  according-  to  the  author  the  needle  should  be  thrust  to  the 
extent  of  two-thirds  of  the  depth  of  the  narrowest  diameter  of  the 
tumor.  The  method  has  been  used  by  him  for  seven  years  in  nearly 
one  hundred  and  fifty  cases.  It  is  claimed  that  by  this  method  pain  is 
much  relieved  and  very  little  loss  of  time  is  incurred.  Interstitial  car- 
bolic injections  have  sometimes  been  followed  by  surprisingly  satisfactory 
results  at  my  hands. 

A  method  of  treatment  in  the  same  direction — namely,  the  injection 
of  an  antiseptic  solution — has  recently  been  advocated  by  Welander.^ 
His  solution  is  made  as  follows  :  Benzoate  of  mercury,  1.0;  chloride  of 
sodium,  0.3;  and  distilled  water,  100.  Of  this  liquid  one  or  more 
Pravaz  syringefuls  are  injected  into  the  most  prominent  part  of  the 
tumor.  Welander  claims  great  success  for  this  treatment,  and  he  is 
indorsed  by  Spietschka,^  who  gave  it  a  good  trial,  which  was  followed 
by  satisfactory  results. 

In  all  cases  when  these  injections  are  made  the  parts  must  be  ren- 
dered aseptic,  and  great  care  should  be  exercised  in  the  technique  of  the 
injection. 

W' hen  abortive  measures  fail  in  cases  of  inguinal  ganglionic  hyper- 
plasia it  is  Avell  not  to  temporize,  but  to  resort  at  once  to  the  radical 
operation  of  total  extirpation.  The  operative  field  is  shaved  and  ren- 
dered surgically  clean ;  then  a  long,  free  incision  is  made  parallel  with 
Poupart's  ligament  and  over  the  most  prominent  part  of  the  swelling. 
It  may  be  necessary  also  to  make  a  vertical  incision  in  order  to  have 
more  space  to  work  in.  This  vertical  incision  may  be  of  advantage  in 
drainage.  When  the  parts  are  exposed  all,  the  glands,  even  if  they  are 
seemingly  healthy,  are  to  be  dissected  out.  In  this  operation  the  sur- 
geon may  have  to  go  down  to  and  even  between  the  femoral  vessels. 
He  should  therefore  work  slowly  and  cautiously,  taking  out  the  ganglia 
with  the  handle  of  the  scalpel  or  by  means  of  his  finger-nails.  Parts 
should  never  be  violently  torn.  The  ganglia  will  be  found  to  be  firm 
oval  masses  as  large  as  a  bean  and  larger,  and  will  be  readily  recognized 
when  the  operator  has  become  a  little  familiar  with  the  operation.  All 
bleeding  vessels  must  be  tied.  The  wound  when  finished  must  be  saucer- 
shaped,  and  should  be  well  irrigated  with  1  :  2000  bichloride  solution. 

1  "  The  Abortive  Treatment  of  Buboes  and  Lymphadenitis  generally  by  Carbolic-acid 
Injection,"  Am.  Journ.  Med.  Sciences,  April,  1882. 

^  '•  Versuche  einen  Abortivbehandlung  der  Bubonen,"  Arch,  fur  Derm.und  Syph.,  1891, 
pp.  43  et  seq. 

3  Ibid.,  Ergiinzungsheft,  No.  2,  1892,  pp.  63  et  seq. 


BUBOES.  517 

It  is  then  packed  with  iodoform  gauze,  over  which  absorbent  cotton  and 
layers  of  bichloride  gauze  are  held  in  place  by  a  spica  bandage. 

Suppurating  buboes  may  be  treated  by  the  old-time  method  of 
incision,  followed  by  antiseptic  irrigation  and  careful  packing.  The 
disadvantages  of  this  method  are  that  a  long  time  is  required  in  the 
healing  of  the  parts,  the  dressings  cause  pain,  and  a  compromising  scar 
is  left. 

Within  the  past  decade  a  method  of  treating  suppurating  buboes  has 
been  proposed  and  perfected,  which  I  have  no  doubt  will  in  a  great  meas- 
ure replace  all  others.  This  method  of  treatment  seems  to  have  been  first 
devised  by  Scott  Helme,^  and  was  most  prominently  brought  forward  by 
Fontan.^  The  active  agent  in  this  treatment  is  iodoform  thrown  into 
the  abscess-cavity.  The  technique  of  the  operation  has  been  modified 
for  the  better  by  Dr.  J.  R.  Hayden,^  and  it  is  his  method  which  I  use 
with  much  satisfaction  and  success  in  my  hospital  service.  It  is  as 
follows : 

1.  The  operative  field  is  shaved  and  rendered  surgically  clean.  2. 
A  few  drops  of  an  8  per  cent,  cocaine  solution  are  injected  beneath  the 
skin  Avhere  the  puncture  is  to  be  made.  3.  A  straight,  sharp-pointed 
bistoury  is  thrust  well  into  the  most  prominent  part  of  the  mass  until  pus 
flows.  4.  All  of  the  pus  is  forced  out  through  this  opening  by  firm  but 
gentle  pressure,  as  this  procedure  is,  as  a  rule,  very  painful.  5.  The 
abscess-cavity  is  irrigated  with  pure  peroxide  of  hydrogen  until  it  returns 
practically  clear.  6.  It  is  then  irrigated  with  1 :  5000  bichloride-of-mer- 
cury  solution,  all  of  which  is  carefully  squeezed  out.  7.  The  now  thor- 
oughly cleansed  abscess-cavity  is  completely  filled  with  10  per  cent, 
iodoform  ointment  by  means  of  an  ordinary  conical  glass  syringe  pre- 
viously warmed  in  hot  water,  and  a  finger  held  over  the  puncture  until — 
8.  A  cold  wet  bichloride  dressing  is  applied  with  a  fairly  firm  spica  band- 
age. The  cold  congeals  the  ointment  at  the  puncture,  and  thus  prevents 
its  escape  into  the  dressing. 

The  patient  should  be  kept  very  quiet  for  the  first  twenty-four  to 
forty-eight  hours,  in  bed  if  possible,  although  this  is  not  absolutely 
necessary. 

The  dressing  should  be  changed  at  the  end  of  three  or  four  days.  It 
is  not  often  necessary  to  repeat  the  processes  of  irrigation,  cleansing,  and 
injection. 

Though  it  has  been  claimed  that  buboes  are  cured  by  this  method  in 
six  or  eight  days,  the  time  occupied  is  usually  between  ten  and  twenty- 
one,  which  may  be  said  to  be  an  excellent  showing.  Besides  this  advan- 
tage, there  is  no  necessity  for  painful  applications  or  dressings,  and  the 
scar  left  is  usually  so  small  that  it  is  necessary  to  look  for  it  very  closely 
in  order  to  find  it. 

The  treatment  of  the  so-called  strumous  buboes  should  be  radical  and 
thorough.  The  parts  are  shaved  and  rendered  as  nearly  as  possible 
surgically  clean.  Then  a  long  free  incision  in  the  course  of  Poupart's 
ligament  is  made,  and,  if  the  bubo  is  large,  is  crossed  at  its  middle  by  a 
smaller  vertical  incision.     Then  the  ganglia  and  the  aifected  tissues  are 

^  Chicago  Med.  Journ.  and  Exam.,  Sept.,  1886,  vol.  liii.,  No.  3. 

^  "Gu^rison  rapide  des  Bubons  par  I'lnjection  de  Vaseline  iodoform^e,"  Arch,  de  3I6d. 
Navale,  1889,  vol.  lii.  pp.  5  et  seq.  ^  American  Journ.  Med.  Sciences,  Nov.,  1895. 


518  THE  CHANCROID   OB  SOFT  CHANCRE. 

carefully  but  thoroughly  removed  in  the  manner  already  described.  All 
the  bluish,  thickened  integument  should  be  cut  off  with  the  scissors,  and 
care  should  be  particularly  exercised  that  any  sinuses  in  the  skin  should 
be  exsected.     The  wound  is  then  antiseptically  treated. 

Dr.  F.  S.  Watson^  has  published  an  essay  in  which  he  states  that  by 
means  of  excision  and  most  thorough  antiseptic  measures  he  has  been 
able  to  get  union  by  first  intention  in  10  out  of  20  unselected  cases  of 
buboes  of  all  kinds,  in  all  but  4  of  which  the  overlying  skin  was  in- 
flamed, and  in  some  necrotic.  The  following  rules  were  followed :  1, 
to  remove  all  diseased  tissue,  and  to  leave  as  far  as  possible  a  perfectly 
healthy  surface  in  every  part  of  the  wound  (to  secure  this  it  is  always 
necessary  to  carry  the  dissection  down  to  the  fascia  covering  the  abdom- 
inal muscles ;  sometimes  to  expose  the  femoral  vessels,  and  generally 
the  external  inguinal  ring) ;  2,  to  excise  such  portions  of  the  skin  as 
threatened  to  become  necrotic  or  had  already  become  so ;  3,  to  curette 
the  under  surface  of  the  skin-flaps ;  and,  4,  to  thoroughly  swab  the 
whole  wound  Avith  dry  sterilized  gauze-sj^onges  or  sjDonges  wet  with  a 
solution  of  corrosive  sublimate,  1  :  4000. 

In  carrying  out  this  operation  Watson  makes  a  crescentic  cut  "'  carried 
well  below  the  area  of  inflamed  skin  through  the  healthy  skin.  From 
this  line  a  flap  is  dissected  up,  extending  to  a  line  well  above  the  dis- 
eased glands  and  exposing  them  thoroughly.  After  their  removal  the 
flap  is  turned  down  and  its  edge  sutured  on  the  line  of  the  first  incision." 
Drainage  may  be  made  by  means  of  sterilized  strands  of  silk  passed 
through  an  opening  below  the  line  of  the  incision.  The  second  incision 
used  is  a  long  one  parallel  with  Poupart's  ligament,  and  an  elliptical 
piece  of  skin  corresponding  to  the  site  of  the  ganglia  is  dissected  off, 
and  then  the  edges  of  the  wound  are   sutured. 

It  may  be  said  of  this  radical  operation  that  it  will  certainly  leave 
very  large  and  very  much  depressed  scars,  corresponding  to  the  amount 
of  tissue  which  is  removed.  It  has  been  found  in  this  method,  more- 
over, that  the  suppurating  process  sometimes  burrows  away  from  the 
part  operated  on,  and  that  a  very  severe  condition  of  abscess  is  pro- 
duced. 

Chancroidal  bubo  may  in  its  early  stage,  when  suppuration  has 
taken  place  and  when  the  skin  is  not  much  involved,  be  successfully 
treated  by  the  iodoform-vaseline  method,  which  will  sometimes  bring 
about  a  cure  even  Avhere  the  skin  is  thinned  and  reddened.  This  treat- 
ment should  always  be  used  in  appropriate  cases  of  chancroidal  bubo. 

If  in  this  form  of  suppurative  adenitis  the  skin  is  much  destroyed, 
particularly  if  perforation  has  occurred,  the  long  inguinal  incision  should 
be  made  in  most  rigid  antiseptic  conditions,  and  the  abscess-cavity  should 
be  thoroughly  cleansed  by  curetting,  by  the  removal  of  all  diseased 
ganglia,  and  by  the  copious  irrigation  of  hot  bichloride  solution,  1  :  2000. 
The  wound  should  then  be  dusted  with  iodoform  and  packed  with  gauze, 
well  covered  with  gauze  and  absorbent  cotton,  and  the  whole  should  be 
well  retained  by  a  spica  bandage.  In  these  cases  it  may  be  necessary 
to  remove  the  dressing  and  to  freely  irrigate  the  wound  with  the  bichlo- 
ride solution  once  or  perhaps  twice  a  day.  When  granulations  begin  to 
appear,  balsam-of-Peru  gauze  may  be  used  instead  of  iodoform  dressing. 

^  Journal  of  Cutaneous  and  Gen.-urin.  Diseases,  vol.  xi.,  1893,  pp.  45  et  seq. 


PART    III. 
SYPHILIS. 

CHAPTER    L. 

GENERAL  CONSIDERATIONS  AS  TO  ITS  NATURE,  EVOLUTION, 

AND  COURSE. 

Syphilis  is  a  chronic  infectious  disease  which  begins  in  a  local 
lesion,  which  lesion  is  caused  by  some  morbid  secretion  or  virus  or  the 
blood  derived  from  a  previous  syphilitic  person.  Beginning  thus  as  a 
local  infection,  it  promptly  invades  the  whole  organism,  more  especially 
its  connective  tissue,  induces  inflammatory  processes  of  a  low  grade, 
and  gives  rise  to  a  low  form  of  cell-growth  called  granulation  tissue. 
Syphilitic  inflammation,  when  uncomplicated,  does  not  produce  pus. 
It  is  therefore  a  chronic  granulation-tissue  disease  of  protracted  and 
irregularly  intermittent  course,  Avhich  in  some  respects  resembles  lep- 
rosy and  tuberculosis,  but  which  in  many  points  differs  from  them,  par- 
ticularly in  the  matter  of  the  initial  lesion,  which  the  latter  diseases  do 
not  seem  to  have,  or  at  least  it  has  not  as  yet  been  found  in  either. 

Syphilis  pursues  a  course  peculiar  to  itself.  In  its  early  stages  it 
presents  points  of  resemblance  in  its  evolution  and  course  to  the  exan- 
themata and  to  diphtheria,  but  here,  again,  many  features  are  absent 
which  are  necessary  to  make  the  simile  complete.  Syphilis  originates 
in  a  fixed  and  visible  infectious  secretion ;  the  exanthemata  likewise 
originate  in  a  volatile  or  fixed  infection ;  they  have  periods  of  incuba- 
tion— syphilis  two,  the  exanthemata  one — which  are  followed  by  con- 
stitutional disturbance  and  fever,  syphilis  in  this  feature  being  com- 
paratively mild.  Further,  they  all  have  extensive  integumentary  and 
mucous-membrane  lesions,  which  in  the  exanthemata  are  always  inflam- 
matory during  their  whole  course,  while  in  syphilis  they  are  moderately 
hypergemic  and  essentially  proliferative.  Here  is  a  radical  point  of 
difference :  the  exanthematous  eruptions  are  simply  inflammatory,  and 
if  cell-proliferation  occurs  it  is  of  a  simple  nature,  a  mere  increase  of 
the  normal  cells.  The  opposite  occurs  in  syphilis :  the  inflammatory 
process  is  less  active,  and  always  results  in  infiltration  of  ncAv  cells  en- 
tirely foreign  in  their  nature.  In  diphtheria  there  is  a  demonstrable 
micro-organism  which  attacks  the  system  in  one  spot,  usually  the  throat, 
and  exceptionally  in  other  regions.  From  this  local  infective  focus  gen- 
eral constitutional  symptoms  are  developed,  such  as  fever,  headache, 
pains  in  bones  and  joints,  neuralgias,  paralyses,  albuminuria,  and,  in 
some   cases,  generalized  exanthemata.     Thus   syphilis  resembles  diph- 

519 


520  SYPHILIS. 

theria  in  its  local  origin,  its   systemic  poisoning,  its  peripheral  paraly- 
ses, its  infectious  nephritis,  and  its  dermal  rashes. 

Syphilis  is  really  a  disease  of  such  protean  aspects  that  in  some  of 
its  very  numerous  phases  it  presents  points  of  resemblance  more  or  less 
strong  to  almost  every_  other  morbid  condition  or  disease.  Indeed,  the 
metamorphoses  of  syphilis  are  infinite.  Reasoning  analogically,  Avith 
the  features  and  pathological  nature  of  leprosy,  tuberculosis,  the  exan- 
themata, and  diphtheria  in  mind,  one  is  forcibly  impressed  with  the 
view  that  syphilis  also  is  a  disease  of  microbic  origin,  but,  striking  as  is 
the  probability,  the  facts  in  our  possession  to-day  do  not  warrant  us  to 
go  as  far  as  some  authors  do  who  unhesitatingly  call  syphilis  a  disease 
of  bacterial  origin.  A  number  of  observers  have  found  in  active  and 
early  syphilitic  lesions  certain  micro-organisms  which  have  been  revealed 
by  delicate  staining  methods,  but  their  numbers  have  been  small,  their 
presence  not  absolutely  constant,  and,  furthermore,  no  cultures  have 
been  made,  and  consequently  inoculation-experiments  have  not  been 
tried. 

In  the  wide  range  of  infectious  diseases  we  uniformly  observe  local 
symptoms  due  to  the  microbes,  and  general  symptoms  resulting  from 
intoxication  produced  by  the  poisonous  secretions  or  toxines  developed 
by  them,  and  various  and  varied  tissue-changes.  Now,  in  syphilis  it  is 
very  probable  that  the  initial  lesion  with  its  textural  peculiarities  is  the 
result  of  the  action  of  certain  specific  virulent  microbes.  With  the 
development  of  the  lesion  it  is,  reasoning  on  analogical  evidence,  not 
doing  violence  to  probability  to  suppose  that  from  this  original  infectious 
focus  a  diffusible  poison  is  proliferated  which  gives  rise  to  such  fugitive 
and  ephemeral  affections  (usually  irritative)  as  meningeal  hyperemia, 
disturbances  of  the  reflexes,  erythematous  rashes,  icterus,  and  pains  in 
the  muscles,  bones,  joints,  and  fasciae.  The  fever,  the  debility,  the 
nervous  disturbances,  the  anasmia  and  chlorosis  from  malnutrition,  and 
the  underlying  changes  in  the  blood,  diminution  in  the  proportion  of 
its  solid  elements  and  the  increase  in  the  number  of  leucocytes, — all 
these  point  to  the  existence  of  an  intense  microbic  poison  which  has 
been  diffused  throughout  the  system.  Superadded  to  these  constitu- 
tional manifestations  there  are  the  many  cell-changes  which  syphilis 
always  gives  rise  to.  In  our  advanced  state  of  knowledge  we  can  only 
explain  these  complex  morbid  conditions  and  processes — since  they  re- 
semble very  closely,  and  even  exactly,  similar  ones  in  other  diseases  in 
which  the  existence  of  a  bacterium  is  absolutely  certain — by  assuming 
that  they  are  the  result  of  a  vij'us  animatum  the  micro-organism  of 
which  is  unknown  to  us. 

Whatever  may  be  its  origin,  syphilis  is  a  disease  sui  generis,  which 
stands  out  prominently  in  pathology  as  a  distinct  succession  of  correlated 
morbid  processes  which  may  resemble  many  or  all  other  morbid  pro- 
cesses and  diseases  in  part  or  in  Avhole,  but  which  is  essentially  diff'er- 
ent  from  them  all.  There  is  no  etiological  relation  whatever  between 
syphilis  and  chancroid.  Syphilitic  lesions  and  syphilitic  integument 
and  mucous  membranes  may  be  the  seat  of  invasion  of  pus-microbes 
which  produce  in  them  lesions  identical  to  the  eye  with  the  chancroid, 
but  these  are  merely  local  accidents  not  in  any  manner  related  etio- 
logically  to  the  syphilitic  process.     They  are  simply  evidences  of  the 


ITS  NATURE,  EVOLUTION,  AND  COURSE.  521 

vulnerability  of  the  tegumentary  tissues  of  syphilitics  to  invasion  by 
pyogenic  organisms. 

There  are  two  clearly-defined  forms  of  syphilitic  infection — the  one 
called  the  acquired  form,  which  begins  in  a  local  or  primary  lesion,  the 
hard  chancre,  and  the  other  the  hereditary,  incorrectly  called  the  con- 
genital, form,  in  which  there  is  no  local  primary  lesion,  the  disease 
usually  beginning  Avith  general  manifestations.  In  the  acquired  form 
the  infection  is  derived  from  a  person  previously  infected  in  whom  the 
disease  is  active.  In  the  majority  of  cases  syphilis  is  contracted  in  the 
sexual  act,  and  for  this  reason  this  disease  is  classed  among  the  venereal 
diseases.  It  is  then  syphilis  of  genital  origin.  There  are,  however, 
many  instances  in  which  syphilis  is  not  contracted  in  coitus — for  exam- 
ple, from  kissing  a  syphilitic,  by  inoculation  in  operations  upon  and 
examinations  of  syphilitics,  and  from  contamination  from  any  article 
which  by  some  means  or  accident  may  be  smeared  with  the  syphilitic 
virus.  These  latter  forms  are  termed  cases  of  extragenital  syphilis,  and 
from  the  fact  that  in  most  instances  there  is  no  moral  transgression  or 
erotic  origin  in  their  causation,  they  are  classed  under  the  category  of 
syphilis  insontium,  syphilis  of  the  innocents  or  unmerited  syphilis. 

Acquired  syphilis  is  never  developed  spontaneously :  its  virus  enters 
the  organism  at  the  point  of  infection,  and  always  begins  with  the  de- 
velopment of  a  local  lesion  called  the  chancre,  the  hard  or  Hunterian 
chancre,  the  infecting  chancre,  the  initial  sclerosis,  the  initial  lesion,  the 
primitive  neoplasm,  and  the  primary  lesion.  No  attention  whatever 
should  be  paid  to  cases  called  sypldlis  cVemhlee,  in  which  it  is  claimed 
that  syphilis  began  without  an  initial  lesion.  As  Ricord  graphically 
remarks,  "  Syphilis  never  invades  the  organism  without  causing  its  gap 
{troll) ;  it  always  has  a  port  of  entry.  This  gap,  this  port  of  entry,  is 
the  accident  of  contagion  (initial  lesion),  which  is  the  prelude  to  all  the 
others,  Avhich  is  always  separated  from  them  by  an  interval  more  or  less 
long,  and  Avhich  is  the  indispensable  exordium  of  the  disease." 

Syphilis,  therefore,  is  communicated  to  the  healthy  person  by  means 
of  the  secretions  of  a  person  suffering  from  that  disease,  and  the  first 
evidence  of  the  infection  is  shown  in  the  initial  lesion.  Mankind  ^ 
alone  seems  susceptible  to  the  action  of  the  syphilitic  virus,  since  experi- 
ments upon  animals  have  clearly  shown  that  they  are  immune  to  it. 

Hereditary  syphilis  is  that  form  in  which  the  infection  is  derived 
from  one  or  both  parents  who  are  the  victims  of  an  active  state  of  the 
disease  at  the  time  of  conception.  It  is  very  doubtful  whether  true 
syphilis  can  be  transmitted  to  the  child  during  gestation,  particularly  at 
its  late  period. 

For  purposes  of  clinical  description  and  for  various  therapeutic  con- 
siderations it  is  well  to  preserve  Ricord's  division  of  the  disease  into 
three  periods — the  primary,  the  secondary,  and  the  tertiary.  The  pri- 
mary period  or  stage  of  syphilis  is  divided  into  two  parts,  called  periods 
of  incubation.  The  first  period  of  incubation  is  the  time  which  elapses 
between  the  infecting  coitus  or  contamination  and  the  appearance  of  the 
hard  chancre.  The  second  period  of  incubation  includes  the  interval 
of  time  between  the  appearance  of  the  initial  lesion  or  chancre  and  the 
evolution  of  secondary  manifestations.     The  secondary  stage  occupies 

^  Vide  infra. 


522  SYPHILIS. 

the  first  year  or  two,  in  which  the  lesions  are  generalized,  rather  super- 
ficially seated,  and  of  tolerably  mild  nature  and  course.  The  tertiary 
stage  begins  at  the  expiration  of  two  years,  and  perhaps  in  some  cases 
earlier,  and  is  peculiar  in  the  fact  that  its  lesions  are,  as  a  rule,  more 
localized  and  circumscribed,  but  are  deeper-seated  and  of  a  more  severe 
character. 

Though  this  division  is  oftentimes  chronologically  incorrect,  and 
though  anatomically  there  are  many  exceptions  to  it,  it  is  the  best  we 
have,  and  it  can  be  put  to  a  good  purpose  as  a  working  clinical  basis 
when  its  shortcomings  are  clearly  known.  Ricord's  division  assumes  a 
uniform  methodical  and  progressive  course  and  development  of  the  dis- 
ease, which,  however,  may  be  observed  in  some  cases  and  is  wanting  in 
others. 

The  mode  of  development  of  syphilis  in  its  primary  period  is  pecu- 
liarly orderly  and  slow,  is  unattended  with  any  striking  features,  and  is 
nearly  always  quite  regular  in  its  course  and  chronology,  so  that  toler- 
ably clear  lines  may  be  laid  down  concerning  it.  After  the  infecting 
coitus  or  contamination  of  the  subject  nothing  is  usually  to  be  seen  of 
the  impending  infection  for  some  time.  It  sometimes  happens  that  pus- 
infection  occurs  synchronously  with  the  syphilitic  infection.  In  such  a 
case  a  chancroid  appears  in  a  day  or  two,  and  it  may  continue  to  exist 
up  to  the  time  of  the  appearance  of  the  syphilitic  chancre  or  it  may  be 
cured  before  that  event.  In  somewhat  rare  cases  herpetic  vesicles 
appear  just  after  coitus  upon  the  spot  on  which  later  on  the  chancre 
appears.  In  like  manner  traumatisms,  such  as  fissures  and  excoriations, 
may  show  themselves  quite  promptly,  but  these  are  only  accidents. 

It  must  be  remembered  that  there  is  no  haphazard  about  the  devel- 
opment of  the  chancre.  Wherever  the  poison  has-been  implanted  there 
the  initial  lesion  develops.  As  Ricord  so  brightly  and  happily  says : 
"  In  the  case  of  syphilis  the  person  is  first  punished  where  he  has  sinned. 
If  the  penis  and  it  alone  has  been  exposed,  it  is  on  the  penis  that  he  is 
hit.  If  the  exposure  has  been  b,y  the  mouth  or  the  anus,  it  is  upon  the 
mouth  or  the  anus  that  the  first  accident  (initial  lesion)  manifests 
itself.  Look  at  the  case  of  nurses :  they  are  exposed  at  the  breast,  and 
it  is  there  that  they  are  first  aff'ected." 

The  disease  always  begins  at  the  infected  part,  which  is  commonly 
the  genital  organs.  In  somewhat  rare  cases  two  parts  of  the  body  may 
be  infected  at  the  same  time.  Thus  we  find  the  initial  lesion  of  the 
penis  not  very  infrequently  coexistent  with  a  similar  lesion  on  the  lip 
or  the  face  or  the  finger  or  other  parts  of  the  body.  These  cases  are 
classed  under  the  head  of  chancre  a  distance. 

In  many  cases  the  secondary  stage  is  quite  regular  and  the  morbid 
processes  develop  themselves  superficially  and  in  mild  form.  Then  in 
due  time  (the  disease  for  any  reason  being  progressive)  tertiary  symp- 
toms show  themselves,  and  we  have  an  orderly  and  tolerably  systematic 
evolution  of  syphilis  from  the  primary  through  the  secondary  to  the 
tertiary  stage.  But  in  many  cases  there  is  a  Avant  of  uniformity  of 
evolution,  for  lesions  of  a  tertiary  character  appear  precociously ;  they 
may  coexist  with  secondary  lesions,  and  not  infrequently  after  the  pre- 
cocious appearance  of  tertiary  lesions  those  of  the  secondary  period 
show  themselves.     While,  therefore,  it  is  often  impossible  to  draw  sharp 


ITS  NATURE,  EVOLUTION,  AND  COURSE.  523 

lines  of  difference  between  a  secondary  and  a  tertiary  stage,  we  can 
hold  fast  in  most  cases  to  the  following  course  in  our  clinical  studies 
and  in  regulating  our  therapeutics — namely,  to  consider  superficial 
lesions  of  the  skin  and  mucous  membranes  and  various  systemic  symp- 
toms and  conditions  known  to  be  of  early  development  as  evidences  of 
the  secondary  period  and  claiming  an  appropriate  treatment,  and  to 
look  upon  deep-seated  lesions  of  the  connective  tissues  and  those  of 
bones  and  viscera  as  belonging  to  the  tertiary  period  and  requiring 
treatment  for  advanced  stages. 

The  general  symptoms  of  syphilis  usually  make  their  appearance  with 
a  great  degree  of  order  and  regularity.  This  fact  is  most  apparent  in 
those  lesions  which  follow  immediately  upon  the  secondary  period  of  incu- 
bation, and  which  vary  but  little  in  different  subjects.  Allow  any  patient 
with  a  chancre  to  go  without  treatment,  and  it  may  be  predicted  "with 
almost  absolute  certainty  that  within  three  months  he  or  she  will  be 
attacked  by  the  following  category  of  symptoms  with  but  little  variation 
— viz. :  general  lassitude,  accompanied  by  headache  and  fugitive  pains  in 
various  parts  of  the  body  ;  alopecia ;  an  eruption  of  erythematous  patches 
or  papules  upon  the  skin  ;  pustules  upon  the  hairy  scalp ;  enlargement 
and  induration  of  the  post-cervical  glands ;  and  milk-white  or  granular 
patches,  which  may  become  hypertrophied  or  ulcerated,  upon  the  mucous 
membrane  of  the  mouth,  anus,  or  vulva. 

Subsequent  to  the  first  outbreak  of  general  syphilis  the  same  uni- 
formity does  not  prevail,  and  certain  symptoms  are  absent  in  one  case  and 
present  in  another,  or  they  appear  to  be  modified  by  the  constitution  of 
the  patient,  the  hygienic  conditions  in  which  he  is  placed,  his  habits,  and 
especially  by  treatment.  But  if  we  take  a  number  of  cases,  some  of 
which  supply  what  is  wanting  in  others,  we  find  that  we  can,  as  it  were, 
make  up  a  complete  series,  in  which  the  symptoms  progress  by  a  regular 
gradation,  and  may  be  divided  into  two  classes  distinguishable  by  the 
time  of  their  appearance,  their  character,  and  their  seat.  Those  of  the 
first  class  follow  immediately  upon  the  earliest  general  symptoms  before 
mentioned,  with  which  they  are  evidently  identical  in  character.  Those 
of  the  second  class,  as  a  rule,  do  not  occur  until  after  a  certain  interval 
which  experience  enables  us  to  determine  with  great  precision.  Again, 
the  order  of  the  two  classes  is  never  reversed.  For  instance,  a  patient 
who  has  been  suffering  with  symptoms  belonging  to  the  third  period,  as 
deep  tubercles  of  the  cellular  tissue  or  caries  of  the  bones,  is  never  known 
to  exhibit  the  premonitory  fever,  exanthematous  eruption,  and  other  early 
symptoms  of  the  second.  The  disease  progresses  with  greater  rapidity  in 
some  cases  than  in  others,  yet,  owing  to  the  general  uniformity  referred 
to,  simple  inspection  of  a  patient  will  enable  any  one  familiar  with  its 
natural  course  to  arrive  at  an  approximate  conclusion  as  to  the  length  of 
time  that  has  elapsed  since  contagion,  and  also  as  to  the  character  of  the 
preceding  symptoms,  unless  these  have  been  altogether  suppressed  by 
treatment. 

Apparent  exceptions  to  the  regular  succession  of  the  general  symptoms 
of  syphilis  are  met  with,  and  may  readily  deceive  an  inexperienced 
observer.  One  of  the  most  frequent  of  these  is  due  to  treatment.  It 
often  happens  that  a  patient  had  a  chancre  many  years  ago,  and  perhaps 
early  secondary  symptoms,  for  one  or  both  of  which  he  took  mercurials ; 


524  SYPHILIS. 

a  long  period  has  since  passed  without  further  general  manifestations,  but 
his  system  has  continued  under  the  influence  of  syphilis,  which  finally 
becomes  active  again  and  gives  rise  to  tertiary  lesions.  Evidently  the 
exemption  from  late  secondary  symptoms  in  many  cases  may  be  ascribed 
to  mercury  taken  early  in  the  evolution  of  the  infection. 

Again,  the  date  of  the  first  appearance  of  any  lesion  determines  its 
position  in  the  syphilitic  scale,  while  its  persistency  may  be  due  to  many 
causes  too  numerous  to  mention.  It  is  a  very  common  occurrence  for  a 
chancre  to  remain  until  secondary  symptoms  break  out,  but  we  do  not 
therefore  conclude  that  both  belong  to  the  same  order.  In  the  same  way, 
secondary  manifestations  are,  in  some  exceptional  cases,  present  long  after 
tertiary  have  supervened.  Instances  of  this  coexistence  of  secondary 
and  tertiary  lesions  are  seen  in  cases  of  relapsing  papular  eruption, 
mucous  patches,  serous  iritis,  cephalalgias,  neuralgias,  and  afi'ections  of 
fibrous  and  serous  tissues. 

Many  syphilitic  lesions,  and  particularly  eruptions  upon  the  skin  and 
mucous  membranes,  may,  either  with  or  without  treatment,  disappear,  and 
again  return  within  a  limited  period  with  the  same  characters  as  at  first. 
This  tendency,  however,  as  a  rule  to  which  there  are  many  exceptions, 
ceases  with  time,  and  relapses  after  a  considerable  interval  are  in  all  cases 
rare.  For  instance,  syphilitic  erythema,  which  usually  appears  about  six 
weeks  after  the  development  of  the  chancre,  may  perhaps  return  as  late 
as  the  eighth  or  ninth,  and,  it  has  been  claimed,  the  eighteenth,  month,  but 
never  several  years  after  the  chancre.  Cases  of  so-called  tertiary  eryth- 
ema have  been  reported,  but  their  relation  to  syphilis  has  not  generally 
been  well  made  out.  Much  further  observation  must  be  made  before  we 
are  warranted  in  stating  that  there  is  such  a  definite  morbid  entity  as  ter- 
tiary syphilitic  erythema. 

Then,  again,  we  not  infrequently  see  cases  in  which  gummata  and 
tubercular  syphilides  relapse  for  many  years,  and  they  always  preserve 
their  characteristic  individuality  in  each  outbreak.  In  other  cases  these 
dermal  lesions  are  followed  at  varying  intervals  by  eye,  bone,  testicular, 
and  visceral  lesions,  and  perhaps  with  skin  lesions  of  a  diff'erent  character. 

With  the  expiration  of  the  second  period  of  incubation,  or  that  of  local 
manifestations,  the  secondary  stage  of  sypMUs — or,  as  it  is  called,  the 
stage  of  general  or  constitutional  manifestations  or  the  condylomatous 
stage — begins.  In  this  stage,  as  a  rule,  the  lesions  are  superficial,  and 
confined  largely  to  the  skin  amd  mucous  membrane,  consisting  of  erythem- 
atous, papular,  and  pustular  rashes.  The  duration  of  the  secondary  period 
of  syphilis  cannot  be  definitely  stated,  since  it  depends  largely  upon  the 
condition  of  the  constitution  and  the  habits  of  the  patient,  and  also  upon 
the  fidelity  with  which  he  follows  treatment.  In  the  vast  majority  of 
cases — certainly  in  those  in  which  there  is  no  organic  trouble — syphilis 
proves  a  very  tractable  and  curable  disease,  provided  patients  will  follow 
treatment  in  a  careful  and  systematic  manner  during  a  sufiicient  period  of 
time.  If  this  is  done,  the  disease  may  end  with  the  secondary  stage,  the 
patient  thereafter  remaining  healthy. 

The  tertiary  stage  of  syphilis  is  seen  to-day  in  America  much  less 
frequently  than  formerly,  OAving  very  largely  to  our  improved  modes  of 
treatment.  Indeed,  if  cases  of  tertiary  syphilis  are  critically,  but  in  an 
unbiassed  manner,  examined,  it  will  be  found  that  in  the  majority  the 


ITS  NATURE,  EVOLUTION,  AND  COURSE.  525 

long-drawn-out  course  of  the  disease  is,  in  most  instances,  due  to  neglect 
of  or  indifference  to  treatment,  or  to  the  baneful  effects  of  alcohol.  In  a 
small  proportion  of  cases,  however,  the  disease  takes  a  firm  hold  on  the 
patients  Avhose  tissues  seem  to  be  particularly  vulnerable  to  it,  and  in  such 
cases  the  usual  beneficial  results  of  treatment  are  slow  in  making  their 
appearance.     This  form  is  called  malignant  syphilis. 

The  severity  of  the  symptoms  produced  by  syphilis  on  its  first  appear- 
ance in  the  latter  part  of  the  fifteenth  century,  compared  with  its  greater 
benignity  at  the  present  day,  affords  some  ground  for  believing  that  the 
infection  is  slowly  but  gradually  losing  in  intensity,  in  the  same  manner 
as  the  vaccine  virus  becomes  weaker  after  many  successive  removes  from 
the  COW'.  This  fact  was  noticed  by  Astruc  in  the  middle  of  the  last  cen- 
tury, Avho  says  :  '•  Whatever  might  formerly  be  the  power  and  efficacy  of 
the  venereal  disease  when  it  was  new  and  in  vigor,  while  the  undivided 
poison  violently  effervesced,  there  is  nothing  like  it,  I  imagine,  to  be 
feared  from  it  now,  as  it  is  weakened,  become  old,  and  its  force  nearly 
spent." 

It  was  at  one  time  erroneously  supposed  that  the  first  manifestations 
of  syphilis  might  make  their  appearance  at  any  period  subsequent  to 
infection  and  to  the  development  of  the  initial  lesion ;  hence,  that  a 
man  who  had  once  contracted  a  chancre  was  never  safe,  no  matter  how 
long  a  time  had  been  passed  without  any  further  evidence  of  the  disease. 
It  is  now  known  that  if  general  manifestations  are  ever  to  appear  they  will 
show  themselves  within  the  comparatively  limited  period  just  specified. 

In  a  series  of  120  cases  observed  and  tabulated  by  me  the  shortest 
period  of  incubation  was  in  one  case  thirty-five  days,  and  the  longest 
eighty-two  in  one  case,  whereas  in  the  majority  the  general  manifesta- 
tions appeared  within  forty  and  fifty  days.  This  general  average  is  in 
accordance  with  the  results  of  observation  by  Bassereau,  De  Meric, 
Fournier,  Sigmund,  Ricord,  and  others. 

The  testimony  derived  from  artificial  inoculation  (which  has  the  ad- 
vantage that  all  the  steps  of  the  process  are  under  the  direct  observation 
of  the  surgeon)  is  essentially  the  same.  Thus,  in  12  cases  of  inoculation 
of  the  secretion  of  a  chancre,  the  mean  length  of  the  second  period  of 
incubation  was  forty-eight  days ;  in  14  cases,  in  which  the  secretion  of 
various  lesions  of  the  skin  and  mucous  membranes  was  employed,  it  Avas 
forty-five  days ;  in  4  cases,  however,  in  w*hich  the  matter  was  taken  from 
pustules,  it  was  eighty-two  days.  The  second  period  of  incubation  was 
also  prolonged  in  the  case  of  experimental  inoculation  with  syphilitic 
blood. 

The  practical  conclusions  to  be  derived  from  the  foregoing  facts  are 
as  follows : 

1.  It  is  advisable  in  all  ulcers  of  a  doubtful  character  to  defer  gen- 
eral treatment  and  keep  the  patient  under  careful  observation  until  the 
time  for  secondary  symptoms  to  appear  is  passed. 

2.  A  venereal  ulcer  which  is  not  subjected  to  specific  treatment 
(so  called)  will  usually,  if  at  all,  be  followed  by  secondary  symptoms 
within  fifty  days,  and  ahvays  within  six  months. 

3.  The  earliest  symptoms  of  general  syphilis  (except  in  cases  of 
hereditary  origin)  have  been  preceded  by  a  chancre,  probably  within 
fifty   days,   and  certainly  within  six  months. 


526  SYPHILIS. 

■X 

To  recapitulate :  The  primary  stage  of  syphilis  begins  with  the  act 
of  infection,  in  which  the  virus  is  deposited  upon  some  portion  of  the 
body,  genital  or  extragenital.  In  the  vast  majority  of  cases  no  evidence 
of  this  accident  is  seen,  and,  owing  to  various  causes,  such  as  promiscu- 
ousness  of  sexual  contact,  indifference,  and  failure  of  memory,  in  many 
cases  no  precise  data  can  be  obtained  concerning  it.  From  the  date  of 
infection  a  period  of  time  elapses  before  any  visible  manifestation  of 
syphilis  shows  itself,  which  is  called  the  first  period  of  ineuhation. 
Clinical  observations  and  experimental  inoculations  enable  us  to  say 
that  the  duration  of  this  period  may  be,  in  very  exceptional  cases,  as 
short  as  ten  days  and  as  long  as  seventy  days.  I  myself  have  seen  un- 
doubted instances  of  sixty  and  seventy  days'  primary  incubation.  In 
general,  however,  the  average  will  be  found  to  be  between  twelve  or  fifteen 
and  twenty-one  days.  At  the  expiration  of  this  time  the  hard  chancre 
or  initial  lesion  of  syphilis  shows  itself. 

With  the  appearance  of  the  hard  chancre  the  second  period  of  iyicu- 
hatio7i  of  syphilis  begins,  but  not  the  secondary  stage  of  the  disease. 
This  period  is  rather  more  regular  than  the  first  period  of  incubation, 
and  lasts  usually  about  forty  or  forty-five  days,  sometimes  as  long  as 
sixty,  and  very  exceptionally  seventy  and  ninety  days.  Cases  of  longer 
incubation  than  just  stated  should  be  received  Avith  much  caution  and 
the  elements  of  fallibility  carefully  probed.  The  length  of  the  secondary 
period  of  incubation  may,  to  a  certain  extent,  be  modified  by  influences 
which  may  govern  the  circulation,  such  as  heat  and  alcoholics.  In 
general,  in  hot  weather  the  end  of  the  secondary  period  comes  quite 
promptly,  while  in  cold  weather  it  may  be  delayed.  In  weakly,  thin, 
and  anaemic  subjects  the  second  period  may  be  much  prolonged.  I  re- 
cently waited  for  the  evolution  of  secondary  manifestations  in  a  cadav- 
erous young  man  for  eighty-two  days  before  they  appeared.  In  the  case 
of  a  man  forty-three  years  old  the  first  period  of  incubation  was  twenty- 
one  days.  On  the  forty-seventh  day  of  the  second  period  of  incubation 
he  was  attacked  with  severe  pleuro-pneumonia,  which  lasted  thirty-one 
days,  and  on  the  day  following  severe  general  syphilitic  manifestations 
showed  themselves.  In  this  case,  therefore,  the  secondary  period  of 
incubation  was  seventy-eight  days. 

The  morbid  phenomena  observed  during  this  period  of  incubation 
are  the  development  and  growth  of  the  initial  lesion  or  chancre,  and 
the  enlargement  of  the  inguinal  ganglia  in  immediate  anatomical  con- 
nection, which  becomes  appreciable  sometimes  as  early  as  the  fifth  day, 
but  usually  from  the  seventh  to  the  tenth.  In  some  cases  there  is  an 
induration  of  the  lymphatic  vessels  leading  from  the  chancre  to  the 
ganglia.  This  lymphatic  hyperplasia  goes  on  slowly  and  painlessly 
until  the  ganglia  become  much  enlarged.  These  two  periods  of  incu- 
bation, the  primary  and  the  secondary,  constitute  the  first  or  primary 
stage  of  syphilis,  which  may  occupy  in  its  evolution  from  sixty  to  ninety 
days,  rarely  longer.  The  disease,  then,  may  said  to  have  become  fully 
developed,  and  at  this  date  general  systemic  manifestations  and  symp- 
toms appear  which  constitute  what  is  called  secondary  syphilis. 

While,  in  general,  syphilis  runs  a  mild  course,  its  gravity  should 
never  be  underestimated.  On  this  subject  I  can  do  no  better  than  to 
quote  in  full  Fournier's  graphic,  eloquent,  and  in  every  way  admirable 


ITS  NATURE,  EVOLUTION,  AND   COURSE.  ^'21 

exordium  as  to  the  necessity  of  appreciating  the  nature  and  of  treating 
syphilis  (which,  by  the  way,  is  one  of  the  most  trenchant  passages  in 
syphilographical  literature),  for  the  reason  that  some  may  be  led  astray 
by  the  specious  arguments  of  those  who  claim  syphilis  to  be  a  disease 
of  decided  benignity.  He  says:  "  Is  it  or  is  it  not  necessary  to  treat  a 
syphilitic  patient  ?  Is  it  or  is  it  not  beneficial  that  he  should  be  treated  ? 
In  order  to  answer  a  proposition  thus  stated,  let  us  consider  what  risks 
such  a  patient  runs,  by  stating  his  condition  clearly.  To  what  dangers, 
in  fact,  is  he  exposed  ?  Let  us  set  forth  his  pathological  balance-sheet, 
if  I  may  speak  thus — a  balance-sheet  which,  if  not  certain  and  inevi- 
table, is  at  least  probable  and  possible.  What  can  such  a  patient  have  ? 
What  lesions  is  he  liable  to  develop  some  day  or  other  ?  And  these 
lesions,  are  they  of  such  a  character  that  it  will  be  urgent  or  advanta- 
geous that  they  should  be  treated  ?  What  he  can  have  are  at  first 
lesions  without  any  real  gravity,  but  which  are  at  least  very  disagree- 
able to  some,  particularly  if  they  are  visible :  thus  he  may  have  cuta- 
neous syphilides  of  various  forms,  very  annoying  syphilides  of  the 
mucous  membranes,  engorgments  of  the  ganglia,  alopecia,  and  onyxis. 
In  the  second  place,  there  are  more  serious  lesions,  from  the  fact  that 
some  of  them  are  very  painful :  they  are  angina,  cephalalgia,  various 
pains  wath  nocturnal  exacerbations,  insomnia,  myalgia,  pain  in  the 
joints,  inflammation  of  tendons,  periostitis,  etc.  Should  not  the  possi- 
ble anticipation  of  such  troubles  justify  the  intervention  of  treatment? 
But  we  have  really  a  third  order  of  lesions,  which  are  much  more  seri- 
ous and  Avhich  may  involve  and  compromise  important  organs.  Only 
to  cite  the  most  common  of  this  group,  Ave  shall  find  affections  of  the 
eye,  such  as  iritis,  choroiditis,  and  retinitis,  which  are  capable  of  im- 
pairing or  even  extinguishing  vision  ;  sarcocele,  Avhich  may  induce  dis- 
organization and  atrophy  of  one  or  both  testicles  and  thus  produce 
impotence ;  gummy  tumors,  which  often  perforate  and  destroy  the 
velum  palati  and  leave  a  double  and  revolting  infirmity ;  paralyses  of 
the  eye  and  face;  hemiplegia  and  paraplegia;  inflammation  of  bone, 
caries,  ozjena,  flattening  and  loss  of  the  nose;  without  speaking  of  the 
possibility  of  hereditary  transmission  and  of  the  introduction  of  syphilis 
into  the  family  circle.  But  this  is  not  yet  all.  If  we  consult  a  man- 
ual of  pathological  anatomy,  we  shall  find  there  described  fatal  lesions 
attributable  to  syphilis  alone.  The  causes  of  death  in  syphilis  are 
many  and  varied — death  by  hepatic  lesions,  cirrhosis,  and  hepatitis 
gummosa ;  death  by  lesions  of  the  meninges ;  by  cerebral  gummata 
and  syphilitic  encephalitis ;  by  lesions  of  the  spinal  cord,  which  are 
more  common  than  is  generally  believed ;  by  exostoses  of  the  cranium 
and  vertebra ;  by  lesions  of  the  kidneys,  of  the  larynx,  and  of  the 
lungs  ;  and,  more  rarely,  by  lesions  of  the  oesophagus  and  rectum  ;  death 
by  consumption  and  progressive  cachexia.  These  are,  in  short,  the 
possible  consequences  of  syphilis,  and  such  is  the  perspective  ofi'ered  to 
a  person  who  contracts  this  contagion.  Dare  we  call  a  disease  benign 
which  can  end  thus  ?  Can  a  disease  be  called  benign  which  is  fraught 
with  such  serious  accidents  and  Avhose  pathological  anatomy  is  so  rich 
and  varied  ?  Dare  we  tell  persons  afflicted  with  this  disease  to  leave  it 
untreated,  to  let  things  go,  and  to  Avait  patiently  the  possible  results  of 
such  an  infection,  Avithout  Avarning  them  of  it?" 


528  SYPHILIS. 


CHAPTER    LI. 

PATHOLOGY  OF  SYPHILITIC  INFECTION  AND  OF  THE   SYPHIL- 
ITIC PROCESSES. 

Considered  structurally,  syphilitic  inflammation  is  in  many  respects 
similar  to  tubercular  inflammation,  and  the  lesions  of  syphilis  viewed  as  a 
whole  resemble  tuberculosis  morphologically  more  closely  than  any  of  the 
other  classes  of  inflammation.  In  all  probability,  syphilis  is  also  due  to 
the  presence  in  the  body  of  some  form  of  bacterium  which  yields  a  spe- 
cific form  of  toxine  as  a  largely  instrumental  factor  in  producing  some  of 
the  syphilitic  manifestations. 

The  presence  of  such  a  bacterium,  however,  is  still  entirely  hypothet- 
ical :  we  do  not  know  with  certainty  of  any  such  organism,  and  the 
bacillus  occurring  in  small  numbers  in  syphilitic  lesions,  described  by 
Lustgarten,  furnishes  no  evidence  of  being  causally  associated  with  the 
disease.  This  alleged  bacillus  of  Lustgarten  has  never  been  isolated  and 
cultivated  on  artificial  media  or  subjected  to  inoculation-experiment,  nor 
has  this  discovery  of  Lustgarten  received  any  special  corroboration.  The 
analogy,  however,  which  syphilis  bears  to  other  specific  or  infectious  dis- 
eases in  which  the  bacterial  origin  is  quite  thoroughly  knoAvn  furnishes, 
as  we  have  already  seen,  strong  reasons  for  believing  in  a  similar  cause  for 
syphilis. 

With  the  exception  of  the  formation  of  gummata,  the  characteristic 
feature  of  the  secondary  and  tertiary  periods,  and  an  early  and  persistent 
involvement  of  the  blood-vessels  throughout  the  whole  course  of  the  dis- 
ease, the  lesions  of  syphilis  are  not  essentially  distinctive.  In  addition  to 
these  two  characteristic  lesions  of  syphilitic  inflammation,  a  third  and  rather 
deeply-rooted  tendency  exists  to  the  production  of  new  connective  tissue, 
especially  in  the  central  nervous  system  in  the  late  stages  of  the  disease, 
sometimes  years  after  the  invasion  of  the  primary  sore.  This  late  pro- 
duction of  connective  tissue  is  a  slow,  persistent,  gradually  progressive 
process,  and  many  of  the  scleroses  of  the  nervous  system — such  as  tabes 
dorsalis,  for  instance — may  be  ascribed  to  the  poison  of  syphilis.  Whether 
this  late  and  chronic  production  of  connective  tissue  in  the  nervous  system 
is  due  to  some  inherent  property  of  the  syphilitic  virus,  stimulating 
the  connective-tissue  cells  directly,  or  whether  the  new  tissue  grows  as  a 
result  of  the  tendency  of  syphilis  to  damage  the  blood-vessels,  is  not 
definitely  determined. 

Beyond  these  three  more  or  less  distinctive  traits  of  syphilitic  inflam- 
mation— viz.  the  gummy  tumor,  the  persistent  involvement  of  the  blood- 
vessels, and  the  late  and  gradual  production  of  new  tissue  in  the  central 
nervous  system — the  general  lesion  of  the  disease  is  the  occurrence  of 
more  or  less  circumscribed  tissue,  which  consists  of  small  round  cells,  or 
of  these  mingled  with  larger  polyhedral  cells,  or  occasionally  giant-cells. 
This  is  the  tissue  which  is  found  in  the  earlier  stages  of  the  disease  in  the 
initial  sores,  papules,  tubercles,  and  condylomata. 

This  newly-formed  richly  cellular  tissue,  occupying  large  or  small 
areas,  may  be  circumscribed  or  spread  out  more  diffusely,  especially  in 


PATHOLOGY  OF  SYPHILITIC  INFECTION,  ETC. 


529 


the  mucous  membranes.     These  foci,  as  a  rule,  contain  few  blood-vessels, 
and  tend  to  undergo  coagulation-necrosis,  and  to  disintegrate  at  their 

Fig  188 


Showing  the  chancre  (at  the  right  upper  part)  and  smaU  vessels  with  the  coat-sleeve  arrangement 
of  the  cell-infiltration  in  the  deep  connective  tissue  under  and  beyond  the  chancre.  (Vessels 
represented  by  red  dots  in  Figs.  188  and  189.) 

centres.     Finally,  they  may  be  converted  into  cicatricial  tissue.     The 
blood-vessels  near  these  inflammatory  foci  frequently  have  swollen  or  pro- 

FiG.  189. 


Showing  the  coat-sleeve  arrangement  of  the  cell-infiltration  in  the  skin,  far  away  from  the 
chancre,  which  part  to  the  eye  looks  healthy. 

liferating  endothelium  and  infiltrated  walls.     Later  on  the  blood-vessels 
may  become  diseased    independently  by  chronic  processes.     They  may 

34 


530 


SYPHILIS. 


Fig.  190. 


become  subject  to  thickening  or  obliterating  endarteritis,  or  otherwise 
undergo  extensive  changes. 

In  the  primary  lesion  or  chancre  there  is  a  small  round-celled  infiltra- 
tion of  the  connective  tissue,  proliferation  of  the  connective-tissue  cells, 

and  an  abundance  of  leucocytes.  (See 
Figs.  188  and  189,  from  a  section 
of  a  chancre  of  the  prepuce  of  four 
days'  duration.)  A  chancre  also  shows 
more  or  less  necrosis  or  degeneration 
of  its  constituent  cells.  An  uncom- 
plicated chancre  in  its  early  stages  is 
really  quite  identical  in  its  general 
structure  to  a  small  superficial  ulcer  or 
patch  of  granulation,  except,  however, 
in  the  chancre  there  is  distinctly  more 
necrosis  and  degeneration  of  its  con- 
stituent small  spheroidal  cells. 

The    blood-vessels    surrounding    the 
chancre,  as  well  as  those  some  consider- 
able distance  from  the  chancre,  even  in 
its    earliest   stages    of  development,  are 
quite   uniformly    changed.      (See   Figs. 
190    and    191.)      The   endothelial   cells 
are  swollen  or  proliferating,  the  walls  of  the  vessels  may  be  infiltrated 
(Fig.  190),  and,  finally,  the  perivascular  spaces  are  crowded  with  prolifer- 
ating polyhedral  cells  (Figs.  189  and  190). 


A  small  artery  taken  from  a  section  of 
the  tissue  depicted  in  Fig.  188,  more 
highly  magnified.  Both  the  middle 
and  outer  coats  of  the  vessel  are  infil- 
trated with  small  round  cells.  The 
lining  endothelial  cells  are  also 
swollen. 


Fig.  191. 


A  vein  just  below  the  bed  of  the  same  chancre  shown  in  Fig.  188.    The  lymph-space  about  the 
vein  is  distended  with  polyhedral  cells. 

While  this  condition  of  the  blood-vessels  may  be  found  associated  with 
other  forms  of  inflammation,  especially  when  the  vessel  is  directly  in  the 
path  of  an  advancing  inflammation  or  lies  on  the  border-line  of  the  nor- 


PATHOLOGY  OF  SYPHILITIC  INFECTION,  ETC. 


531 


mal  tissue,  in  a  chancre  the  extensive  distribution  and  early  involvement 
of  the  vessels  are  peculiar  and  characteristic.  The  extensive  distribution 
of  the  perivascular  changes,  their  topographical  arrangement,  and  early 
involvement  in  regions  slightly  beyond  the  chancre  are  the  striking  fea- 
tures in  the  initial  sore,  rather  than  any  peculiarity  of  the  structure  of  the 
lymph-space  lesion. 

There  are,  however,  certain  stages  in  the  development  of  chancroid  in 
which  the  perivascular  spaces  leading  from  this  form  of  sore  exhibit  a 
similar  condition,  and,  like  the  vessel-spaces  in  syphilis,  seem  to  be  prop- 
agating a  virus  to  the  inguinal  lymph-nodes. 

Thus,  Avhatever  the  causal  agent  of  syphilis  may   be,  it  very  soon 


Fig.  J  92. 


Fig.  193. 


^>T| 


\ 


Showing  dorsal  vein  of  penis,  which  is  the  seat 
of  early  peri-  and  endophlebitis  (chancre  near 
glans). 


Same  as  Fig.  192.  The  large  cords  repre- 
sent the  veins,  the  more  tortuous  ones 
the  lymphatics. 


reaches  the  perivascular  spaces  and  travels  nlong  these,  or  it  initiates  a 
proliferation  of  cells  in  the  lymph-spaces  about  the  vessels,  which  rapidly 
propagates  and  extends  along  these  spaces  to  more  distant  parts  of  the 
body. 

This  early  and  extensive  lesion  of  the  lymph-spaces  about  the  blood- 


532  SYPHILIS. 

vessels,  especially  the  smaller  veins,  enables  us  to  understand  more  def- 
initely how  the  virus  of  syphilis  spreads,  how  it  travels  along  these 
lymph-spaces,  accompanying  the  vessels  to  the  root  of  the  penis,  to  the 
first  set  of  lymph-nodes  which  such  a  set  of  perivascular  lymphatics  com- 
municate with — namely,  the  inguinal  ganglia.  From  these  inguinal  nodes 
the  cell-proliferation,  in  response  to  the  syphilitic  virus,  is  propagated,  it 
would  seem,  to  the  lymph-nodes  in  general  throughout  the  body  in  greater 
or  less  extent,  and  in  this  way  the  general  adenopathy  is  established. 
The  plates  of  Kulneif  ^  (Figs-  192  and  193)  of  St.  Petersburg  are  espe- 
cially instructive  in  this  connection,  and  show  this  extension  of  proliferat- 
ing cells  along  the  perivascular  lymph-spaces  from  the  primary  sore  to  the 
inguinal  lymph-glands.  Both  of  these  figures  illustrate  the  so-called 
lymphatic  cord  of  syphilis,  which  is  really  nothing  more  than  an  exten- 
sion, along  the  lymphatics  of  the  larger  veins,  of  the  same  process  in  the 
terminal  and  peripheral  perivascular  lymphatics  surrounding  the  chancre, 
already  shown  in  Figs.  188,  189,  and  190. 

Finally,  in  regard  to  this  extension  of  syphilis  through  the  perivas- 
cular spaces  from  the  primary  sore  to  the  inguinal  glands,  it  may  be 
pointed  out  that  it  occurs  very  early  and  proceeds  with  great  rapidity. 
As  soon  as  the  chancre  appears  the  network  of  peripheral  perivascular 
lymph-spaces  is  already  involved,  and,  as  indicated  by  the  line  of  pro- 

FiG.  194. 

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'i'"j^-      -     -  ,        . -  ,      .     ■  ., '^        •>■   -      ' i'fx £%,.■■•  ■!> 

^~-  ,         -  .      .  _       .  -,         .  ^^^^.-  -^ 


s--5-^s^MV^ri' .  ■'  .-"'■  ■■■■'  ■ 


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'J\c.     "-•'      i~^ 


V- 


From  a  section  of  a  chancre  of  the  prepuce  at  the  twentieth  day  from  its  first  appearance.  The 
indurating  oedema  corresponds  to  a  distention  and  infiltration  of  the  upper  layers  of  the  derma 
which  extends  as  a  zone,  a;,  x,  x,  about  the  centre  of  the  chancre  at  a.  The  infiltration  of  the 
walls  of  the  vessels  is  also  well  exhibited,  especially  at  6. 

liferating  cells  along  the  venous  lymph-spaces,  the  virus  is  already  on  the 
path  to  the  inguinal  lymph-nodes.  It  can  be  seen,  therefore,  that  it  is  im- 
possible to  stay  the  course  of  syphilis  by  excising  the  chancre.  Not  only 
the  chancre,  but  all  this  chain  of  venous  lymph-spaces  communicating 
with  the  inguinal  lymph-node,  would  also  have  to  be  removed  to  inter- 
rupt the  syphilitic  infection  of  the  body. 

^  "  On  the  Question  of  the  so-called  Lymphangitis  in  the  Early  Stage  of  the  Primary 
Syphilitic  Sclerosis,"  Inaug.  Dissert,  1889. 


PATHOLOGY  OF  SYPHILITIC  INFECTION,  ETC.  533 

The  stage  of  induration  or  indurating  oedema  remains  to  be  considered 
in  describing  the  structure  of  a  chancre.  If  a  chancre  at  the  well-pro- 
nounced stage  of  induration  be  examined  microscopically  (Fig.  194), 
it  will  be  seen  that  the  semi-necrotic  mass  of  small  spheroidal  cells  (Fig. 
194,  a)  composing  the  bed  and  main  bulk  of  the  ulcer  is  circumvallated 
by  a  zone  of  oedema  and  cellular  infiltration  of  the  papillary  portion  of 
the  derma  (Fig.  194,  a;,  x,  x).  Indurating  oedema,  then,  as  the  name 
implies,  is  a  wall  about  the  chancre  wherein  the  interfibrillary  spaces  of 
the  pars  papillaris  are  distended  with  fluid  and  small  round  cells  (Figs. 
194  and  195). 

Fig.  195. 


,;.  ,  .[.-.,■■'.»»<,••.■ 

'  •■'  .'■  ^' 

liiiii'l 

'    ''.'•■;  -''  ?  '/-' 

■0 

if;K':{'/-^;-r./.v'-.^y-:: :  ■:.;v:,.r... ^. 

;•■;  \^.yj''}^'/ff'^^^ 

y 

From  a  portion  of  the  section  corresponding  to  Fig.  194,  more  highly  magnified.    The  interfibril- 
lary sjjaces  of  the  upper  layers  of  the  derma  are  distended  with  fluid  and  small  round  cells. 

To  recapitulate  briefly  the  series  of  changes  in  a  chancre :  When  the 
causal  agent  of  syphilis,  presumably  some  form  of  bacterium,  enters 
through  the  skin  or  mucous  membrane,  it  excites  local  leucocytosis  and 
exudative  inflammation,  with  more  or  less  necrosis ;  there  are  also  prolif- 
eration of  the  connective-tissue  cells,  a  propagation  of  proliferating  cells 
along  the  perivascular  lymph-spaces,  and  later  a  wall  of  infiltration  and 
oedema  of  the  upper  corium  layers  formed  about  the  periphery  of  the 
ulcer  corresponding  to  the  stage  of  indurating  oedema.  Finally,  the  sore 
tends  to  heal  and  become  converted  into  scar-tissue. 

Following  the  initial  sore  there  may  be  inflammation  of  the  lymph- 
nodes,  of  the  skin  and  mucous  membranes,  of  the  bones,  and  of  several 
viscera,  which  are  structurally  similar  in  each  case. 

Although  not  confined  strictly  to  the  secondary  stage  of  syphilis,  the 
gummy  tumors  or  gummata  form  the  distinctive  feature  of  this  stage,  and, 
structui'ally,  are  characteristic  of  syphilis.  A  small  gumma  consists  of  a 
mass  of  small  spheroidal  and  epithelioid  cells,  and  occasionally  giant-cells. 
Small  gummata  may  resemble  miliary  tubercles  so  closely  that  from  mi- 
croscopical appearances  alone  it  is  difficult  to  distinguish  them  apart. 
The  larger  gummata  have  rather  characteristic  gross  appearances :  to  the 


634  SYPHILIS. 

naked  eye  they  appear  as  grayisli-white,  rather  firm,  spherical  nodules ; 
they  generally  have  a  firm,  cheesy  centre  and  a  translucent  pearly  capsule 
mergino'  into  the  surroundincr  tissue.  In  structure  such  a  s;umma  has  a 
granular  necrotic  centre  surrounded  by  a  connective-tissue  envelope,  which 
is  generally  infiltrated  Avith  small  round-cells  and  sends  off"  prolongations 
into  the  surrounding  tissue,  so  that  when  situated  in  the  viscera  the 
gumma  is  quite  sharply  circumscribed.     (See  Fig.  196.) 

Fig.  196. 


;i.-'4;^;^'l    .  -•.> 


':'yf 

/0  ■^■•^s:^';^:(>fev5^ 


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A  gumma  of  the  liver  which  has  a  cheesy  centre,  a  connective-tissue  capsule  with  processes 
extending  into  the  surrounding  tissue,  and  infiltration  of  the  same  with  small  round  cells. 

This  description  outlines  the  broader  features  of  syphilitic  inflamma- 
tion as  a  phase  or  variety  of  inflammation  in  general,  but  we  cannot  in- 
terpret these  morbid  changes  very  intelligently  until  the  micro-organism 
of  syphilis  is  discovered  and  the  nature  and  action  of  its  toxine  is 
learned. 

The  chronic  production  of  neuroglia  in  the  central  nervous  system, 
due  to  syphilis,  should  not  be  confused  with  a  more  specialized  form  of 
syphilis  of  the  nervous  system  which  not  infrequently  occurs  in  untreated 
or  badly-treated  cases.  This  foi-m  of  involvement  of  the  nervous  system, 
termed  usually,  and  badly,  "syphilis  of  the  nervous  system,"  may  occur 
moderately  early  in  the  disease.  It  has  a  subacute  character,  is  prone  to 
occur  in  a  disseminated  form,  especially  in  the  spinal  cord,  and  consists 
of  masses  of  small  round  or  fusiform  cells,  which  involve  either  the  gray 
or  Avhite  matter. 


VEHICLES  OF  INFECTION.  535 


CHAPTER   LII. 

VEHICLES  OF  SYPHILITIC  INFECTION;  NORMAL  SECRETIONS 
NON-INFECTIOUS ;  AND  THE  VARIOUS  MODES  OF  SYPHILITIC 
INFECTION. 

Vehicles  of  Syphilitic  Infection. 

Clinical  observation  and  experimental  inoculations  have  proved  be- 
yond a  doubt  that  the  secretion  of  the  initial  lesion  contains  in  a  high  degree 
the  virus  of  syphilis.  It  is  from  the  secretions  of  the  initial  lesion  that 
the  infection  with  the  disease  is  derived  in  the  great  majority  of  cases. 

Equally  as  virulent  are  the  secretion  and  the  tissue-detritus  of  the 
secondary  lesions  known  as  condylomata  lata  and  mucous  patches  which 
occur  so  frequently  in  and  about  the  mouth  and  face  and  on  the  genital 
and  anal  regions.  Numerous  experimental  inoculations  have  been  made 
with  these  secretions  the  results  of  which  prove  beyond  any  doubt  their 
infectious  quality.^  By  some  observers  it  is  held  that  these  secretions  are 
the  most  common  sources  of  syphilitic  infection.  They  in  all  probability 
rank  next  in  point  of  frequency  of  infection  to  that  of  the  initial  lesion, 
for  the  reason  that  they  are  seated  on  exposed  parts  and  parts  with  which 
others  are  liable  to  come  in  immediate  contact. 

Experimental  inoculations  (of  course  upon  human  subjects,  since 
animals  are  immune)  have  proved  beyond  all  doubt  that  the  secretions 
from  pustules,  from  syphilitic  tubercle,  and  from  ulcers  and  papules  pro- 
duce typical  syphilitic  infection  in  the  person  operated  upon. 

Numerous  experimental  inoculations,  already  alluded  to,  with  the  blood 
of  syphilitics  have  given  rise  to  well-marked  instances  of  syphilitic  infec- 
tion. Clinical  observation  has  frequently  confirmed  the  results  of  experi- 
mentation as  to  the  infectious  quality  of  the  blood  of  syphilitic  subjects. 

It  seems,  however,  that  it  is  only  in  the  quite  early  period  of  the 
disease,  Avhen  the  infection  is  active,  that  the  blood  is  most  poisonous. 
With  the  decline  of  the  disease,  particularly  when  it  has  been  profoundly 
modified  by  mercurial  treatment,  the  blood  becomes  more  and  more  feebly 
infectious,  so  that  in  general  after  one  or  two  years'  thorough  treatment 
it  is  harmless.  At  best  it  is  the  least  infectious  of  all  syphilitic-bearing 
secretions  or  fluids. 

The  initial  lesion  of  syphilis,  therefore,  has  its  origin — 

1.  In  the  secretion  of,  and  organized  matter  derived  from,  a  previous 
hard  chancre  or  initial  lesion  ; 

2.  In  the  secretions  and  the  organized  matter  of  the  secondary  lesions 
of  syphilis,  whether  of  the  skin  or  of  the  mucous  membrane:  that  of 
mucous  patches  and  condylomata  lata  has  been  shown  to  be  especially 
contagious,  and  that  of  papules  and  tubercles  less  so ; 

3.  In  the  secretions  of  hereditary  syphilis  in  its  active  state,  which 
arise  from  buccal  mucous  patches  or  erosions,  condylomata  lata  of  the 
mouth  or  anus,  and  also  from  ulcerated  tubercular  lesions ; 

4.  In  the  blood  of  persons  in  the  active  state  of  syphilis :  the  lymph 
also  may  communicate  the  disease. 

'  Auspitz,  op.  cit.,  p.  101  et  seq. 


536  SYPHILIS. 

Such  is  the  bland,  unirritating  character  of  the  various  infecting 
secretions  of  syphilis  that  it  is  very  probable  a  door  of  entry,  such  as  a 
fissure,  an  abrasion,  or  other  denuded  surface,  perhaps  so  small  as  not  to 
be  visible,  is  generally  necessary  for  their  introduction.  It  is  claimed, 
however — and  no  doubt  reasonably — that  the  virus  may  penetrate  the 
thin,  soft,  and  moist  epithelium  of  mucous  membrane.  Clinical  facts 
show  clearly  that  it  may  penetrate  into  the  orifices  of  the  mucous  and 
sebaceous  follicles,  and  in  them  take  root. 

Syphilis  pursues  essentially  the  same  course  whether  derived  from 
a  primary  or  secondary  lesion ;  in  the  latter  case,  as  in  the  former,  the 
initial  lesion  is  a  chancre. 

It  is  conceded  by  most  authorities  that  only  the  secretions  of  secondary 
lesions  are  infectious,  and  those  of  the  tertiary  period  are  inert.  Unfor- 
tunately, we  are  not  in  possession  of  enough  knowledge  upon  this  subject 
to  make  positive  statements.  It  is  very  certain  that  when  the  disease  is 
active,  as  shown  by  the  extent  and  severity  of  its  lesions,  the  secretions 
of  its  bearer  are  markedly  infectious.  As  time  passes  the  morbid  condi- 
tion tends  in  most  cases  to  attenuation,  and  the  infectious  nature  of  the 
secretions  grows  less.  There  is  a  natural  tendency  in  very  many  cases 
for  the  disease  to  grow  less  and  less  active  until  in  the  end  its  virulence 
may  be  lost.  This  gradual  extinction  of  the  disease  may  take  place  spon- 
taneously without  the  aid  of  therapeutics,  but  this  natural  involution  can 
never  be  relied  upon.  The  most  potent  element  in  curing  the  disease  and 
in  rendering  the  subject  incapable  of  infecting  others  by  any  means  is 
active  and  energetic  treatment  kept  up  for  the  first  two  years  or  longer. 
Under  proper  treatment  the  infectiousness  of  the  disease  more  or  less 
rapidly  diminishes,  and  finally  becomes  extinct.  My  studies  and  obser- 
vations have  convinced  me  that  in  the  majority  of  cases  in  which  the 
treatment  has  been  ample  and  well  directed  a  cure  is  obtained  in 
two  or  three  years,  and  then,  of  course,  the  subject  does  not  give  forth 
infectious  secretions.  It  is  very  probable  that  the  secretions  and  tissue- 
elements  of  many  of  the  tertiary  lesions,  particularly  when  they  are  active 
and  numerous  and  occurring  within  three,  four,  or  five  years,  may  be 
endowed  with  a  virulent  power,  and  that  as  they  grow  older  and  less 
numerous  they  may  lose  this  virulence.  We  are  sadly  in  want  of  exact 
knowledge  on  this  important  subject. 

The  Normal  Secretions  in  Syphilitic  Subjects. 

The  normal  secretions  of  a  syphilitic  subject  do  not  of  themselves 
contain  any  virulent  principle.  They  may  be  contaminated  by  admixture 
of  secondary  secretions  and  of  the  tissue-elements  of  secondary  lesions, 
and  by  blood.  The  saliva  is  perfectly  harmless  if  the  patient's  mouth  is 
free  from  syphilitic  lesions  and  erosions  or  fissures.  This  has  been  clearly 
proved  by  the  classical  experiments  of  Diday  and  Profeta,  which  need  not 
be  detailed  here.  When  mucous  patches,  condylomata  lata,  and  buccal, 
tonsillar,  and  pharyngeal  hyperplasiffi,  excoriations,  and  fissures  exist  in 
the  mouth,  the  saliva  is  contaminated  by  their  secretions,  and  is  then 
potently  infectious.  Since  it  is  so  common  to  see  lesions  of  continuity  in 
the  mouth  of  syphilitics,  it  is  the  duty  of  the  surgeon  to  be  always  on  the 
watch  for  them  and  to  warn  patients  to  avoid  kissing.     Indeed,  as  a  rule, 


VEHICLES   OF  INFECTION.  537 

all  subjects  of  syphilis,  even  tliougli  their  mouths  seem  to  be  healthy, 
should  avoid  the  contact  of  this  part  'with  healthy  individuals  until  they 
are  pronounced  cured  by  the  surgeon. 

The  experiments  of  Vidal  have  shown  that  the  tears  are  innocuous. 
Any  secreting  syphilitic  lesion  of  the  eyes,  such  as  chancre  or  mucous 
patch  of  the  conjunctiva  and  secondary  hyperplasia  of  the  caruncle,  may 
of  course  contaminate  this  secretion. 

The  semen  of  a  man,  even  in  the  secondary  stage  of  syphilis,  is  not 
per  se  an  infectious  fluid.  It  may  remain  on  the  mucous  membrane  of 
the  female  genitals  for  a  long  time  without  causing  any  bad  result.  It 
does  not  contain  an  active  virulent  principle.  This  Avas  w^ell  shown  by  a 
number  of  well-performed  experiments  by  Mireur,  who  first  produced 
excoriations  upon  healthy  subjects  by  instruments  and  by  blistering,  and 
then  placed  upon  them  the  semen  of  a  man  suifering  severely  from  sec- 
ondary syphilis.  In  his  four  experiments  absolute  failure  to  inoculate 
resulted. 

When  the  semen  of  a  man  suffering  from  an  active  form  of  syphilis 
fecundates  the  female  ovum,  in  the  majority  of  cases  he  transmits  the  dis- 
ease to  the  infant.  In  this  way  alone  is  the  semen  of  the  syphilitic  man 
dangerous. 

There  are  a  number  of  cases  reported  in  literature  in  which  it  is 
claimed  that  women  were  directly  infected  by  the  semen  of  syphilitic  men, 
the  more  notable  ones  being  those  of  Smith  and  Jordan.  Years  ago  I 
submitted  all  the  cases  of  this  so-called  method  of  infection  to  a  rigid  and 
impartial  examination  and  analysis,  which  need  not  be  detailed  here,  and 
the  conclusion  reached  was  that  the  infection  was  due  to  blood  exuding 
in  the  sexual  act  from  the  penis  upon  some  abrasion  or  fissure  of  the 
female  genitals.  Seeing  that  nearly  twenty  years  have  elapsed  since  a 
case  of  this  alleged  mode  of  infection  has  been  reported,  it  may  be  inferred 
that  there  are  no  longer  any  believers  in  it. 

The  milk  of  the  syphilitic  woman  does  not  possess  infectious  qualities. 
Padova  and  Profeta  made  inoculations  and  injections  upon  healthy  per- 
sons with  this  secretion  derived  from  an  infected  woman,  and  were  re- 
warded with  uniformly  negative  results.  In  like  manner  the  sweat  has 
been  shown  to  be  innocuous  upon  careful  and  intelligent  experimental 
inoculation. 

It  is  to  be  presumed  that  the  urine  of  syphilitic  subjects  does  not  con- 
tain the  germs  of  the  disease. 

Modes  of  Infection. 

These  are,  first,  direct  contact ;  second,  mediate  infection  ;  and  third, 
hereditary  transmission.  We  are  warranted  in  assuming  that  in  all  in- 
stances of  syphilitic  infection  there  is  a  lesion  of  continuity  or  gap  in 
the  epithelium  of  the  skin  or  mucosa. 

Infection  by  direct  contact  is  the  most  common  mode  of  contamination, 
and  the  sexual  act  is  the  one  by  which  the  disease  is  in  most  cases  given 
and  received. 

Direct  syphilitic  infection  frequently  occurs  in  unnatural  and  beastly 
methods  of  indulgence  between  persons  of  the  same  and  the  opposite  sex. 
In  this  way  are  developed  chancres  of  the  anus,  of  the  tongue,  of  the 
folds  between  the  breast  and  the  sides  of  the  chest,  of  the  axillae,  and  of 


538  SYPHILIS. 

the  tonsils.  I  have  known  several  instances  in  whiph  men  were  infected 
upon  the  penis  bj  contact  ah  ore  with  men  or  women  who  had  syphilitic 
lesions  in  their  mouths.  Several  men  have  told  me  that  they  followed 
this  practice,  thinking  that  by  it  they  would  escape  syphilitic  infection. 

Kissing  also  is  a  prolific  source  of  infection,  and  by  this  act  chancres 
of  various  parts  of  the  body  ai'e  produced. 

Not  infrequently  hereditarily  syphilitic  children  infect  their  nurses 
upon  the  nipple  from  mucous  patches  in  the  mouth.  Then,  again,  chil- 
dren have  been  infected  from  chancres  or  condylomata  lata  on  the  nipples 
of  their  nurses. 

I  have  a  number  of  times  seen  chancres  of  the  nipple  in  women  pro- 
duced by  suction  of  ar  man  having  mucous  patches  in  his  mouth.  Then, 
again,  I  have  seen  two  instances  of  chancre  of  the  nipple  in  men  con- 
tracted from  the  mouths  of  syphilitic  women  in  the  act  of  suction. 

There  are  in  literature  many  cases  reported  in  which  syphilitic  mid- 
wives,  usually  of  the  lower  classes,  have  infected  nursing  women  with 
syphilis  upon  the  nipple  in  the  act  of  suction  or  drawing  the  breast, 
which  they  sometimes  perform. 

In  some  European  countries,  particularly  Roumania,  a  singular  mode 
of  transmission  is  said  to  occur.  It  is  the  custom  there  to  attribute  all 
affections  of  the  eyes  to  foreign  bodies,  for  the  relief  of  which  there  is  a 
class  of  women,  called  "leeching  oculists,"  who  suck  or  cleanse  the  eye- 
lids with  their  tongues.  One  of  these  women,  having  mucous  patches  in 
her  mouth,  conveyed  the  disease  to  many  persons. 

Syphilitic  infection  is  sometimes  produced  during  brawls  and  fights  in 
which  an  infected  person  bites  his  or  her  antagonist.  In  this  way,  also 
in  exuberant  embraces  between  the  sexes,  one  or  the  other  sometimes 
becomes  syphilitic.  I  vividly  recall  the  case  of  a  lady  who  had  a  hard 
chancre  under  her  chin  who  was  playfully  bitten  by  a  syphilitic  lover, 
and  that  of  a  gentleman  having  a  chancre  of  the  neck  who  was  bitten  in 
an  amorous  encounter  with  a  puella  jnihlica. 

Surgeons  ver}'-  frequently  contract  syphilis  on  cuts  and  abrasions 
about  the  fingers  and  hands  when  operating  upon  syphilitic  subjects. 
Physicians,  accoucheurs,  and  midwives  also  frequently  contract  syphilis 
in  vaginal  examinations  of  infected  women.  They,  in  turn,  have  been 
known  to  spread  infection  far  and  wide  in  an  epidemic  form  by  infecting 
women  during  examinations  about  the  genitals  by  means  of  their  finger- 
chancres.  From  the  infected  wives  the  husbands,  children,  and  friends 
have  become  contaminated. 

There  are  many  cases  in  literature  in  which  syphilis  has  been  commu- 
nicated in  the  operation  of  tattooing,  the  operator  using  his  own  saliva, 
which  was  contaminated  by  the  secretion  of  raucous  patches.^ 

In  the  operation  of  skin-gi-afting  the  disease  has  been  given  to  the  per- 
son operated  upon  by  the  graft,  which  was  derived  from  a  syphilitic  subject. 

Dentists  sometimes  contract  syphilis  from  the  mouths  of  infected  cli- 
ents, and  it  is  very  probable  that  the  latter  are  sometimes  infected  by 
means  of  instruments  smeared  with  active  syphilitic  secretions.  It  is  a 
good  rule  to  avoid  the  services  of  a  careless  or  uncleanly  dentist. 

1  The  details  of  these  interesting  cases  would  require  too  much  space.  The  reader 
will  find  them  in  Dr.  Buckley's  work,  Syphilis  of  the  Innocent,  which  gives  a  comprehen- 
sive, up-to-date  bibliography  of  published  cases  of  extragenital  chancres. 


VEHICLES  OF  INFECTION.  539 

In  ritual  circumcision,  when  the  flow  of  blood  is  stanched  by  immer- 
sion of  the  infant's  penis  in  the  mouth  of  the  operator,  there  is  danger  of 
syphilitic  infection. 

In  these  days,  when  pure  bovine  virus  is  used  in  vaccination,  there 
is  no  possibility  of  the  transmission  of  syphilis  by  that  secretion.^  The 
danger  arises  in  carelessness  on  the  part  of  the  operator  in  using  a  soiled 
scarificator.  In  the  hurry  incident  to  the  vaccination  of  many  persons 
the  surgeon  is  liable  to  become  careless  and  to  fail  to  cleanse  his  instru- 
ment  after  each  operation.  In  this  way  it  may  happen  that  a  syphilitic 
patient  may  be  vaccinated  and  the  instrument  used  may  become  smeared 
with  blood  and  tissue-debris.  Then,  if  this  instrument  is  used  to  scarify 
the  next  subject  without  having  been  cleansed  or  subjected  to  a  flame, 
this  blood  and  these  tissue-elements  are  firmly  implanted  upon  and  into 
his  or  her  excoriated  surface,  and  it  is  pretty  certain  that  syphilitic  infec- 
tion will  be  produced.  I  saw  a  striking  instance  of  this  form  of  trans- 
mission of  syphilis  many  years  ago  when  most  of  the  inmates  of  the 
Blackwell's  Island  penitentiary  were  vaccinated.  The  victim  was  a  baby, 
the  ofi"spring  of  a  convict  mother,  and  the  source  of  the  infection  was  a 
female  prostitute  suff"ering  from  active  secondary  syphilis  who  was  vacci- 
nated immediately  before  the  infant.  The  golden  rule  of  action  under 
these  circumstances  is  to  have  an  alcohol  flame  at  hand,  and  to  submit 
the  scarificator  to  it  after  each  operation.  A  longer  time  will  of  course 
be  required,  but  there  would  be  no  fear  of  syphilitic  infection. 

Mediate  Infection. — In  this  form  of  infection  the  disease  is  com- 
municated by  means  of  articles,  implements  or  instruments  which  have 
become  smeared  or  impregnated  with  the  syphilitic  virus.  In  the  cases 
of  this  form  of  infection  the  contaminated  parts  are  most  commonly  the 
lips,  the  gums,  the  mouth,  and  the  eyelids.  Any  part  of  the  integument 
and  of  the  genitals  may  also  be  the  seats  of  infection.  The  following  list 
includes  most  of  the  articles  and  instruments  which  have  been  found  to 
be  the  agents  of  mediate  syphilitic  infection  :  cigars,  cigar-  and  cigarette- 
holders,  pipes,  tooth-brushes,  tooth-powders,  drinking  utensils,  knives, 
forks,  spoons,  razors,  towels,  sponges,  pillows,  masks,  gloves,  wash-rags, 
linen  thread,  silk  thread,  pins,  needles,  children's  toys,  nursing-bottles, 
rubber  tubes,  babies'  rubber  rings,  trousers,  women's  drawers,  bandages, 
surgical  and  cupping  instruments,  manicure  instruments,  syringes,  scari- 
fiers, dental  implements  and  appliances,  caustic-holders,  blowpipes,  paper- 
cutters,  lead-pencils,  speaking-trumpets,  musical  instruments,  fish-horns, 
whistles,  the  mouth-piece  of  the  telephone,  chewing-gum,  and  even  pas- 
tilles and  candy. 

There  is  a  mode  of  syphilitic  infection  which  has  not  yet  been 
described — it  is  really  auto-infection.  It  generally  occurs  in  this  Avay :. 
A  man,  fearing  to  contract  venereal  diseases  or  for  other  reasons,  contents 
himself  with  a  digital  exploration  or  fondling  of  the  female  genitals. 
Upon  the  latter  condylomata  lata  or  syphilitic  excoriations  being  present, 
the  fingers  of  the  man  become  soiled  with  their  secretion.  Then  by  acci- 
dent the  virus  is  transferred  by  the  finger  or  fingers  of  the  man  to  some 
other  part  of  his  own  body,  generally  by  scratching  or  picking.  In  this 
mode  the  finger  becomes  a  medium  of  infection,  and  the  infected  parts  are 

^  The  reader  is  referred  to  an  exhaustive  discussion  of  this  subject  by  Fournier,  enti- 
tled Lemons  sur  la  Syphilis  vaccinale,  Paris,  1889. 


540  SYPHILIS. 

usually  the  alse  nasi,  the  tip  of  the  nose,  the  chin,  the  cheek,  the  neck, 
the  arm,  and  the  back  of  the  hand. 

It  is  rather  revolting  to  one's  feeling  to  put  the  matter  on  paper,  but 
the  interests  of  medical  science  certainly  warrant  the  recital.  I  have  seen 
two  cases  in  educated  and  religious  people  in  which  the  weight  of  evidence 
strongly  pointed  to  the  origin  of  their  labial  chancres  in  the  communion 
cup.  KnoAving  as  we  do  so  well  that  many  innocent  persons,  particularly 
women,  become  unconscious  victims  of  syphilitic  infection  and  still  follow 
the  observances  of  a  religious  life,  it  is  not  far-fetched  to  assume  that 
their  diseased  mouths  may  contaminate  the  sacred  chalice. 


CHAPTER    LIIL 
THE  CHANCRE,  OR  THE  INITIAL  LESION. 

At  the  end  of  the^rs^  'period  of  incubation  the  first  evidence  of  syphi- 
litic infection  shows  itself  in  the  form  of  a  small  and  usually  innocent- 
looking  lesion,  which,  as  we  have  seen,  is  called  the  initial  lesion,  the 
Hunterian  chancre,  and  by  other  terms.  In  the  great  majority  of  cases 
the  initial  lesion  is  seated  on  the  sexual  organs,  and  it  is  then  termed 
genital  chancre,  Avhile  that  found  elsewhere  on  the  body  is  called  extra- 
genital chancre. 

This  first  period  of  incubation,  as  we  have  seen,  varies  in  length 
between  twelve  and  thirty,  and  most  exceptionally  forty,  fifty,  sixty,  and 
seventy,  days.  It  follows,  therefore,  that  if  a  man  seeks  information  as 
to  his  chances  and  condition  after  a  suspected  or  suspicious  coitus,  he  must 
be  told  that  at  any  time  between  the  fifteenth  and  sixtieth  or  seven- 
tieth days  the  chancre  may  appear,  and  that  he  must  be  constantly  on 
the  watch  for  it,  for  his  own  benefit  in  promptly  seeking  treatment  and  for 
the  protection  of  women  with  whom  he  may  have  intercourse.  In  the 
vast  majority  of  cases  it  is  not  necessary  to  prolong  a  man's  anxiety  and 
even  agony  beyond  thirty  days. 

It  is  very  important  that  clear  ideas  should  be  held  as  to  the  indura- 
tion of  chancres.  The  terms  hard  and  indurated  chancres  act  as  stumbling- 
blocks  to  very  many  physicians  in  their  estimate  of  the  nature  of  genital 
ulcers  and  lesions.  The  tendency,  I  observe,  has  been  not  so  much  to 
form  an  opinion  by  a  consideration  of  the  physical  appearance  of  a 
given  lesion  as  by  its  relative  hardness  and  softness  of  structure. 
When  a  genital  lesion  is  brought  to  the  attention  of  the  surgeon,  he 
instinctively  feels  of  it,  and  in  general,  if  he  can  find  no  resistance  or 
induration,  he  at  once  pronounces  it  to  be  a  soft  sore,  or  chancroid.  In 
this  way  mistakes  in  diagnosis  are  made  every  day.  Now,  in  the  outset 
it  is  important  to  know  that  induration  is  not  present  in  primary  syphilitic 
lesions  in  their  early  days.  The  cell-proliferation  which  gives  rise  to  the 
symptom  of  induration  goes  on,  as  a  general  rule,  slowly,  and  it  is  seldom 


THE  CHANCRE,    OR   THE  INITIAL  LESION.  541 

clearly  and  sharply  appreciable  before  the  tenth  day ;  and  in  broad, 
general  terms  it  may  be  stated  that,  as  a  rule,  fourteen  days  elapse  before 
sharply-marked,  circumscribed,  easily  appreciable  induration  is  present  in 
a  primary  syphilitic  sore. 

In  a  large  majority  of  cases  there  is  but  one  chancre  or  initial  lesion, 
but  it  is  not  at  all  uncommon  to  see  two  or  three,  and  exceptionally  four, 
six,  seven,  and  even  more,  initial  lesions.  There  is  a  deep-rooted  and 
widely  prevalent  view  in  the  minds  of  many  medical  men  that  the  initial 
lesion  is  invariably  solitary,  and  that  when  several  genital  ulcers  and 
even  excoriations  are  seen  they  must  be  chancroids.  As  a  result  of  this 
an  incalculable  number  of  mistakes  in  diagnosis  are  constantly  made, 
which  result  in  disappointment  and  often  disgust  to  the  patient,  and  in 
deep  chagrin  to  the  surgeon.  This  opinion  is  a  relic  of  the  old-time  over- 
elaborated  differential  diagnosis  between  the  chancre  and  the  chancroid. 
Dualists  harped  upon  the  solitary  chancre  and  the  multiple  chancroid.  It 
must  be  remembered  that  a  multiplicity  of  lesions  is  only  measurably  pre- 
sumptive of  their  being  chancroids,  and  that  there  is  a  large  chance  that 
they  may  be  hard  chancres  ;  consequently,  their  examination  should  always 
be  very  carefully  and  thoroughly  made.  The  penis,  the  female  genitals, 
the  female  breasts,  and  the  cephalic  regions  are  the  parts  upon  which 
multiple  lesions  are  most  commonly  found. 

In  the  male  chancres  are  found  on  the  glans,  on  the  prepuce,  on  the 
skin  of  the  penis,  on  various  parts  of  the  penis,  involving  the  meatus, 
within  the  urethra  (not  visible  on  forced  separation  of  the  lips  of  the 
meatus,  but  recognized  by  palpation,  inflammation  of  the  lymphatics,  etc.), 
on  the  scrotum  and  peno-scrotal  angle,  the  anus,  the  lips,  the  tongue,  the 
gums  and  hard  palate,  the  pharynx,  including  the  tonsils,  the  nose,  the 
pituitary  membrane,  the  eyelids,  the  fingers,  and  on  the  legs. 

In  women  chancres  are  found  on  the  labia  majora,  at  the  entrance  of  the 
vagina,  the  meatus,  the  nymphse,  the  fourchette,  the  sheath  of  the  clitoris, 
the  anus,  the  buttocks,  the  thighs,  the  lips,  the  labial  commissures,  the 
nostrils,  and  the  breasts,  one  or  both. 

As  we  have  seen  in  the  previous  chapter,  the  initial  lesion  consists  of  a 
localized  mass  or  tumor  of  granulation-tissue.  In  its  very  earliest  stages 
it  consists  of  small  round-cells  which  are  seated  in  coat-sleeve-like  arrange- 
ment around  the  vessels.  In  this  condition  the  symptom  of  induration 
cannot  be  clearly  defined.  As  the  lesion  grows  older  these  cells,  Avhich 
some  think  are  emigrated  white  blood-corpuscles,  become  more  numerous 
and  closely  packed,  and  they  develop  into  elongated  connective-tissue 
cells.  When  this  occurs  induration  is  perceptible  to  the  touch.  Besides 
these  component  parts — namely,  infiltrated  blood-vessels,  small  round 
cells,  and  spindle-shaped  cells — there  are  intermixed  among  them  cells 
resulting  from  hyperplasia  of  the  fixed  connective  tissue.  These  ele- 
ments, therefore,  constitute  what  we  call  the  hard  or  indurated  chancre. 

Appearance  of  the  Initial  Lesion  or  Chancre. 

It  is  very  necessary  that  the  diagnosis  of  the  chancre  should  be  made 
early,  since  a  prompt  recognition  of  its  highly  infectious  nature  may  save 
other  persons  from  contamination.  In  its  early  stages  the  chancre  is  such 
a  seemingly  trifling  and  innocent  lesion  that  its  virulence  is  very  apt  to 
be  overlooked. 


542  SYPHILIS. 

There  are  six  conditions  under  ■v\-liicli  chancres  appear  at  their  very 
beginning  :  these  are — First,  the  chancrous  erosion ;  second,  the  silvery 
spot ;  third,  the  dry  papule  or  patch  ;  fourth,  the  umbilicated  papule  or 
nodule  or  follicular  chancre ;  fifth,  the  purple  necrotic  nodule ;  and,  sixth, 
the  ecthymatous  chancre. 

Besides  the  six  type  forms,  there  are  the  following  varieties  which  are 
due  to  certain  changes  to  which  the  primary  sore  is  liable :  the  ulcus 
elevatum,  multiple  herpetiform  chancre,  the  parchment  chancre,  the 
annular  chancre,  the  indurated  nodule  or  mass,  the  chancre  with  cream- 
green  membrane,  and  infecting  balano-posthitis. 

The  Chancrous  Erosion. — The  chancrous  erosion,  by  far  the  most  com- 
mon form,  is  really  the  primordial  lesion  from  which  all  chancres  develop. 
It  begins  as  a  minute,  sharply-rounded  excoriated  spot,  the  surface  of 
which  is  on  a  level  with  the  surrounding  parts.  It  looks  exactly  like  an 
erosion  or  shedding  of  the  uppermost  epithelial  layer.  (See  Plate  III.,  Fig. 
1.)     The  color  is  a  dull  red,  which  later  on  may  assume  a  coppery  hue. 

This  form  of  chancre  is  most  marked  on  the  internal  surface  of  the 
prepuce,  by  which  it  is  protected  from  the  air,  irritation,  and  friction ; 
and  it  is  in  this  situation  that  it  is  most  frequently  met  with.  It  has 
generally  a  circular  or  ovoid,  but  sometimes  irregular,  outline.  Its  floor 
is  but  slightly,  if  at  all,  excavated,  and  occasionally  is  even  elevated 
above  the  surrounding  integument.  It  has  a  smooth,  polished  surface, 
usually  destitute  of  granulations,  but  sometimes  slightly  granular  and 
velvety,  from  which  considerable  serous  fluid  oozes,  particularly  on  manip- 
ulation. Its  surface  is  destitute  of  the  consistent  and  adherent  exudation 
of  the  chancroid.  At  times  it  is  dark  or  even  black,  owing  to  molecular 
gangrene.     This  lesion  sometimes  becomes  decidedly  saucer-shaped. 

Usually  there  is  but  one  such  lesion,  but  there  may  be  three,  four,  or 
five,  and  very  exceptionally  more  than  a  dozen.  When  a  number  of  these 
chancrous  erosions  are  grouped  together  in  the  corymbus-like  form  peculiar 
to  herpetic  vesicles,  for  which  they  are  very  liable  to  be  mistaken,  they 
are  called  multiple  herpetiform  chancres,  a  variety  first  described  by 
Dubuc.  These  chancres  have  a  diameter  of  a  line  or  less  ;  they  look  like 
small  round  excoriations,  of  a  deep-red,  sometimes  coppery  hue,  which 
bleed  readily  and  have  a  very  slight  induration  of  their  bases.  The  indu- 
ration often  increases  at  a  later  period.  From  five  to  fourteen  chancres 
may  be  observed  upon  the  prepuce  or  glans.  In  their  first  stage  the 
diagnosis  is  difiicult,  but  the  absence  of  itching  and  burning,  their  dark 
color,  and  their  chronicity  are  points  which  aid  in  distinguishing  them  from 
herpes.  Another  important  feature  is  that  their  surface  is  very  smooth  and 
shining.  Moreover,  induration  of  the  inguinal  ganglia  is  soon  developed. 
The  duration  of  these  herpetic  chancres  is,  according  to  Dubuc,  a  month 
or  six  weeks.  In  exceptional  cases,  in  which  the  chancres  are  not  close 
together,  they  remain  separate  during  their  whole  course.  In  the  major- 
ity of  cases  they  are  closely  grouped,  and,  after  remaining  for  several 
weeks  in  the  herpetic  form  they  unite  and  form  a  single  chancre. 

The  chancrous  erosion  is  constantly  mistaken  for  herpes  progen- 
italis,  and  is  in  many  instances  pronounced  by  the  surgeon  to  be  a 
simple  chafe  or  excoriation.  Consequently,  it  is  always  well  to  be 
cautious  and  slow  in  expressing  opinions  concerning  small  and  seem- 
ingly insignificant    lesions  of   the  genitals.      The    smooth,   shining  sur- 


PLATE 


10. 


Hard   Chancres. 


THE  CHANCRE,   OR  THE  INITIAL  LESION.  543 

face  of  the  syphilitic  lesion  is  in  many  cases  clearly  diagnostic,  but  it  may, 
owing  to  extraneous  influences,  become  rather  granular  and  perhaps  ul- 
cerated. Leloir  claims  that  herpetic  vesicles  give  issue,  particularly  if 
pressed  between  the  finger  and  thumb,  to  a  copious  serous  secretion, 
and  that  this  does  not  occur  in  cases  of  the  chancrous  erosion ;  there- 
fore, that  this  is  a  diagnostic  sign  between  herpes  and  the  syphilitic 
lesion.  The  truth  is  (see  Chapter  XXXVI.,  p.  429)  that  the  chancrous 
erosion  gives  issue  to  far  more  serum  than  does  the  herpetic  lesion. 

As  the  chancrous  erosion  grows  older  it  becomes  rather  more  salient, 
and  sometimes  its  surface  is  a  third  or  more  of  a  line  above  the  normal 
plane.  It  may  also  become  complicated  by  induration  in  the  connec- 
tive tissue  beneath  it.  When  it  simply  remains  a  superficial,  compact 
lesion,  the  induration  is  spread  out  into  a  disk-like  mass,  and  the  lesion 
is  then  called  the  parchment-like  chancre.  On  the  other  hand,  when 
the  syphilitic  process  dips  down  into  the  subcutaneous  connective  tissue, 
and  is  complicated  with  indurating  oedema,  the  chancrous  erosion  becomes 
the  indurated  nodule.  Parchment-chancres  are  mostly  found  on  the 
integument  of  the  penis  and  sometimes  in  the  vulva.  Indurated  chan- 
cres are  mostly  found  in  the  sulcus  coronarius,  particularly  near  the 
frsenum.  (See  Plate  III.  Fig.  9.)  As  the  chancrous  erosion  grows  old 
it  may  show  a  tendency  to  become  more  or  less  papillated  or  even  the 
seat  of  well-marked  granulations. 

In  many  cases  the  sharply-limited  area  beneath  the  chancrous  erosion 
becomes  the  seat  of  new  cell-growth,  and  a  much  deeper  lesion  then 
results.  As  a  rule,  coincidently  with  the  development  of  the  underly- 
ing tissue  the  chancrous  erosion  becomes  more  salient  above  the  normal 
plane,  even  to  the  extent  of  two  or  several  lines.  The  lesion  is  then 
known  by  the  old-time  name  ulcus  elevatmn,  which  is  partly  incorrect, 
since  there  is  in  uncomplicated  cases  no  ulcerative  process  present.  In 
like  manner,  according  to  the  old  nomenclature,  a  salient  chancroid  was 
called  ulcus  elevatum.  They  are  both  the  result  of  sharply  circum- 
scribed cell-growth,  in  one  case  (chancre)  specific,  in  the  second  (chan- 
croid) simply  inflammatory. 

In  many  cases  these  flat  or  elevated  chancres  become  covered  with  a 
false  membrane,  very  incorrectly  called  "  diphtheritic,"  which  is  peculiar 
in  having  a  color  which  is  a  mixture  of  a  cream  with  a  light-green  tint. 
This  membrane  may  exist  for  longer  or  shorter  periods.  As  it  grows 
old,  if  not  shed  it  sometimes  becomes  in  whole  or  in  part  of  a  brown  or 
brownish-black  color.  It,  as  a  rule,  does  not  cover  the  whole  of  the 
chancrous  surface,  but  rather  its  central  portions,  leaving  the  margins 
free.  This  film-like  or  more  dense  membrane  is  very  distinctive,  even 
diagnostic  of  chancres.  It  is  well  shown,  as  to  extent  and  color,  in 
Fig.  3,  Plate  III.,  seated  on  a  well-marked  indurated  nodule.  (In 
Figs.  2,  4,  and  8  also  it  is  well  portrayed  from  my  own  cases.)  This 
membrane  often  becomes  discolored  by  the  admixture  of  dirt  and  also 
as  a  result  of  minute  hemorrhages.  Thus  in  Fig.  5  the  membrane  is 
darker  than  it  is  in  the  previous  figures,  while  in  Fig.  7  it  reaches  its 
acme.  This  membrane  may  remain  on  the  sore  for  a  short  or  a  long 
time.  If  antiseptic  lotions  or  iodoform  is  used,  it  melts  away  and  an 
erosive  chancrous  surface  is  left.  This  lesion  may  very  properly  be  called 
the  chancre  with  the  cream  and  green-colored  membrane. 


544  SYPHILIS. 

In  some  rare  cases  these  chancres  become  necrotic,  an  accident  whicli 
is  well  shown  in  Fig.  6,  Plate  III. 

The  Silvery  Spot. — This  lesion,  first  described  by  me,  is  very  rare 
and  presents  well-marked  features.  It  generally  occurs  on  the  glans  and 
on  the  lips  of  the  meatus,  and  at  first  it  looks  as  if  a  pinhead-sized  spot 
of  mucous  membrane  had  been  touched  with  carbolic  acid  or  nitrate  of 
silver.  Examined  with  a  magnifying  glass,  there  is  no  other  change  evi- 
dent than  the  peculiar  staining  of  the  superficial  epithelial  cells.  The 
silvery  lesion  increases  slowly  but  visibly  day  by  day,  and  preserves  its 
integrity  of  surface  until  it  reaches  an  area  of  about  a  line,  when,  coin- 
cidently  with  the  subjacent  induration,  which  has  been  simultaneously 
developing,  and  which  has  slowly  raised  it  up  into  salience,  it  disappears, 
and  is  replaced  by  a  smooth,  shiny  surface  like  that  of  the  chancrous 
erosion  or  that  of  some  indurated  nodules. 

The  Dry  Papule — Papule  Seche  of  Lancer eaux. — This  chancre  is 
usually  found  upon  the  glans  or  prepuce  when  not  in  a  state  of  coaptation, 
and  consequently  is  always  developed  in  a  very  dry  condition.  4-S  a 
rule,  it  is  solitary,  and  is  not  uncommonly  seen  on  persons  who  have  been 
circumcised  or  who  have  short  prepuces.  It  is  found  upon  the  integu- 
ment of  the  penis,  about  the  pubes,  on  the  thighs,  and  elsewhere  upon 
the  body.  This  form  of  the  initial  lesion  begins  as  a  dull-red  spot,  which 
increases  in  area  as  it  grows  to  a  height  of  from  a  half  to  one  line,  and 
even  half  an  inch.  Its  evolution  is  slow  and  aphlegmasic,  and  when 
fully  developed  it  often  resembles  somewhat  a  not  very  scaly  papule  or 
patch  of  psoriasis,  but  is  of  denser  consistence.  Its  surface  is  flat  or 
slightly  convex,  its  color  a  brownish-red,  and  it  may  or  may  not  have  a 
faint  inflammatory  areola.  It  may  thus  run  its  course  and  subside  grad- 
ually into  a  deeply  pigmented  macule,  or  it  may  become  exulcerous  on 
its  surface.  From  this  exulcerous  condition  it  not  infrequently  becomes 
encrusted,  in  which  case  there  may  be  the  creamy-green  membrane  or  a 
thin  brown  or  brownish-black  crust  over  its  surface. 

A  modification  of  this  form  of  the  initial  lesion  has  been  described  as 
"  diphtheroid  of  the  glans,"  a  very  incorrect  term,  since  neither  in 
appearance  nor  course  does  the  lesion  at  all  resemble  diphtheritic  mem- 
brane, which  is  always  seated  on  an  excoriated  surface.  It  consists  of 
patches  of  a  glistening  grayish-white  color,  presenting  either  a  greasy 
sensation  to  the  fingers  or  something  like  that  of  wet  chamois-skin.  The 
lesion  is  slightly  salient,  not  at  all  indurated,  involves  the  superficial 
tissues,  the  mucous  membrane  of  the  glans,  and  sometimes  of  the  pre- 
puce, and  has  sharply  defined  borders  and  gives  rise  to  no  secretion 
from  its  surface.  It  may  involve  more  or  less  of  the  glans,  and  is  some- 
times continuous  with  an  indurated  nodule  of  the  prepuce.  In  this 
lesion  the  syphilitic  cells  are  developed  in  the  superficial  tissues  of  the 
glans,  which  are  thereby  thickened  and  assume  a  leathery  appearance. 
The  Avhitish  color  is  probably  due  to  the  close  packing  of  the  cells. 

The  Umbilieafed  Papule  or  Follicular  Chancre  is  a  rare  form  of  the 
initial  lesion,  of  which  I  have  seen  six  cases.  It  begins  as  a  small 
pinkish  elevation  of  the  size  of  a  milium,  with  a  minute  depression  in 
the  centre,  which  grows  slowly  and  assumes  in  form  the  appearance  of 
a  tumor  of  molluscuni  sebaceum.  Further  increase  takes  place  until  a 
pea-sized  tumor  is  formed.     As  the  lesion  grows  the  central  depression 


THE  CHANCRE,   OR   THE  INITIAL  LESION.  545 

becomes  broader  and  deeper,  until  in  its  full  development  the  chancre 
is  cup-shaped  and  as  if  set  in  the  mucous  membrane,  Avith  its  borders 
markedly  elevated.  It  is  firmly  indurated,  sharply  circumscribed,  and 
the  deeply  concave  surface  is  smooth,  glossy,  of  a  deep-red  color,  and 
exulcerated.  In  two  cases  the  veins  and  lymphatics,  enlarged  to  the 
calibre  of  a  goosequill,  extended  along  the  penis,  and  the  shape  of  the- 
lesion  could  be  compared  to  a  miniature  flute.  In  this  form  of  chancre 
the  syphilitic  virus  probably  enters  the  duct  of  a  Tyson's  gland  or  one 
of  the  minute  crypts  or  invaginations  of  the  mucous  membrane,  and 
there  produces  a  subcutaneous  nodule  which  develops  in  the  manner 
just  described. 

The  Necrotic  Nodule. — The  purple  necrotic  nodule  is  also  a  rare 
form  of  the  initial  lesion.  It  is  always,  according  to  my  experience, 
found  upon  the  glans  penis  and  in  the  coronary  sulcus.  It  begins  as  a 
small  dark-red  spot  which  soon  becomes  elevated ;  as  it  grows  its  color 
deepens ;  it  becomes  salient  and  roundedly  convex  on  its  surface.  Pal- 
pation shows  that  it  is  of  firm  texture  and  perhaps  of  much  density.  In 
its  period  of  full  development  it  is  a  purplish  papule  with  shining  sur- 
face, about  as  large  as  a  split  pea,  sometimes  larger.  It  may  happen 
that  no  visible  degenerative  changes  may  take  place  in  this  lesion,  in 
which  event  it  slowly  subsides,  loses  its  color,  and  on  its  site  a  depressed 
pigmented  cicatrix  is  left.  Then,  again,  necrosis  occurs  in  its  whole 
extent.  It  slowly  or  promptly  exulcerates  and  melts  away,  and  when 
healing  has  taken  place  there  is  a  distinct  loss  of  tissue,  as  if  the  part 
had  been  taken  out  with  a  punch. 

In  these  cases  the  necrosis  probably  results  from  the  interference 
with  the  circulation  exerted  by  the  dense  cell-infiltration.  This  under- 
lying cause  may  be  rendered  more  active  by  such  external  influences  as 
irritation  and  dirt.  A  depraved  condition  of  the  system  of  the  patient 
may  also  have  its  influence  in  the  matter.  When  Ave  consider  the  den- 
sity of  many  chancres,  it  seems  remarkable  that  we  do  not  encounter 
extensive  necrosis  in  them  more  frequently  than  we  do. 

The  Ecthymatous  Chancre. 
The  ecthymatous  chancre  is  simply  a  chancre  Avhich  becomes  covered 
with  a  pus-crust.  It  is  developed  from  the  dry  papule  or  the  chancrous- 
erosion  or  the  ulcus  elevatum.  The  surface  of  the  lesion  becomes  mildly 
exulcerated,  and  slowly  a  flat  crust  forms  which  is  of  a  brownish-black 
or  greenish-brown  color.  (See  Fig.  10,  Plate  III.)  The  crust  is  formed 
of  pus-cells,  tissue-detritus,  and  numerous  microbes.  The  term  "  ecthym- 
atous "  might  carry  with  it  the  impression  that  the  lesion  begins  as  a 
pustule ;  this  it  never  does.  It  is  simply  a  hard  chancre  which  is  mildly 
irritated  on  its  surface,  and  as  a  result  slowly  becomes  covered  Avith  a 
crust.  In  this  particular  only  does  this  lesion  resemble  ecthyma.  This 
form  of  chancre  is  found  upon  cutaneous  surfaces,  particularly  of  the 
penis  and  the  juxtagenital  parts.  It  may  be  found  elscAvhere  on  the 
integument.     The  lesion  may  be  single  and  sometimes  multiple. 

The  Parchment  Chancre. 
The  so-called  pnrchment-like  chancre  is,  as  we  have  seen,  simply  a 
chancrous  erosion  in  Avhich  the  cell-proliferation  is  superficially  distrib- 


546  SYPHILIS. 

uted  in  a  flat  disk-like  form.  It  is  usually  found  on  the  integument  of 
the  penis,  the  lesion  varying  in  size  from  one-third  of  an  inch  to  one 
inch  in  diameter. 

The  Annular  Chancre. 

The  term  "annular  chancre"  is  applied  to  primary  lesions  in  which 
the  great  part  of  the  new  growth  is  developed  in  a  rmg-like  form,  the 
centre  of  the  lesion  being  less  thickened  and  infiltrated.  Sometimes 
this  ringed  development  is  strikingly  apparent,  in  others  it  is  less  so. 
This  form  of  chancre  is  found  on  the  internal  surface  of  the  prepuce, 
sometimes  on  the  glans,  and  again  on  cutaneous  surfaces,  particularly 
of  the  penis.  This  annular  development  of  the  chancre  is  well  shown 
in  Fig.  4,  Plate  III.,  in  the  large  lesion.  It  must  be  remembered  that 
the  tissue  within  the  ring  is  hyperplasic,  but  much  less  so  than  its 
margin. 

The  indurated  nodule  is  a  localized  mass  of  syphilitic  cells  which 
have  developed  by  age  and  the  activity  of  proliferation  from  any  of  the 
above-described  forms  of  initial  lesion.  Whereas  in  some  cases  the  infect- 
ing process  is  limited  in  its  whole  course  to  the  upper  part  of  the  derma 
or  mucosa,  in  many  cases  the  infiltration  invades  the  underlying  con- 
nective tissue.  Then  we  have  small  circumscribed  masses  or  small  or 
large  nodules.  In  the  male  these  nodular  lesions  are  most  commonly 
found  near  the  frsenum  and  in  the  mucous  layer  of  the  prepuce  near  the 
coronal  sulcus,  also  upon  the  meatus,  sometimes  the  glans,  and  on  the 
skin.  (See  Figs.  3,  8,  and  9,  Plate  III.)  These  nodules  may  be  very 
small — for  example,  of  the  size  of  large  bird-shot — even  near  the 
frsenum,  in  which  case  their  nature  is  apt  to  be  overlooked.  Then, 
again,  they  occur  in  goodly  sizes,  as  large  as  a  split  pea  and  larger,  and 
as  diifuse  masses  of  an  inch  or  more  in  thickness  and  of  corresponding 
breadth.  In  some  cases  the  indurated  nodule  rapidly  becomes  covered 
with  epithelium,  and  then  exists  as  a  well-defined,  sharply-limited  lump 
in  and  under  the  skin.  It,  however,  may  have  the  appearance  of  the 
chancrous  erosion,  or  it  may  become  encrusted  by  the  cream -gray  false 
membrane,  which  from  many  causes,  as  we  have  seen,  sometimes  becomes 
brown  or  greenish-black.  These  indurated  nodules  in  untreated  cases 
remain  for  long  periods,  Aveeks  and  months,  in  an  indolent  condition, 
and  then  their  size  may  be  increased  by  a  circumambient  hard  oedema. 
The  result  is  that  a  very  large  lesion  is  produced.  (See  Figs.  7  and  9, 
Plate  III.)  In  this  state  of  aphlegmatic  chronicity  the  surface  of  the 
lesion  may  become  markedly  papillated  or  warty,  and  it  may  then  be 
mistaken  for  cancer  of  the  penis.  I  have  known  a  number  of  such  errors 
when  amputation  of  the  penis  had  been  decided  upon. 

These  indurated  nodules  very  often  are  extremely  slow  in  disappear- 
ins;,  even  under  active  local  and  constitutional  treatment. 

Infecting  Balano-posthitis. 

Under  the  term  "infecting  balano-posthitis,"  first  described  by 
Mauriac,  is  understood  a  development  of  the  initial  lesion,  in  a  diifuse 
plate-like  form,  in  the  mucous  layer  of  the  prepuce,  and  sometimes  also 


THE  CHANCRE,    OR   THE  INITIAL  LESION.  547 

in  the  superficies  of  the  glans.  This  lesion  usually  begins  as  a  goodly- 
sized  ehancrous  erosion,  Avhich  spreads  peripherally  until  more  or  less 
or  perhaps  the  whole  prepuce  is  involved  in  the  hyperplastic  process. 
The  appearance  of  the  parts  is  then  striking.  The  prepuce  is  thickened, 
usually  of  a  dull,  deep  red,  and  has  a  velvety  excoriated  appearance. 
Retraction  of  the  prepuce  becomes  difficult  and  perhaps  impossible. 
Not  infrequently  this  condition  of  the  prepuce  coexists  and  merges  with 
a  circumscribed  indurated  nodule  or  nodules  at  the  coronal  sulcus  or 
frienum. 

This  infecting  balano-posthitis  is  sometimes  seen  in  a  condition  which 
has  not  been  hitherto  described.  The  infecting  process  then  begins  with 
little  or  no  excoriation,  and  the  parts  are  normal  in  color.  The  prepuce 
gradually  becomes  thickened  until  more  or  less  of  its  extent  is  involved 
in  patches  or  disks.  The  color  of  the  parts  being  normal,  the  surgeon 
is  liable  to  overlook  the  nature  of  the  process.  I  have  seen  several  cases 
in  Avhich  the  only  visible  evidence  of  disease  was  that  the  inner  layer  of 
the  prepuce  was  thrown  into  little  transverse  folds.  On  palpation  a 
mild,  diffuse,  not  well-circumscribed,  thickening  is  felt.  The  course  of 
the  lesion  is  chronic,  but  it  yields  readily  to  internal  and  external  treat- 
ment. The  lesion  consists  of  an  infiltration  of  the  submucous  tissue 
with  hypergemia ;  in  other  words,  it  is  a  combination  of  cell-infiltration 
and  hard  oedema. 

Induration. 

By  the  term  "  induration  "  we  include  not  only  the  sclerotic  process 
which  forms  the  chancre,  but  also  the  complicating  hard,  indurating, 
and  sclerotic  oedema  which  develops  around  the  chancre,  and  also  some 
early  secondary  lesions,  such  as  mucous  patches  and  papules.  The 
pathology  of  this  indurating  process  is  given  in  Chapter  LI.  ;  its  clini- 
cal history  comes  under  the  general  term  "induration." 

Induration  as  a  symptom  depends  entirely  on  the  growth  of  the  in- 
itial lesion.  At  first  there  is  only  a  mild  hyperplasia,  but  as  the  cell- 
increase  goes  on  the  hardening  of  the  tissues  occurs.  In  most  cases 
fully  ten  days,  even  fourteen  days  and  longer,  elapse  before  we  have 
that  hard,  indolent,  circumscribed  lesion  which  presents  such  a  marked 
contrast  to  the  features  of  diff"use,  doughy,  inflammatory  hyperplasia. 

The  induration  of  chancre  is,  as  we  have  seen,  a  peculiar  hardness 
of  the  tissues  around  and  beneath  the  sore.  Simple  inflammation  may 
occasion  an  effusion  of  plastic  material  and  consequent  engorgement 
about  any  sore ;  but  specific  induration  is  of  an  entirely  distinct  cha- 
racter. The  latter  is  formed,  as  the  French  say,  "a/roe'c?" — that  is, 
without  inflammatory  action ;  the  deposit  takes  place  in  the  absence  of 
all  symptoms  of  inflammation,  pain,  heat,  redness,  and  swelling,  and 
so  silently,  so  insidiously,  that  the  patient  is  often  ignorant  of  its  pres- 
ence or  discovers  it  only  by  accident.  No  event  is  more  common  than 
for  a  surgeon  to  be  consulted  by  a  man  Avho  states  that  he  had  a  sore 
some  weeks  ago,  which  gave  him  no  concern,  and  healed  up,  but  he  has 
recently  found  that  it  left  a  lump  behind  it.  This  lump  is  the  specific 
induration. 

Again,  specific  induration  and  inflammatory  engorgement  difl"er  in 
their  objective  symptoms.     The  boundaries  of  the  former  are  clearly 


548  SYPHILIS. 

defined,  -while  the  extent  of  the  latter  cannot  be  limited  with  nicety; 
the  one  terminates  abruptly,  the  other  shades  gradually  into  the  normal 
suppleness  of  the  part ;  the  first  is  freely  movable  upon,  the  second 
adherent  to,  the  tissues  beneath.  The  difference  in  the  sensations  they 
impart  to  the  fingers  is  still  greater :  specific  induration  is  so  firm, 
hard,  and  resistant  that  it  is  often  compared  to  a  "split  pea"  or  mass 
of  cartilage ;  the  softer  and  doughy  feel  of  common  inflammatory 
engorgement  requires  no  description.  It  is  hardly  necessary  to  say 
that  there  is  no  incompatibility  between  these  two  pathological  condi- 
tions which  can  prevent  their  coexistence,  and  hence  arises,  in  some  few 
cases,  a  difficulty  of  diagnosis.  The  effect  of  simple  inflammation, 
however,  subsides  in  a  few  days  or  in  a  week  or  two  at  farthest,  and 
lays  bare  the  specific  induration,  which  may,  for  a  time,  have  been 
buried  beneath  it ;  and  under  all  circumstances  reference  may  be  made 
to  the  neighboring  ganglia,  the  induration  of  which  is  equally  constant 
and  significative  with  that  of  the  chancre. 

In  the  masses  of  induration  of  considerable  size  to  which  the  above 
description  chiefly  refers  the  adventitious  deposit  occupies  the  skin  or 
mucous  membrane  bordering  upon  the  edges  of  a  sore,  and  also  the 
cellular  tissue  beneath  it.  In  the  parchment  chancre,  as  we  have 
seen,  the  induration  process  is  limited  to  the  thickness  of  the  mucous 
membrane. 

In  general  it  may  be  said  that  induration  is  extensive  in  proportion 
as  the  connective  tissue  is  abundant.  Thus  at  the  fraenum  and  in  the 
balano-preputial  furrow  it  is  generally  exuberant,  while  on  the  glans 
penis  it  is,  as  a  rule,  limited  in  area  and  thickness,  owing  to  the  small 
quantity  of  submucous  connective  tissue. 

Specific  induration  usually  remains  for  a  long  time  after  the  cica- 
trization of  the  chancre,  and,  unless  dissipated  by  treatment,  may  in 
most  cases  be  felt  for  at  least  two  or  three  months,  and  often  longer. 
Thus  near  the  frsenum  and  behind  the  sulcus  coronarius  it  mav  in  neg- 
lected  cases  remain  nearly  a  year.  It  is  also  persistent  when  it  attacks 
the  glans  penis.  In  women  induration  of  the  labia  majora,  and  also  of 
the  labia  minora,  may  last  for  long  periods. 

Induration  is  sometimes  much  shorter  lived ;  the  parchment  form 
especially,  and  exceptionally  the  small  nodules,  may  entirely  disappear 
in  a  remarkably  rapid  manner  before  the  chancre  heals,  and  the  cicatrix 
present  as  soft  a  base  as  the  chancroid. 

As  the  process  of  absorption  goes  on  the  indurated  mass  becomes 
less  firm  and  resistant,  and  gradually  softens  until  it  can  finally  no 
longer  be  detected.  In  other  instances,  after  partial  absorption  has 
taken  place,  the  induration  suddenly  resumes  its  earlier  dimensions  ; 
and  this  is  most  likely  to  occur  upon  the  first  appearance  of  secondary 
symptoms  or  at  a  subsequent  relapse  of  the  same. 

Under  the  name  of  "  indurations  de  voisinage  "  Fournier  describes 
masses  of  induration  contemporaneous  with  the  chancre,  and  occurring 
secondarily  at  a  short  distance  from  it.  Although  the  surface  of  such 
indurations  usually  remains  intact,  it  may  take  on  ulceration  in  the 
manner  hereafter  described. 

Relapsing  Indurations  {also  called  Pseudo-chancre  indure,  Chancre 
redux). — The  genital  organs  may  at  any  time  in  the  course  of  syphilis. 


THE  CHANCRE,    OR   THE  INITIAL  LESION.  549 

"be  the  seat  of  indurated  nodules,  Avhich  are  liable  to  be  mistaken  for 
primary  lesions. 

They  are  of  two  kinds,  the  superficial  and  deep.  The  superficial 
induration  is  in  every  respect  like  a  true  chancre,  consisting  of  a  local- 
ized infiltration,  somewhat  elevated,  having  a  smooth,  exulcerated  sur- 
face which  secretes  a  scanty  mucous  fluid.  It  generally  appears  upon 
the  mucous  layer  of  the  prepuce  or  upon  the  glans  in  the  form  of  a 
small  papule.  It  runs  an  indolent  course,  but  may  reach  quite  a  large 
size.  It  may  be  accompanied  by  enlargement  of  the  inguinal  ganglia 
if  it  appear  within  the  first  and  second  years.  It  sometimes  appears 
exactly  on  the  former  seat  of  a  primary  lesion,  and  is  generally  solitary. 
It  may  also  develop  upon  an  herpetic  lesion,  on  an  erosion  or  a  fissure. 
It  is  not  uncommonly  seen  as  a  localized  thickening  of  the  mucous 
membrane,  the  surface  of  Avhich  is  intact.  These  superficial  relapsing 
lesions  are  sometimes  very  rebellious  to  treatment,  both  external  and 
internal — a  feature  in  marked  contrast  with  what  occurs  in  the  initial 
lesion. 

These  superficial  relapsing  indurations  in  some  rare  cases  recur  from 
time  to  time  at  intervals  of  months  and  of  a  year  or  two.  I  saw  one 
case  in  which  a  man  was  attacked  six  times  by  these  lesions. 

The  deep  relapsing  induration  occurs  in  the  submucous  connective 
tissue  of  the  prepuce  and  of  the  labia  majora.  It  consists  of  a  sharply- 
defined  nodule  of  cartilaginous  hardness,  freely  movable  and  generally 
not  adherent  to  the  mucous  membrane.  Its  growth  is  rapid,  and  it 
sometimes  reaches  the  size  of  a  nutmeg.  There  may  be  several  of  these 
tumors,  and  I  have  seen  five  in  one  case.  The  lesion  may  remain  inac- 
tive for  a  long  time,  causing  no  pain,  but  giving  some  inconvenience  in 
coitus.  In  some  cases  it  contracts  adhesions  with  the  surroundins;  soft 
parts ;  exceptionally,  it  undergoes  necrosis  and  forms  a  deep  ulcer  which 
is  difficult  to  cure.  In  Avomen  the  infiltration  is  often  verv  laro-e,  in- 
volving  perhaps  the  whole  labium.  The  induration  is  very  marked  and 
often  persists  for  years.  In  rare  cases  the  lips  and  the  labia  minora 
are  involved.  There  is  usually  no  enlargement  of  the  inguinal  ganglia 
with  the  deep  induration,  either  in  men  or  in  women. 

These  indurations  may  occur  as  early  as  the  first  and  as  late  as  the 
tenth  year  of  syphilis.  They  are  amenable  to  early  treatment,  but  are 
more  obstinate  with  age.  They  have  been  known  to  undergo  spontane- 
ous involution  and  to  relapse  after  complete  cure.  It  is  important  to 
distinguish  them  from  primary  lesions  of  syphilis.  Many  of  the  re- 
ported cases  of  reinfection  have  no  doubt  been  in  reality  examples  of 
relapsing  induration. 

The  secretion  of  the  syphilitic  chancre  is  serous  in  character,  and  its 
sero-purulence  or  purulence  is  due  to  adventitious  causes,  such  as  irritants 
of  various  kinds.  There  is  every  reason  to  believe  that  much  of  the 
destructive  metamorphosis  of  chancres  is  engrafted  upon  them  by  pyo- 
genic microbes.  Indeed,  in  many  instances  we  see  not  only  syphilitic 
infection  from  a  chancre,  but  also  pyogenic  infection.  The  immaturity 
of  the  newly-organized  cells  renders  their  existence  precarious,  and  in 
consequence  we  frequently  see  on  the  surface  of  chancres  molecular  decay 
or  gangrene.  This  form  of  decay  also  has  its  origin  in  the  strangulation 
of  the  capillaries  by  the  closely-packed  new  cells,  the  result  of  which  is 


550  SYPHILIS. 

necrosis  limited  to  the  parts  supplied.  This  strangulation  of  the  vessels 
is  an  important  factor  in  the  phagedena  which  sometimes  attacks  hard 
chancres. 

After  healing  and  absorption  the  chancre  usually  leaves  its  indelible 
trace,  as  some  French  authors  call  it,  in  the  shape  of  a  more  or  less  well- 
developed  scar,  which  is  generally  depressed,  and  sometimes  it  is  nodular. 

The  duration  of  the  initial  lesion  of  syphilis  is  very  variable,  and 
depends  largely  upon  the  extent  and  density  of  the  new  growth.  In 
some  cases  it  is  so  slight  and  insignificant  that  it  comes  and  goes  with- 
out its  presence  having  been  known  or  without  leaving  a  trace.  This 
anomaly  is  sometimes  seen  in  women,  less  commonly  in  men.  The  tissue 
forming  the  primary  nodule,  being  of  unstable  nature,  is  peculiarly  sus- 
ceptible to  the  action  of  mercury,  under  which  it  can  often  be  seen,  as  it 
were,  to  melt  away.  So  that  if  the  chancre,  as  it  often  does,  lasts  until 
the  evolution  of  secondary  lesions,  it  usually  disappears  quite  rapidly 
under  the  influence  of  systematic  treatment.  But  in  some  cases  it  is  very 
voluminous  and  persistent,  and  may  exist  for  months.  Those  old-time 
and  oft-quoted  cases  in  which  it  is  said  to  have  lasted  years  were  in  all 
probability  instances  of  fibroid  cicatrices  resulting  from  chancres.  I  have 
seen  many  of  these  which  had  been  regarded  as  persistent  and  permanent 
indurations,  whereas  the  syphilitic  neoplasm  had  vanished  years  before 
and  was  replaced  by  firm  fibrous  tissues. 

Ricord  first  called  attention  to  the  fact,  which  has  since  been  verified 
by  many  observers,  that  a  chancre  during  the  reparative  period  may  be 
transformed  into  a  mucous  patch,  and  thus  a  primary  be  changed  into  a 
secondary  lesion.  This  transformation  may  take  place  upon  any  part  of 
the  body,  whether  of  skin  or  mucous  membrane,  but  more  frequently 
upon  the  latter,  especially  when  habitually  in  contact  with  an  opposed 
surface,  whereby  heat  and  moisture  are  maintained  ;.  as,  for  instance,  upon 
the  internal  surface  of  the  prepuce  and  the  labia  majora  and  upon  the 
lips  and  tongue.  Davasse  and  Deville  have  carefully  studied  the  pro- 
gressive changes  by  which  this  process  is  accomplished.^  The  surface  of 
the  chancre  loses  its  grayish  aspect  and  fills  up  with  florid  granulations, 
commencing  at  the  circumference,  as  in  the  ordinary  period  of  repair  ;  but 
just  as  these  changes  are  reaching  the  centre  of  the  sore  a  narrow  white 
border  of  plastic  material  appears  around  its  margin,  and,  extending 
toward  the  centre,  finally  covers  it  with  the  membranous  pellicle  which 
is  characteristic  of  a  mucous  patch.  If  the  patient  does  not  come  under 
observation  until  these  changes  have  been  effected,  the  initial  lesion  of 
his  disease  may  be  supposed  to  be  a  mucous  patch  instead  of  a  chancre. 

Phagedena  is  to-day  a  rather  rare  complication  of  hard  chancre,  and 
when  present  may  be  mild  or  severe.  In  some  cases  only  the  parts  in 
the  vicinity  of  the  chancre  are  attacked,  and  the  process  is  of  not  long 
duration.  In  very  severe  cases  the  glans  or  the  penis  itself  may  be  more 
or  less  destroyed.  Bad  instances  of  phagedena  are  usually  observed  in 
careless,  unhealthy,  and  intemperate  patients,  particularly  in  those  who 
are  uncleanly  and  apply  too  strong  caustic   applications  to  their  chancres. 

^  "  Etudes  cliniques  des  Maladies  veneriennes;  des  Plaques  muqueuses,"  Arch.  gen.  de 
Med.,  4e  Serie,  vol.  ix.  p.  182. 


THE  CHANCRE,    OR  THE  INITIAL  LESION.  551 

Chancres  of  the  Urethra. 

Chancres  may  be  seated  on  one  or  on  both  lips  of  the  meatus,  but 
they  most  commonly  involve  the  circumference  of  the  urethra.  In  some 
cases  there  is  no  ulceration  of  any  degree,  the  lip  or  lips  of  the  meatus 
being  scarcely,  if  any,  redder  than  normal,  and  the  only  appreciable  mor- 
bid process  being  the  condensation  and  induration  of  the  parts.  Indu- 
ration here  is  usually  very  well  marked.  Sometimes  one  lip  of  the  mea- 
tus and  the  wall  of  the  urethra  feel  as  if  formed  of  a  thin  plate  of  ivory. 
This  same  condition  is  often  found  in  both  lips.  Then,  again,  a  distinct, 
hard  nodule  may  be  felt  at  the  distal  end  of  the  urethra.  Chancres  at 
the  meatus  may  be  of  the  form  of  chancrous  erosions  or  they  may  present 
the  typical  cream-green  tint,  which  may  become  of  a  deep,  dull  green  or 
even  of  a  greenish-black  color.  A  diagnostic  mark  of  much  importance 
in  this  form  of  chancre  is  the  purplish-blue  color  of  the  glans  in  a  halo- 
like form.     This  is  well  shown  in  Fig.  8,  Plate  III. 

Chancres,  usually  of  the  erosive  form,  are  found  down  the  urethra, 
even  as  deep  as  three  or  four  inches. 

All  chancres  of  the  meatus  and  urethra  cause  more  or  less  impediment 
to  urination.  This  is  observed  to  be  particularly  severe  in  cases  in  which 
a  pinhead-sized  stenosis  of  the  canal  has  been  produced  by  the  infecting 
hyperplasia,  when  pain  and  difficulty  in  micturition  are  excessive. 

These  chancres  give  issue  to  a  scanty  or  moderately  profuse  sero-puru- 
lent  fluid,  which  may  mislead  the  surgeon  into  the  belief  that  the  case  is 
one  of  anomalous  gonorrhoea.  In  all  cases  which  give  a  history  of  a 
painless  affection  with  non-inflammatory  and  scant  muco-purulent  secre- 
tion the  condition  of  the  urethral  walls  must  be  examined  with  a  view  of 
determining  whether  a  chancre  is  present.  In  some  cases  there  is  a  pro- 
fuse purulent  discharge,  and  exceptionally  acute  symptoms  are  present. 

Chancres  of  the  fossa  navicularis  and  of  the  deeper  parts  begin  pain- 
lessly, with  mere  gluing  of  the  lips  of  the  meatus  as  their  first  symptom. 
Soon  there  is  slight  pain  as  the  urine  first  passes,  and  the  patient  dis- 
covers a  thickening  of  the  tissues  at  the  site  of  the  chancre.  The  dis- 
charge is  sometimes  muco-purulent,  but  again  may  be  decidedly  purulent, 
and  as  considerable  in  quantity  as  in  ordinary  gonorrhoea.  This  is  due 
to  the  fact  that  the  lesion  sets  up  a  urethritis  of  the  contiguous  membrane. 
Externally  is  found  in  the  corpus  spongiosum  a  hard,  tender,  circum- 
scribed nodule,  which  gives  pain  on  urination  and  on  erection  of  the  penis- 
With  the  endoscope  we  observe  rigidity  and  erosion  of  the  urethral  walls,, 
which  have  a  grayish-red  color. 

Chancres  of  the  Scrotum. 

In  somewhat  rare  cases  chancres  appear  on  the  scrotum,  usually  on  its 
anterior  or  lateral  portion,  rarely  on  the  back  part. 

The  initial  lesion  in  this  locality  is,  as  a  rule,  of  goodly  size,  varying 
between  that  of  a  three-cent  silver  piece  and  that  of  a  quarter-dollar, 
sometimes  even  larger.  Two  varieties  of  lesion  are  commonly  met  with 
— the  chancrous  erosion  and  the  encrusted  chancre.  The  lesion  is  round 
or  oval,  somewhat  elevated,  having  a  smooth,  flat,  velvety  surface  when 
of  the  erosive  type,  and  being  somewhat  concave  or  saucer-shaped  when 
of  the  encrusted  type.     The  false  membrane  which   covers  scrotal  chan- 


552  SYPHILIS, 

cres  (see  Fig.  5,  Plate  IV.)  is  of  the  grayish-green  color  already 
described,  but  it  may  become  yellowish  and  brown,  and  even  black. 
These  lesions  are  sharply  marginated  and  have  a  narrow  red  areola. 
There  is  usiially  not  much  induration  connected  with  them,  and  it  is  in 
general  of  the  parchment  variety.  There  may  be  one  or  two  chancres, 
rarely  more  than  three.  I  once  saw  an  inflamed  and  exulcerated  wen 
on  the  anterior  wall  of  the  scrotum  which  had  been  mistaken  for  an  exu- 
berant hard  chancre. 

Chancres  of  the  Anus. 

Chancres  are  found  beyond  the  anal  ring  at  its  margin,  and  within  the 
ring  as  far  up  as  an  inch  and  perhaps  farther.  These  lesions  in  this  loca- 
tion do  not  usually  present  clearly-cut  features.  Outside  the  anal  ring 
they  may  be  oval  or  round  or  of  irregular  outline.  They  are  of  a  pale 
Tose,  sometimes  red,  color,  covered  with  a  slimy  secretion,  and  perhaps 
creased  or  fissured.  Within  the  anal  ring  they  are  usually  found  in  the 
shape  of  sluggish,  hardened  fissures.  These  are  much  less  painless  than 
simple  fissures — a  diagnostic  point  of  much  importance.  A  further  point 
is  that  with  this  form  of  chancre  there  is  marked  enlargement  of  the 
inguinal  ganglia. 


CHAPTER    LIV. 

EXTEAGENITAL  CHANCRES. 

Chancres  of  the  General  Integument. 

Chancres  appearing  on  parts  other  than  the  genital  organs  are  called 
extragenital  chancres.  They  are  mostly  found  on  the  face,  the  neck,  the 
arms,  the  fingers,  the  hypogastrium  ;  in  fact,  they  may  be  found  on  any 
part  of  the  body.  Chancres  begin  as  a  small,  dull-red  papule  with  more 
or  less  scaliness,  which,  if  situated  on  parts  in  coaptation  with  another  sur- 
face of  integument,  becomes  a  chancrous  erosion,  and  in  that  form  runs 
its  course.  Usually  these  chancres  become  encrusted.  The  crust  at  first 
is  of  the  cream-green  color,  but  this  feature  may  soon  be  lost,  owing  to 
■dust  and  dirt  lodging  on  the  lesion.  Then  we  see  flat,  tolerably  well- 
indurated  disks  of  round  or  oval  outline,  which  have  a  brownish-red 
margin  which  may  be  raised  in  a  lip  form.  The  greater  part  of  the  lesion 
is  then  covered  with  a  chamois-skin-like  or  yellowish-brown  or  dark- 
brown  crust. 

These  lesions  have  an  average  size  of  half  an  inch  to  an  inch  in  diameter. 
In  some  cases  their  extent  is  even  greater.  About  the  cheeks  they  may 
develop  into  regular  tumors  of  the  size  of  a  horse-chestnut  or  of  half  an 
apple. 

Chancres  of  the  general  integument  run  a  chronic,  indolent,  painless 


PLATE  IV, 


-•'''•'''''^^'^sii^^^.^^^ 


Extra-Genital   and    Uterine  Clnancres. 


EXTRAGENITAL   CHANCRES.  553 

course,  and  may  last  one  or  more  and  even  six  months  before  sinking 
down  and  fading  away.  They  usually  give  rise  to  no  painful  symptoms, 
and  early  in  their  course  they  have  no  concomitant  phenomena  except  the 
painless  enlargement  of  the  lymphatic  ganglia  of  the  region  upon  which 
they  are  developed.  When  they  finally  undergo  resolution  they  leave 
pinkish,  brownish-red,  and  brownish-black  pigmented  spots,  with  more 
or  less  atrophy  and  cicatrization  of  the  skin,  which  last  for  a  long  time. 


Chancres  of  the  Finger. 

These  chancres  are  found  most  commonly  among  surgeons,  obstet- 
ricians, dentists,  midwives,  and  nurses,  male  and  female.  In  these  indi- 
viduals the  infection  is  usually  contracted  in  operations  either  upon  a 
newly-made  cut  or  an  abrasion,  excoriation  of  the  skin,  or  upon  some 
simple  lesion  present  upon  the  skin,  as,  for  instance,  eczema  and  derma- 
titis due  to  the  use  of  antiseptics  and  irritations.  Among  the  laity  chan- 
cres of  the  fingers  are  not  very  common,  and  they  are  usually  the  result 
of  libidinous  toying  with  the  genitals  of  an  infected  woman.  Finger-chan- 
cres also  sometimes  result  from  the  bite  of  a  person  having  syphilitic 
lesions  in  the  mouth,  and  they  have  been  known  to  follow  a  blow  received 
upon  the  mouth  of  a  person  suffering  then  from  specific  lesions. 

These  chancres  form  on  some  part  of  the  nail-margin,  also  on  the  sides 
and  on  the  pulp  of  the  finger  and  along  its  continuity.  There  is  usually 
but  one  chancre — sometimes  two,  and  rarely  more. 

On  the  finger  we  find  the  scaling  papule  or  tubercle,  the  excoriated  or 
ulcerated  nodule  or  mass,  the  fungating  chancre,  and  the  panaritium-like 
chancre. 

The  scaling  papule  or  tubercle  is  the  rarest  of  all  forms  of  finger- 
chancre.  It  is  usually  found  on  the  dorsal  surface  of  a  phalanx,  and 
sometimes  on  the  sides  and  palmar  surface  of  the  fingers.  It  begins  as  a 
papule,  and  runs  its  course  as  a  tolerably  well-circumscribed,  indurated, 
and  more  or  less  scaly  lesion  of  a  dull  coppery-red  or  purplish-red  color. 
When  near  joints  this  chancre  may  become  more  or  less  exulcerated. 

The  Excoriated  or  Exulcerated  Nodule  or  Mass. — This  is  the  most 
common  form  of  chancre  of  the  finger.  It  is,  as  a  rule,  found  near  the  tip 
of  the  finger.  It  usually  begins  as  a  small  pustule,  a  minute  excoriation, 
or  as  a  fissure  or  hang-nail.  The  cell-growth  increases  rapidly,  and  the 
lesion  in  its  early  days  is  indolent  and  painless.  In  a  few  weeks  the 
chancre  becomes  fully  developed  into  a  large,  fleshy,  smooth  or  granular, 
or  even  lumpy  mass  of  dull -red  color,  sometimes  with  a  purplish  tinge. 
There  may  be  density  in  the  morbid  tissue,  but  certainly  no  typical  indu- 
ration. Very  often  the  chancre  is  soft  and  pulpy.  These  chancres,  being 
exuberant  in  development,  produce  much  deformity  in  the  parts  affected. 
Their  shape  depends  on  the  site  upon  which  they  are  developed.  They 
are  sometimes  the  seat  of  severe  and  continuous  pain.  If  untreated  or 
irritated,  these  chancres  remain  in  an  indolent  condition  for  a  long  time. 

The  Fungating  Chancre. — This  form  of  finger-chancre  develops 
usually  on  the  pulp  of  the  organ  and  around  the  last  phalanx.  A  warty 
or  decidedly  papillomatous  mass,  sometimes  of  much  exuberance,  is  pro- 
duced, which  is  indolent  in  its  course  and  presents  sometimes  a  very  deep- 


554  SYPHILIS. 

red  color,  and  not  uncommonly  a  purplish-red  color,  sometimes  tinged 
with  grav. 

This  form  of  chancre  may  be  attended  with  more  or  less  pus.  Its 
course  is  chronic  and  indolent. 

The  Panaritiiun-Iike  Chancre. — This  chancre  usually  begins  in  the 
integument  of  the  nail-margin  in  a  cut  or  fissure  or  hang-nail  or  some 
inflammatory  lesion.  Soon  an  excoriated  spot  forms,  which  may  be 
localized  to  one  part  of  the  nail-margin,  or  this  latter  may  be  wholly 
involved.  When  fully  developed  we  find  an  encrusted  or  exulcerated 
swelling  of  more  or  less  extent.  The  surface  frequently  becomes  covered 
with  a  yellowish-green  or  dark-green  membrane,  and  the  thickening  of 
the  chancre  extends  to  the  parts  beyond.  This  lesion  is  frequently 
attended  with  severe  pain  during  its  very  chronic  course.  (See  Fig.  6, 
Plate  IV.) 

In  almost  all  cases  of  finger-chancre  developed  near  the  nail-margin  or 
tip  more  or  less  of  the  appendage  is  destroyed,  not  infrequently  its  whole 
extent. 

Much  ultimate  deformity  is  frequently  produced  by  these  finger- 
chancres,  both  in  the  nail  and  as  to  the  symmetry  of  the  pulp  of  the 
finger.  In  somewhat  exceptional  cases  septic  infections  are  concomitants 
of  finger-chancres. 

Usually  the  epitrochlear  ganglion  in  anatomical  association  with  the 
affected  member  is  enlarged,  often  to  a  considerable  size,  varying  from 
that  of  a  nutmeg  or  that  of  a  pea  to  that  of  a  horse-chestnut.  Sometimes 
there  is  no  perceptible  enlargement  of  the  epitrochlear  ganglia,  in  which 
event  those  of  the  axillae  are  much  swollen.  There  is  usually  swelling  of 
the  axillary  ganglia  concomitant  to  that  of  the  epitrochlear  ganglia. 

In  some  rare  cases  the  swellings  of  the  epitrochlear  and  axillary 
ganglia  go  on  to  suppuration. 

Cases  of  syphilitic  infection  of  patients  by  surgeons,  obstetricians, 
and  midwives^  havino;  chancres  on  their  fincrers  are  not  at  all  uncommon. 

^  A  number  of  years  ago  I  had  under  observation  a  whole  family  who  became  infected 
with  syphilis  through  the  finger  of  a  German  midwife,  who  had  a  chancre  on  her  right 
index  finger.  This  family  consisted  of  the  father  and  mother  and  four  children,  three 
girls  and  one  boy.  The  wife  had  severe  ulcerative  lesions  in  the  region  of  the  fourchette, 
and  the  husband  had  three  chancres  of  the  prepuce  and  glans,  while  both  suffered  severely 
from  buccal  mucous  patches  and  condylomata  ani.  The  eldest  girl,  aged  twelve,  had 
a  large  chancre  of  the  left  cheek;  the  second  girl,  aged  ten,  a  chancre  of  the  lower 
lip  ;  and  the  third  child,  a  boy,  had  a  panaritium-like  chancre  of  the  left  index  finger. 
The  fourth  child  was  a  baby  girl,  who  had  a  very  superficial  parchment-like  chancre  of 
the  tip  of  the  tongue.  In  these  cases  I  convinced  myself  that  tlie  mother  was  infected 
by  the  midwife,  the  father  received  the  infection  from  his  wife,  who  by  kissing  infected 
the  first,  second,  and  fourth  children,  while  the  third  cliild,  the  boy,  infected  himself  by 
picking  with  his  finger  the  chancre  on  the  cheek  of  his  eldest  sister. 

In  this  connection  the  following  case  is  very  interesting:  Bardinet  ("Syphilis  cora- 
muniquee  par  le  Doight  d'une  Sage  fern  me,"  Anvalfs  d' Hygiene  pub.  et  Med.  legale,  July, 
1874)  was  appointed  by  the  local  authorities  to  investigate  the  causes  and  natiu-e  of  an 
epidemic  which  appeared  in  the  town  of  Brive,  France.  He  ascertained  that  those 
affected  were  parturient  women  (or  their  relatives,  such  as  husbands  and  children)  who 
had  been  attended  at  childbirth  by  a  certain  midwife.  Upon  inve.'^tigation  and  examin- 
ation of  her  it  was  found  that  in  February,  1873,  she  had  an  ulcer  on  tiie  riorder  of  the 
nail  of  the  right  middle  finger,  which  was  afterward  followed  by  sy])hi]itic  manifestations. 
The  syphilitic  chancre  upon  the  finger  was  very  obstinate  to  treatment,  and  continued  in 
an  ulcerated  condition  until  the  following  October.  In  the  mean  time  she  had  attended, 
according  to  her  statement,  fully  fifty  women  in  confinement.  It  was  only  determined 
that  fourteen  women  were  infected  by  her  with  syphilis,  though  it  was  suspected  that 


EXTRAGENITAL  CHANCRES.  555 

Such  persons  thus  affected  shouki  not  perform  operations  or  make  exam- 
inations upon  any  patients. 

It  is  a  peculiarly  striking  fact  that  physicians  and  surgeons  are  very 
slow  to  appreciate  the  nature  of  chancres  on  their  fingers.  They  usually 
delude  themselves  with  the  idea  that  their  lesion  is  a  simple  one,  though 
obstinate  in  its  course,  and  they  consider  it  due  to  some  infection  other 
than  that  of  syphilis  or  an  anatomical  ulcer.  In  the  majority  of  cases  it 
will  be  found  that  when  a  physician,  surgeon,  dentist,  obstetrician,  or 
midwife  has  a  small  (or  even  large)  indolent  sore  on  his  or  her  finger,  the 
lesion  is  indicative  of  syphilitic  infection.  It  is  a  good  rule  always  to  be 
suspicious  of  an  indolent  sore  on  the  finger  of  a  professional  person. 

In  some  rare  cases  chancres  of  the  finger  become  contaminated  with 
infectious  material  and  more  or  less  severe  pyaemia  or  septicemia  appears 
to  complicate  the  case. 

Chancres  of  the  Lip. 

Chancres  of  the  lip  are  quite  common.  They  are  usually  seated  on 
the  vermilion  border,  sometimes  on  the  inner  border,  and  again  on  both 

others  were  likewise  contaminated,  and  that  they  concealed  the  matter  from  motives  of 
shame  and  secrecy.  The  following  are  the  facts:  Between  February  28th  and  March 
15th  she  cared  for  three  women,  who  became  syphilitic.  Between  the  latter  date  and 
June  2Sth,  though  she  attended  a  number  of  women,  no  cases  of  syphilis  could  be  ascer- 
tained to  have  occurred.  From  this  date  until  October  she  attended  fifteen  more  women, 
of  whom  only  one  escaped  syphilis.  It  is  suspected  that  in  the  interval  of  six  weeks 
during  which  no  cases  of  infection  are  noted  such  did  really  occur,  but  that  they  were 
hushed  up ;  again,  it  was  thought  that  perhaps  during  this  period  or  a  part  of  it  the 
digital  ulcer  did  not  yield  an  infecting  secretion,  owing  to  the  applications  which  were 
then  made.  Eight  of  the  husbands  of  the  fourteen  women  who  thus  became  syphilitic 
were  also  infected,  as  well  as  nine  infants  of  the  latter,  four  of  whom  died  of  syphilis. 
Thus  we  certainly  have  a  total  of  thirty-one  cases  of  syphilis,  out  of  which  there  were 
four  deaths,  caused  by  one  woman  who  had  a  chancre  on  her  finger.  It  is  thought,  how- 
ever, that  the  actual  number  was  nearly  one  hundred.  The  fact  of  the  infection  having 
originated  from  the  woman's  finger  was  very  clearly  established,  but  in  the  cases  of 
several  of  the  children  it  must  be  confessed  that  the  syphilis  underwent  a  rather  early 
evolution. 

The  conduct  of  this  midwife  cannot  be  commented  upop-*.oo  severely,  for  she  evidently 
knew  of  the  serious  nature  of  the  disease  which  she,P"^  '  .umunicating,  yet  her  cupidity 
incited  her  to  continue  her  ministratiims.  She  was  .icd,  found  guilty,  and  sentenced  to 
a  mild  fine  and  two  years'  imprisonment. 

Fritsch  states  that  he  had  known  eight  midwifery  assistants  (young  medical  men)  who 
suffered  from  digital  chancres,  and  that  he  knew  of  one  woman  who  was  infected  with 
syphilis  by  one  of  them. 

As  an  historical  fact  it  may  be  of  interest  to  mention  that  in  1727  an  epidemic  of 
syphilis  broke  out  in  the  little  village  of  Sainte  Euphemie,  in  the  department  of  Drome, 
France.  This  epidemic  has  been  chronicled  in  history  hy  Jean  Bayer  under  the  title 
Mai  de  Sainte  Euphemie.  This  scourge,  it  is  stated,  had  its  origin  in  a  pustule  upon  the 
right  index  finger  of  a  midwife.  During  four  months  this  lesion,  accompanied  with 
painful  swelling  of  the  arm  and  a  generalized  rash,  existed,  and  all  the  time  the  woman 
exercised  her  calling.  More  than  fifty  women,  her  immediate  victims,  were  infected  upon 
the  genitals,  and  from  them  the  disease  spread  to  their  husbands  and  children.  Though 
the  course  of  the  syphilis  in  all  the  cases  was  very  severe,  there  is  no  mention  of  a  fatal 
result. 

Brambilla  ("Caso  importante  de  infectione  sifilitica."  Gazetia  Medica  Italiana  Lom- 
bardicL,  No.  24,  1877,  p.  2.31)  reports  the  case  of  a  midwife  who  became  infected  upon  the 
left  thumb,  and  had  very  severe  generalized  syphilitic  .'symptoms  and  manifestations.  She 
was  treated  and  promptly  cured,  and  there  is  no  evidence  that  she,  on  her  part,  communi- 
cated the  disease  to  any  one  else.  This  observation  is  rendered  the  more  interesting  by 
the  fact  that  confrontation  was  accomplished,  and  the  person  from  whom  the  midwife 
received  the  infection  was  found  to  have  four  ulcerated  papules  of  the  vulva  and  anus 
and  bi-inguinal  adenopathy. 


556  SYPHILIS. 

the  vermilion  border  and  the  skin.  They  may  be  seated  on  the  cutaneous 
portion  of  the  lip  alone.  These  chancres  are  rarely  seen  early  in  their 
course,  since  their  nature  is  frequently  unrecognized  until  they  have 
reached  full  development.  They  begin  as  small  round  or  oval  excoria- 
tions or  as  fissures,  and  are  at  first  looked  upon  as  cold  sores  or  cracks  of 
the  lip. 

It  sometimes  happens  that  a  minute  excoriation  or  small  fissure  will 
run  a  very  ephemeral  course,  and  disappear  in  a  week  or  ten  days  without 
having  or  leaving  after  it  any  induration.  In  these  cases  the  only  early 
signs  of  syphilitic  infection  is  the  marked  enlargement  of  the  submax- 
illary and  sublingual  glands,  which  may  be  so  extensive  as  to  constitute 
a  temporary  deformity.  But  in  most  instances  chancre  of  the  lip  goes  on 
to  full  development,  producing  a  raw,  eroded,  flat  plaque  or  nodule,  whose 
shape  is  in  conformity  with  the  arrangement  of  the  parts,  or  an  encrusted 
lesion  is  produced.     (See  Fig.  1,  Plate  IV.) 

The  color  of  the  membrane  covering  these  chancres  is  of  greenish- 
cream  or  deep-green  color,  which  is  oftentimes  so  darkened  by  minute 
hemorrhages  that  a  dark-brown  crust  is  left.  In  many  cases  the  lip- 
chancre  is  tolerably  well  defined,  sometimes  resembling  the  rounded 
nodule  seen  on  the  penis ;  then  again  the  chancre  is  spread  out  along  the 
vermilion  border.  The  amount  of  induration  varies  in  some  cases.  In 
the  ephemeral  chancres  it  cannot  be  felt ;  in  other  more  chronic  chancres 
it  is  moderate,  but  somewhat  doughy,  while  it  may  be  found  even  of 
great  extent  and  of  ligneous  hardness.  (See  Fig.  2,  Plate  IV.)  These 
chancres  cause  much  discomfort  by  their  presence  on  the  lip,  and  the 
concomitant  engorgement  of  the  glands  is  often  a  source  of  annoyance 
and  even  pain.     They  often  give  rise  to  a  quite  profuse  viscid  secretion. 

Chancres  of  the  Tongue. 

These  chancres  have  not  clearly-marked  features.  They  appear  as 
tolerably  well-circumscribed  nodules  either  at  the  tip  or  on  the  lateral 
portion.  Their  surfaces  are  red,  eroded,  sometimes  covered  with  a  milky 
pellicle,  frequently  uneven  and  traversed  by  minute  fissures.  Their 
nodular  character,  chronic  indolent  course,  and  external  features  point  to 
their  nature.  The  submaxillary  glandular  enlargement  aids  in  making 
the  diagnosis.  It  must  be  remembered  that  cancer  of  the  tongue  begins 
in  a  little  nodule,  perhaps  warty  in  appearance,  and  is  soon  complicated 
by  glandular  enlargement.  In  persons  under  forty  or  fifty  years  it  will 
generally  be  found  that  the  tongue-lesion  is  of  syphilitic  origin.  In 
middle  and  advanced  age  the  probabilities  are  greater  that  the  lesion  is 
cancerous  than  syphilitic.  In  these  cases  every  phase  should  be  carefully 
studied  in  order  that  a  correct  diagnosis  may  be  made. 

Chancres  of  the  Gums  and  of  the  Hard  Palate. 

These  lesions  are  very  rare  indeed,  and  several  cases  reported  as  such 
were  undoubtedly  those  of  hypertrophic  mucous  patches.  The  surgeon 
should  examine  and  think  long  before  pronouncing  as  chancre  localized 
red  thickening  of  the  mucous  membrane  of  these  parts.  When  they 
exist  these  chancres  are   simply   hypertrophied   chancrous   erosions,  the 


EXTRAGENITAL   CHANCRES.  557 

so-called  ulcus  elevatum.  Owing  to  the  condition  of  the  parts,  it  is  dif- 
ficult to  determine  the  extent  of  the  induration.  As  a  rule,  these  lesions 
cause  little  trouble  and  are  attended  with  scarcely  any  pain  when  unirri- 
tated.  When  seated  near  the  margin  of  tlie  gums  they  may  be  attacked 
by  ulceration. 

Chancres  of  the  Tonsil. 

These  chancres  are  now  known  to  be  sufficiently  common.  The 
comparative  frequency  to-day  of  the  tonsillar  chancre  is  due  to 
the  fact  that  its  existence  is  now  well  known  and  that  surgeons  are 
on  the  lookout  for  it.  I  have  seen  fully  eighteen  cases  and  perhaps 
more. 

The  tonsillar  chancre  never  presents  a  definite  typical  appearance, 
since  the  tissues  upon  which  it  is  seated  differ  in  each  individual.  What- 
ever may  have  been  the  conformation  of  the  parts,  whether  moderately 
smooth  or  more  or  less  anfractuous,  so  will  the  chancre-lesion  be  but  an 
exaggeration  of  that  condition,  due  to  hypergemia  and  hyperplasia  of  the 
parts.  Examination  is  difficult  in  all  cases,  particularly  so  in  some. 
When  accessible  to  the  finger-tip,  the  tonsil-chancre  will  feel  quite  hard, 
brawny,  and  may  even  be  cartilaginous.  In  some  cases  the  new  growth 
is  tolerably  well  circumscribed ;  in  others  it  is  quite  diffuse,  involving  a 
whole  tonsil  and  some  of  the  tissues  around  it.  The  surface  of  the  chan- 
cre may  be  simply  red  and  superficially  eroded  ;  it  may  be  covered  with 
a  milky-looking  membrane,  in  which  case  it  may  look  like  a  mucous 
patch  ;  then,  again,  a  dull-green  membrane  of  considerable  firmness  may 
cover  the  lesion. 

In  most  instances  there  is  but  one  chancre,  involving  more  or  less  of 
one  tonsil.  I  once  saw  a  case  in  which  there  was  a  well-marked  chancre 
on  each  tonsil.  Then,  again,  I  saw  during  its  whole  course  a  chancre 
which  involved  the  two  tonsils  and  the  posterior  pharyngeal  wall.  At 
about  the  time  this  case  was  under  my  care  a  colleague  sent  me  a  similar 
one  for  diagnosis. 

These  chancres  usually  become  troublesome  quite  early  in  their  course. 
The  patients  complain  of  pain,  uneasiness,  and  of  a  difficulty  in  swallow- 
ing. Sometimes  the  suffering  is  very  great.  Then  the  submaxillary, 
sublingual,  and  lymphatic  ganglia  swell  up  very  much  indeed,  so  as  to 
produce  large-sized  bunches  in  the  neck.  These  by  their  size  impede 
motion  and  deglutition  and  add  materially  to  the  patient's  suffering.  The 
ganglia  become  matted  together  into  hard,  firm,  indolent  masses.  In 
some  cases  the  pre-auricular  ganglia  are  enlarged. 

Such  is  the  deformity  of  the  parts,  and  so  great  is  the  discomfort  of 
patients  with  these  chancres,  that  it  may  be  necessary  to  begin  treatment 
before  the  date  of  evolution  of  the  secondary  state.  Usually  these  lesions 
yield  promptly  to  energetic  treatment. 

The  diagnostic  features  of  these  chancres  are — the  history  of  the 
case;  the  slow,  painless  enlargement  of  the  cervical  ganglia;  the 
unilateral  seat  (usually)  of  the  lesion  and  its  appearance ;  the  absence 
of  chancre  elsewliere,  and  the  markedly  loss  engorgement  of  the  ganglia 
of  other  parts  of  the  body ;  and,  later  on  the  evidences  of  constitutional 
syphilis. 


558  SYPHILIS. 

Chancres  of  the  External  Ear. 

Chancres  of  the  ear  are  very  rare.  In  Bulkley's  statistics  of  9058 
cases  of  extragenital  chancres,  derived  from  all  sources,  there  were  27 
cases  of  chancres  of  the  external  ear.  The  parts  which  have  been  found 
to  be  affected  are  as  follows :  the  auricle,  the  lobule,  the  integument  over 
the  mastoid  process,  and  the  base  of  the  tragus.  Chancres  of  the  ear  are 
of  the  dry,  scaling,  erosive,  or  encrusted  forms. 

The  pharyngeal  orifice  of  the  Eustachian  tube  has  been  found  to  be 
the  seat  of  chancre,  resulting  from  catheterization  by  means  of  instru- 
ments soiled  with  syphilitic  material. 


Chancres  of  the  Eyelids. 

These  chancres  are  not  common,  although  there  are  many  cases  re- 
ported in  literature.  They  are  found  on  the  free  margin  of  either  lid  or 
the  adjacent  integument  continuous  with  them,  and  also  on  the  inner  sur- 
face of  the  palpebral  mucous  membrane.  They  are  usually  of  the  erosive 
type,  with  either  slight  or  decidedly  marked  induration,  which,  however, 
does  not  spread  much  around  the  original  lesion.  Fig.  3  of  Plate  IV. 
will  give  a  very  clear  idea  of  these  palpebral  chancres.  The  creamy- 
green  color  of  the  membrane  covering  the  chancre  is  well  shown. 

Chancres  of  the  eyelids  are  always  accompanied  by  painless  hard 
enlargement  of  the  pre-auricular  ganglia,  and  generally  by  a  marked  en- 
largement of  the  cervical  ganglia  of  the  corresponding  side  of  the  face. 
As  a  rule,  a  sharply-defined  nodule  or  plaque  remains  for  a  time  after 
the  healing  of  the  chancre. 

■  Krefting  ^  gives  the  statistics  of  2916  cases  of  chancres,  of  which  539 
were  instances  of  extragenital  infection.  Of  these  extragenital  chancres, 
292  were  in  adults  (61  men  and  231  women)  and  247  were  in  children 
(117  boys  and  130  girls).  Out  of  the  1354  in  men,  there  were  only  61 
cases  of  extragenital  chancres,  which  is  about  4.3  per  cent.,  while  in 
women  the  proportion  of  these  chancres  was  12.8  per  cent.  The  seat  of 
the  extragenital  chancres  was  noted  in  280,  as  follows : 

Lips  and  buccal  commissures,  143  cases — 35  men,  77  women,  and  30  children. 

Gums 1  case  —  1  man. 

Tongue 11  cases —  3  men,    3  women,    "       5         " 

Pharynx 58      "   _  9    "      43       "  6 

Breasts      58      "   —  58       " 

Chin 1  case  —  1  woman. 

Forehead 1     "     —  1       " 

Scalp 2  cases —  1  man,    1       " 

Popliteal  space 1  case  —  1      " 

Abdomen      1     "     —  1      " 

Fingers 4  cases —   3  men,    1      " 

It  will  be  noted  that  in  three-quarters  of  these  cases  the  infection  was 
in  and  about  the  mouth. 

Extragenital  chancres  being  really  accidents,  their  occurrence  is 
largely  determined  by  the  habits  and  customs  of  the  people  infected.     In 

^  "  Extragenitale  Syphilisinfection,  539  Falle,"  Arch,  fur  Derm,  mid  SypL,  1894,  vol. 
xxvi.  pp.  167  et  seq. 


GENITAL  AND  EXTRAGENITAL   CHANCRES  IN  WOMEN.      559 

contrast  with  Krefting's  statistics,  those  of  Salsotto  ^  are  interesting.  In 
201  cases  there  Avere  2  of  chancre  of  the  anus,  1  of  the  thigh,  2  of  the 
inguinal  region,  108  of  the  breast,  2  of  the  chin,  2  of  the  upper  eyelid,  2 
of  the  cheek,  1  of  the  forehead,  2  of  the  fingers,  12  on  the  arm,  1  on  the 
back,  2  on  the  tongue,  1  on  the  gums,  and  61  on  the  lips.  In  this  col- 
lection no  case  of  chancre  of  the  tonsil  was  noted. 


CHAPTER    LV. 

GENITAL  AND  EXTRAGENITAL  CHANCRES  IN  WOMEN. 

Chancres  of  the  genital  organs  are  very  common  in  women,  but 
extragenital  chancres  occur  in  them  much  more  frequently  than  they  do 
in  men. 

Chancres  in  women  are  usually  far  less  regular  in  their  course  than 
they  are  in  men.  In  many  women  the  chancre  is  so  small,  benign,  and 
ephemeral  that  it  may  never  be  seen,  or,  if  seen,  its  nature  is  usu- 
ally not  suspected.  In  very  many  cases,  even  when  the  lesion  is  strik- 
ingly apparent,  its  nature  remains  for  a  long  time  in  doubt,  owing  to  in- 
flammatory complications  and  to  a  want  of  striking  individuality  in  the 
lesion  itself.  Then,  again,  simple  inflammatory  processes  and  chancroidal 
ulcers  often  become  upon  the  female  genitals  so  complicated  and  obscure 
in  appearance  that  they  may  resemble  specific  lesions.  In  women  indura- 
tion as  a  symptom  is  not  so  generally  observed  as  it  is  in  men.  In  some 
females  it  can  scarcely  be  appreciated  by  careful  examination,  and  it  may 
be  very  transitory  in  its  duration,  whereas  in  others  it  attains  large  pro- 
portions, lasts  for  indefinite  periods,  and  may  lead  to  ultimate  deformity. 
In  men  the  chancre  is  readily  examined.  In  women  this  lesion,  owing  to 
the  nature,  inadaptability,  and  inaccessibility  of  the  parts,  is  very  diffi- 
cult of  examination  except  on  protruding  portions  of  the  genitals. 

In  the  majority  of  cases  there  is  but  one  chancre,  but  in  fully  one- 
third  of  the  cases  the  lesion  is  multiple.  There  may  be  two  or  three,  and 
rarely  more  than  eight,  infecting  chancres  in  one  woman. 

The  main  reason  why  chancres  in  the  female  are  so  little  understood, 
are  so  frequently  unrecognized,  and  generally  offer  so  much  difficulty  in 
diagnosis  is  that  there  is  very  little  chance  for  their  study  on  a  large 
scale. 

As  in  men  so  in  women,  the  chancre  is  simply  a  localized  aggregation 
of  a  peculiar  new  specific  cell-growth.  For  clinical  purposes  we  may 
divide  genital  chancre  in  women  into  the  following  varieties :  the 
superficial  or  chancrous  erosion ;  the  scaling  papule  or  tubercle ;  the 
elevated  papule  or  tubercle  (oxulcerated),  ulcus  elevatum ;  the  incrusted 
chancre ;   the  indurated  nodule ;  the  diffuse  exulcerated  chancre. 

This  division,  which  is  clinically  correct,  may  at  the  first  sight  seem 

^  Sifilomi  Extragenitali  ed  Epidemie  di  Sifilide,  brochure,  Turin,  1892. 


560  SYPHILIS. 

puzzling,  but  it  offers  a  basis  for  study  and  observation,  and  its  simplicity" 
will  be  appreciated  as  the  experience  of  the  observer  widens. 

The  Superficial  or  Chancrous  Erosion. 

The  most  constant  early  appearance  of  the  syphilitic  chancre  in 
woraen  is  seen  in  the  form  of  an  erosion  of  the  mucous  membrane. 
In  its  very  early  days  this  lesion  presents  no  well-marked  character- 
istics, and  is  very  liable  to  be  mistaken  for  a  ruptured  herpetic  vesicle, 
an  abrasion,  chafe,  or  scratch.  Such  is  its  seemingly  benign,  superficial, 
and  aphlegmasic  character  and  small  size  that  its  nature  is  frequently 
not  determined  at  the  first  examination.  Indeed,  as  Fournier  says, 
"  nine  times  out  of  ten  the  nascent  chancre  is  not  recognized  as  such." 

The  chancrous  erosion  is  always  found  on  the  surface  of  the  mucous 
membrane.  It  begins  as  a  red  spot,  somewhat  deeper  in  color  than 
the  mucous  surface  on  which  it  is  seated.  It  is  very  rarely,  if  ever, 
seen  in  women  in  the  first  few  days  of  its  existence,  for  the  reason  that 
its  presence  is  usually  unknown  to  its  bearer,  or,  if  it  is  seen  by  her,  it 
appears  so  simple,  mild,  and  harmless  that  its  nature  is  scarcely  ever  sus- 
pected. Thus  it  is  that  when  first  seen  by  the  physician  the  red  spot 
has  become,  by  desquamation  of  its  ephithelium,  an  erosion.  When 
seated  on  smooth  surfaces,  such  as  presented  by  the  internal  surfaces  of 
the  labia  majora  and  the  greater  part  of  the  labia  minora,  this  lesion, 
when  somewhat  advanced,  presents  certain  well-defined  features,  but  when 
it  is  developed  upon  the  anfractuous  surfaces  of  the  fourchette,  the  intro- 
itus  vaginae,  the  vestibule,  and  around  the  urethra,  its  appearance  is  not 
striking,  and  indeed  is  often  misleading  to  the  eye,  while  its  exploration 
is  difficult  and  unsatisfactory  to  the  fingers.  In  very  many  cases  a  catar- 
rhal or  blennorrhagic  condition  of  the  parts  conduces  to  further  obscurity 
of  the  diagnosis. 

When  the  erosion  is  quite  well  developed,  it  presents  the  appearance 
of  a  very  superficially  exulcerated  lesion  of  a  more  or  less  deep-red  color, 
resembling  quite  closely  muscular  tissue.  This  color,  however,  varies  in 
different  cases  between  certain  extremes.  In  very  cleanly  and  anaemic 
women  the  redness  may  be  scarcely  deeper  than  normal,  while  in  uncleanly 
persons,  in  those  suffering  from  simple  or  blennorrhagic  inflammation  of 
the  genital  tract,  in  those  in  whom  the  coaptation  of  the  parts  is  close 
and  tight,  and  in  pregnant  women  the  chancre  may  be  of  an  extremely 
deep  dull-red  tint. 

Upon  smooth,  tolerably  flat  surfaces  the  chancrous  erosion  is  usually 
round  or  oval  in  shape,  though  either  of  these  outlines  may  become  irreg- 
ular. On  anfractuous  surfaces  the  chancre  presents  corresponding  irreg- 
ularities. The  surface  of  the  chancre  is  smooth,  sometimes  even  glisten- 
ing and  shining,  and  shows  that  the  lesion  is  formed  of  tolerably  compact 
tissue.  It  usually  presents  a  solidity  of  structure  which  is  striking. 
When  seated  upon  parts  in  which  the  chancre  is  subjected  to  movement, 
or  in  clefts,  the  smoothness  of  surface  may  be  more  or  less  lost. 

The  secretion  of  the  chancre  is  usually  serous  in  character,  but  it  may 
also  contain  some  leucocytes.  It  varies  in  quantity  considerably :  from 
some  chancres  we  see  very  little  serous  oozing,  while  from  others  it  is  quite 
copious.     When  seated  on  an  inflamed  surface  or  when  the  chancre  is  irri- 


GENITAL  AND  EXTRAGENITAL   CHANCRES  IN  WOMEN.       561 

tated  it  may  secrete  true  pus.  In  some  cases  these  chancres  become  con- 
taminated with  chancroidal  pus,  and  they  are  then  converted  into  ulcers 
whose  nature  it  is  very  difficult  to  determine. 

The  true  chancrous  erosion  scarcely  presents  an  appreciable  elevation, 
and  the  lesion  may  run  its  course  and  disappear  without  ever  becoming 
salient  above  the  normal  plane. 

While  in  general  there  is  not  a  well-defined  margination  of  the  chan- 
crous erosion,  the  eye  can  plainly  see  where  the  lesion  ends  and  where 
sound  tissue  begins.  In  some  cases,  however,  the  circumferential  margin 
becomes  hyperplastic  and  the  chancre  is  converted  into  a  saucer-shaped 
lesion.  The  size  of  these  chancres  varies  considerably  :  some  reach  matu- 
rity and  have  a  diameter  of  a  third  or  half  an  inch,  and  it  is  not  com- 
mon to  see  one  larger  than  an  inch  in  diameter. 

In  many  cases,  even  when  a  satisfactory  examination  is  possible,  no 
evidence  of  induration  can  be  made  out,  and  at  best  soft,  oedematous 
hyperplasia  may  be  felt.  In  other  cases,  however,  induration  of  a  super- 
ficial, flat  character — parchment  induration — can  be  felt. 

In  many  instances  the  chancrous  erosion  runs  its  whole  course  as  a 
non-salient  lesion,  but  in  others  the  erosion  gradually  develops  into  a 
papule  or  tubercle,  the  description  of  which  will  soon  follow. 

While  in  general  the  chancrous  erosion  is  with  difficulty  diagnosti- 
cated in  its  early  days,  if  it  is  protected  from  irritation  and  dirt  and  care- 
fully watched,  its  nature  may  be  determined  in  the  course  of  ten  days  or 
two  weeks,  if  not  sooner.  Herpetic  disks,  chafes,  and  excoriations  usually 
show  a  tendency  to  become  rapidly  cicatrized  by  the  simple  interposition 
of  lint  or  of  a  mild  astringent  wash,  and  from  the  first  they  usually  show 
signs  of  healing.  On  the  other  hand,  despite  judicious  aseptic  measures, 
the  chancrous  erosion  in  most  cases  keeps  on  its  course  without  any  early 
signs  of  healing.  With  this  lesion  the  implication  of  the  ganglia  can  usually 
be  well  made  out  in  about  two  weeks,  and  this  sign,  with  the  typical  appear- 
ance of  the  lesion,  will  usually  make  the  diagnosis  of  syphilis  clear, 

Chancrous  erosions,  when  seated  upon  the  surfaces  of  the  labia,  large 
and  small,  are  very  commonly  multiple,  varying  in  number  from  two  to 
four,  and  even  to  six  and  eight  in  some  cases. 

The  chancrous  erosion  upon  uneven  and  anfractuous  surfaces  is  even 
more  difficult  of  recognition  than  the  lesions  just  considered.  Upon  the 
carunculae  myrtiformes,  about  the  urethra,  at  the  fourchette,  and  around 
the  vaginal  orifice  the  lesion  rarely  has  a  definite  shape  and  outline.  As 
Clerc  says,  the  syphilitic  neoplasm  moulds  itself  to  the  parts  it  is  seated 
upon,  and  when  these  parts  are  uneven,  nodular,  fringed,  and  anfractu- 
ous, its  shape,  outline,  and  general  configuration  are  vague  and  indeter- 
minate. 

The  diagnosis,  at  best  being  very  difficult,  it  is  often  rendered  more 
obscure  and  even  impossible  by  underlying  chronic  and  acute  inflamma- 
tory conditions  of  the  vagina  and  vulva.  I  have  many  times  seen  this 
form  of  chancre  thus  located  pass  wholly  unrecognized  by  careful  and 
skilled  men  in  the  cases  of  women  suff"ering  from  simple  and  blennor- 
rhagic  inflammation  of  the  genitals.  In  practice  the  best  course  to  pur- 
sue when  one  is  consulted  for  or  sees  a  deep-red,  superficially  eroded 
patch,  or  even  papule  of  irregular  outline,  on  the  parts  just  mentioned, 
is  to  keep  them  free  from  all  irritation  and  apply  a  bland  lotion  on  cot- 

36 


562  SYPHILIS. 

ton.  If  the  lesion  is  simple  in  character,  it  will  soon  become  pale  and 
heal,  but  if  it  is  composed  of  syphilitic  cell-growth,  it  Avill  keep  on  in 
most  instances  and  become  further  developed.  Time,  watchfulness,  and 
the  condition  of  the  ganglia  will  Avithin  three  weeks  certainly  make  the 
diagnosis  clear.  It  follows,  therefore,  that  the  physician  should  speak 
guardedly  of  these  lesions,  and  that  he  should  never  pass  them  over  as 
insignificant  or  pronounce  them  offhand  as  being  of  no  moment. 

A  frequent  and  striking  peculiarity  of  the  chancrous  erosion  is  its 
short  period  of  existence.  It  frequently  comes  and  goes  without  the 
knowledge  of  its  bearer.  Physicians,  young  and  old,  are  often  much 
surprised  that  on  female  subjects  presenting  early  secondary  lesions 
they  can  find  no  trace  of  the  chancre.  Not  only  does  this  lesion  fre- 
quently undergo  rapid  involution,  but  it  may  also  leave  after  it  no  trace 
after  the  lapse  of  a  few  days.  Fournier  watched  a  chancrous  erosion 
run  its  course  in  fourteen  days  and  leave  after  it  no  trace.  I  recall  the 
case  of  a  woman  who  had  a  pea-sized  erosion  in  the  cleft  formed  by  the 
labium  majus  and  the  labium  minus  which  I  watched  carefully,  and  in 
which  the  chancrous  lesion  lasted  eighteen  days  and  disappeared  without 
the  slightest  perceptible  trace. 

Sometimes  on  the  involution  of  the  chancre  a  reddened,  very  slightly 
hyperplastic  spot  is  left,  and  one  can  tell  that  the  affected  tissue  is 
slightly  denser  than  normal.  Then,  again,  the  only  trace  left  is  a  cir- 
cumscribed redness,  at  first  rather  deep.  This  gradually  pales,  and  the 
mucous  membrane  is  left  apparently  healthy.  While  in  many  cases  the 
chancre  is  very  ephemeral  and  leaves  a  trace  which  rapidly  disappears, 
in  other  cases  the  red  spot  is  very  persistent,  and  it  may  be  seen  for 
several  months. 

The  chancrous  erosion  usually  leaves  no  evidence  of  a  cicatrix :  the 
reason  of  this  is  that  the  syphilitic  new  growth  composing  it  is  not  copi- 
ous and  condensed  ;  consequently,  it  does  not  destroy  or  impair  the  tissue 
which  it  infiltrates,  and  is  absorbed  without  carrying  away  with  it  any 
normal  cells.  This  lesion,  however,  is  sometimes  accompanied  with  an 
oedematous  condition  of  the  tissues  under  and  around  it.  This  compli- 
cating condition  consists  in  a  slow,  aphlegmasic  thickening  of  the  tis- 
sues. It  may  be  limited  to  a  moderately  wide  area  around  the  sore,  or 
it  may  be  extensive  and  involve  much  tissue.  It  is  not  at  all  uncommon . 
to  see  the  whole  of  a  labium  minus  or  majus  the  seat  of  this  indurating 
oedema.  Tissues  thus  affected  present  a  dense,  firm,  and  somewhat 
elastic  structure,  but  the  induration  in  its  early  periods  is  not  as  hard 
as  that  of  a  typical  initial  sclerosis. 

It  not  infrequently  happens,  particularly  when  the  chancrous  erosion 
is  seated  near  the  integument  or  upon  the  fourchette  or  prepuce  of  the 
clitoris,  that  well-defined  induration  takes  place  under  it,  and  it  becomes 
developed  into  a  typical  indurated  chancre.  This  condition  is  sometimes 
strikingly  well  marked  at  the  fourchette,  where  it  frequently  presents 
a  raw-beef  appearance,  which  is  very  characteristic. 

The  Scaling  Papule  or  Tubercle. 

This  lesion  is  found  upon  the  outer  surface  of  the  labia  majora;  upon 
the  labia  minora  when  they  are  long  and  their  stricture  resembles  that 


GENITAL  AND  EXTRAGENITAL  CHANCRES  IN  WOMEN.       563 

of  the  integument ;  upon  the  prepuce  of  the  clitoris  when  it  is  long  and 
protrudes  from  the  vulva ;  upon  the  internal  surface  of  the  thighs,  the 
inguinal  folds,  and  the  hypogastrium.  It  begins  in  a  very  insignificant 
manner  as  a  small,  dull-red  colored  papule,  which  may  or  may  not  be 
scaly.  This  lesion  increases  circumferentially,  but  usually  does  not 
become  much  elevated.  As  it  grows  it  develops  into  a  flat,  brownish- 
red  and  sometimes  purplish-brown,  perhaps  scaly,  elevation  of  the  skin, 
Avith  a  sharply-defined  margin.  It  may  be  of  the  size  of  a  split  pea,  of 
a  silver  five-cent  piece,  or,  when  on  a  flat  cutaneous  surface,  as  large  as 
a  silver  quarter-  or  half-dollar.  Its  shape  is  round  or  oval,  and  some- 
times, owing  to  the  conformation  of  the  parts,  it  is  of  irregular  outline. 
It  may  present  well-marked  induration  or  this  symptom  may  be  scarcely 
recognized.  In  general  this  lesion  is  unique,  and  exceptionally  two  or 
three  are  found.  Though  it  is  cold  and  aphlegmasic  in  appearance,  it 
presents  to  the  eye  a  compactness  of  structure  giving  one  the  impression 
that  it  has  come  to  stay.  It  runs  an  indolent  course,  and  may  last  sev- 
eral weeks  or  even  months.  It  then  sinks  down  and  withers.  In  most 
cases  it  leaves  after  it  a  deep-brown,  even  a  purplish,  stain,  and  not  un- 
commonly atrophy  of  the  skin  is  produced  by  it.  When  irritated  this 
lesion  loses  its  epidermal  covering  and  becomes  raw  and  exuding.  It 
then  is  developed  into  what  is  called  the  ecthymatous  chancre  (a  bad 
term),  and  may  be  better  classed  as  an  incrusted  chancre.  This  form 
of  chancre  is  far  from  uncommon  in  women. 

In  rare  cases  the  scaling  papule  becomes  very  large  in  area  and  very 
much  elevated,  so  as  to  form  what  we  may  call  an  elephantine  chancre. 
I  have  seen  one  on  the  buttocks  of  a  woman  the  diameter  of  which  was 
two  inches  and  a  half,  and  another  on  the  upper  portion  of  the  thigh 
which  had  an  area  of  an  inch  and  a  half  and  a  height  of  three-quarters 
of  an  inch. 

In  rare  cases  the  scaling  papular  chancre  develops  around  a  hair  and 
forms  a  conical  lesion  of  the  color  just  described.  When  this  occurs  it 
is  not  uncommon  to  see  two  or  three,  or  even  more,  of  these  chancres. 
They  may  run  an  uncomplicated  course,  or  they  may  become  attacked 
'with  ulceration,  in  which  event  the  diagnosis  is  much  obscured,  and 
u  lapse  of  time  is  required  before  their  nature  is  rendered  clear  and 
positive.  The  resulting  ulcers  have  well-defined,  elevated  edges  and  a 
saucer-shaped  surface.  They  vary  in  size  from  a  third  to  half  an  inch. 
All  chancres  of  this  variety  are  rather  slow  in  disappearing. 

The  Elevated  Papule  or  Tubercle  (Ulcus  Elevatum). 

This  chancre  presents  the  appearance  of  a  well-circumscribed,  flat, 
or  elevated  lesion  Avhose  surface  is  similar  to  that  of  the  chancrous  ero- 
sion. Indeed,  it  may  be  defined  as  a  chancrous  erosion  in  which  the 
hyperplastic  process  has  been  very  active  and  productive  of  much  infil- 
tration. Cases  not  infrequently  present  themselves  in  which  we  can 
watch  the  development  of  the  ulcus  elevatum  from  the  chancrous 
erosion. 

The  ulcus  elevatum  is  seen  upon  the  mucous  surface  of  the  labia 
majora  and  minora  in  its  most  t^^pical  type.  This  form  of  chancre  is 
round,  oval,  or  slightly  irregular  in  outline,  and  varies  in  size  from 


564  SYPHILIS. 

a  third  of  an  inch  to  an  inch,  and  even  an  inch  and  a  half.  Its  surface 
is  smooth  and  even  velvety,  and  its  color  is  of  a  deep  red,  like  muscular 
tissue.  In  some  cases  the  smoothness  of  surface  is  replaced  by  an 
uneven,  slightly  granular  condition,  but  in  uncomplicated  cases  nothing 
like  a  warty  or  strawberry  surface  is  seen.  In  old  and  irritated  cases 
of  the  ulcus  elevatum  a  slightly  warty  appearance  of  the  surface  may  be 
present.  In  other  cases,  as  the  lesion  grows  old,  it  assumes  the  appear- 
ance of  condylomata  lata.  The  surface  may  be  flat,  slightly  convex,  or 
even  decidedly  concave.  As  a  rule,  the  margination  of  the  ulcus  eleva- 
tum is  not  sharp  and  steep,  but  in  some  cases  this  feature  is  observed. 
The  secretion  of  this  lesion  is  serous  in  character  and  is  mixed  with 
a  few  leucocytes.  In  consequence  of  the  irritation  of  catarrhal  or  blen- 
norrhagic  secretions,  as  a  result  of  uncleanliness  and  alcoholic  and 
sexual  excesses,  and  of  prolonged  walking  and  fatigue,  the  ulcus  eleva- 
tum may  become  much  hypertrophied,  and  around  it  may  develop  a 
varying  amount  of  indurating  oedema;  or,  from  the  same  causes,  it 
may  become  more  or  less  ulcerated,  in  which  event  its  nature  is  often 
rendered  very  obscure.  A  hyperaemic  condition  of  the  parts  around, 
due  to  pregnancy  or  any  other  source  of  irritation,  is  very  often  a  com- 
plication which  obscures  and  delays  the  diagnosis. 

Careful  palpation  rarely  shows  very  marked  induration  in  the  ulcus 
elevatum.  This  symptom  is  usually  difficult  of  detection,  and  when 
found  it  is  generally  of  the  parchment-like  order,  or  it  simply  gives  the 
impression  of  a  rather  greater  condensation  of  tissue  than  is  normally 
found.  When  this  lesion  is  situated  near  the  juncture  of  the  mucous 
membrane  and  the  integument,  it  may  present  marked  induration.  As 
a  rule,  this  form  of  chancre  is  chronic  in  its  course,  lasts  Aveeks  and 
months,  and  slowly  resolves,  leaving  a  deep-red  spot  Avhich  may  be  very 
persistent  and  is  often  very  useful  in  diagnosis.  In  some  cases  a 
cicatrix  is  left. 

The  Incrusted  Chancre. 

This  chancre,  as  we  have  seen,  is  not  uncommonly  found  upon  juxta- 
pudenal  cutaneous  surfaces,  and  indeed  upon  any  portion  of  the  integu- 
ment. It  has  been  stated  that  incrusted  chancres  are,  as  a  rule,  not 
found  within  the  area  of  the  mucous  membrane  of  the  vulva,  but  that 
their  habitat  is  the  tegumentary  structures.  It  is  true  that  in  most 
instances  vulvar  chancres  are  of  the  erosive  or  papulo-tubercular  variety. 
This  is  largely  due  to  the  fact  that  the  coaptation  of  the  parts  and  their 
moisture,  aided  very  often  by  pathological  secretions,  cause  any  surface 
covering  of  the  chancre  to  melt  away  and  to  disappear.  But  it  is  not  at 
all  uncommon  to  find  chancres  at  the  fourchette  in  an  incrusted  state,  and 
I  have  twice  seen  this  condition  in  vaginal  chancres.  Further,  in  some- 
what rare  cases  I  have  seen  incrusted  chancres  of  the  clitoris,  and  also  of 
the  labia  minora,  when  these  structures  have  been  prominent  in  the  vulva 
and  have  come  to  look  like  integument. 

At  the  fourchette,  besides  the  raw-beef  chancre — the  outcome  of  the 
chancrous  erosion — we  not  uncommonly  find  incrusted  chancres. 

The  incrustation  in  women,  as  in  men,  forms  upon  an  eroded  surface — 
namely,  the  chancrous  erosion,  the  indurated  nodule,  or  the  difi'use  indu- 


GENITAL  AND  EXTRAGENITAL   CHANCRES  IN  WOMEN.       565 

rated  plaque.  It  begins,  as  it  does  in  men,  as  a  thin,  white  film,  present- 
ing a  glistening  appearance,  and  becomes  of  a  greenish-creamy  tint. 

Then,  again,  in  women,  as  in  men,  the  surface  of  the  chancre  may  be 
covered  with  a  thin,  brownish-red,  necrotic-looking  film,  which  consists  of 
the  usual  membrane  discolored  with  blood,  which  may  be  scattered  in 
little  masses  over  the  surface  of  the  chancre,  giving  it  a  spotted  ap- 
pearance. 

Further,  we  find,  though  very  rarely,  the  chancre  called  by  Fournier^ 
chancre  multicolore  or  the  chancre  en  cocarde,  in  which  the  surface  of  the 
chancre  presents  a  series  of  concentric  zones  of  different  colors  which  are 
thought  to  resemble  a  cockade.  This  play  of  color  is  due  to  some  peculiar 
changes  in  the  typical  syphilitic  membrane  of  the  chancre. 

The  incrusted  chancre  may  present  a  smooth  surface  or  it  may  be  more 
or  less  uneven  and  undulating,  owing  to  the  nature  of  the  parts  upon 
which  it  is  seated. 

When  it  is  developed  among  the  hairs,  the  infiltrating  neoplasm  causes 
little  elevations  around  the  hair-follicles ;  as  a  result,  the  surface  of  the 
chancre  is  quite  uneven.  This  is  the  usual  condition  of  chancres  when 
developed  upon  hairy  parts. 

In  the  incrusted  state  the  chancre  may  remain  indolent  and  aphlegmasic 
for  a  long  time.  As  the  lesion  becomes  old  it  is  not  uncommon  to  find 
that  it  is  complicated  with  a  greater  or  less  amount  of  indurating  oedema. 
Under  proper  medication  the  crust  disappears  and  healing  takes  place  in 
the  chancre.     A  cicatrix  is  usually  left. 

The  Indurated  Nodule. 

This  chancre,  so  common  in  men,  is  very  rare  in  women.  In  men  the 
syphilitic  neoplasm  or  nodule,  as  a  rather  general  rule,  becomes  circum- 
scribed in  compact  form  into  a  little  mass ;  in  women  this  new  growth 
tends  to  diffuse  itself  more  loosely  into  the  soft  mucous  tissues.  Thus  it 
is  that  we  rarely  see  the  indurated  nodule  in  the  female  sex,  except  on 
parts  where  the  skin  and  mucous  membrane  fuse  together. 

The  indurated  nodule  is  seen  as  a  sharply-circumscribed  mass  of  indu- 
rated tissue,  which  may  be  rather  broad  and  flat,  or  it  may  have  a  rather 
narrow  base,  sloping  edges,  and  flat  surface.  The  color  of  the  lesion  is 
dull  red,  and  its  surface  may  be  smooth  and  glossy,  or  it  may  present  the 
grayish  color  of  the  incrusted  chancre,  with  all  the  variegations  found 
upon  that.  This  nodule,  like  most  of  its  class,  may  have  a  cartilaginous 
hardness,  sharply  limited  to  its  margin.  The  course  of  this  lesion  is  very 
chronic,  and  on  its  disappearance  a  pigmented  spot  may  be  left  or 
atrophied  skin  may  be  evident. 

The  Diffuse  Exulcerated  Chancre. 

This  lesion  is  observed  not  infrequently  in  women  of  the  lower  order 
who  are  uncleanly  in  their  habits  and  given  to  debauches.  It  presumably 
begins  as  the  chancrous  erosion  develops  into  the  ulcus  elevatum,  and 
from  this  stage  it  further  increases.  It  is  usually  seen  involving  more  or 
less  of  one  lip,  large  or  small.     The  morbid  area  is  much  thickened,  of  a 

^  Lemons  cUniques  sur  la  Syphilis  chez  la  Femme,  Paris,  1881,  pp.  32  et  seq. 


666  SYPHILIS. 

deep-red  color,  and  it  is  exulcerated  over  the  greater  part  of  its  surface. 
In  these  very  large  chancres  we  find  a  raw,  uneven  surface,  and  very  often 
small  or  large  ulcerating  spots.  Their  course  being  very  chronic  and 
indolent,  their  appearance  varies.  Sometimes  they  are  raw  like  beef, 
and  at  others  they  look  like  elephantine  incrusted  chancres.  They  are 
very  often  complicated  Avith  the  development  of  hard  oedema,  in  which 
case,  from  their  chronicity,  their  papillomatous  appearance  (if  present), 
and  great  density,  they  may  be  mistaken  for  epithelioma. 

As  a  rule,  all  chancres  of  the  female  genitals  are  unaccompanied  with 
pain.  In  some  cases  itching  and  burning  are  complained  of,  and  in  some 
chancres  of  the  clitoris  and  fourchette  severe  pain  may  be  felt. 

On  the  labia  majora  we  find  the  incrusted  chancre,  the  chancrous  ero- 
sion, the  ulcus  elevatum,  the  difiuse  exulcerated  chancre,  and  the  indurated 
nodule.  In  the  tissues  of  these  parts  indurating  oedema  is  very  often 
observed  as  a  complication  involving  large  and  small  portions.  This  com- 
plication is  also  found  as  a  result  of  secondary  lesions,  such  as  erosions 
and  condylomata  lata. 

On  the  labia  minora  the  chancrous  erosion,  the  ulcus  elevatum,  and 
the  diffuse  exulcerated  chancre  are  commonly  found.  All  chancres  on 
these  parts  may  be  accompanied  by  mild  or  dense  induration,  which  may 
involve  a  part  or  the  whole  of  the  structure. 

Chancres  of  the  preputial  covering  of  the  clitoris  are  of  the  erosive  or 
incrusted  types.  Very  often  they  are  very  hard,  and,  as  Fournier  says, 
the  clitoris  sometimes  feels  like  a  miniature  ramrod. 

Chancres  of  the  fourchette  are  of  the  erosive,  incrusted,  or  diffusely 
indurated  type. 

Chancres  of  the  introitus  vaginae,  meatus,. and  myrtiform  caruncles  are 
commonly  ill- defined  masses  of  induration  which  frequently  present  no 
characteristic  appearance,  and  whose  diagnosis  is  usually  very  difficult, 
and  frequently  only  possible  after  considerable  delay  and  observation.  On 
these  parts  it  is  very  difficult,  often  impossible,  to  determine  the  extent 
and  density  of  the  induration. 


Chancres  of  the  Vagina. 

These  are  very  rare,  and  when  found  they  are  usually  within  an  inch 
of  the  vaginal  ring.  They  are  found  on  the  anterior  and  posterior  walls 
in  the  form  of  erosions  with  considerable  hardness  or  in  the  incrusted 
state.  Usually  there  is  but  one  chancre ;  sometimes  there  are  two. 
Clerc  ^  states  that  he  never  saw  a  chancre  of  the  vagina,  and  Fournier 
says  that  he  never  saw  one.  I  have  reported  and  figured^  a  case  of 
chancre  of  the  vagina  in  which  there  Avas  one  lesion  in  the  sulcus  to  the 
right  of  the  bladder,  an  inch  within  the  vaginal  ring,  and  another  in 
the  left  sulcus,  which  was  fully  three  inches  up.  In  this  case  there  Avas  a 
well-marked  chancrous  erosion  at  the  fourchette — in  all,  three  chancres, 
two  in  the  vagina  and  one  at  the  fourchette  beyond  the  vaginal  ring. 

1  Traite  pratique  des  Maladies  veneriennes,  Paris,  1866,  p.  101. 

^  "Genital  Chancres  in  Women,"  Neiv  York  Med.  Journal,  Jan.  2,  1892.  To  tliis  paper 
is  added  a  chromo-lithographic  plate  of  figures  representing  the  various  forms  of  chancres 
found  about  the  female  genitals. 


GENITAL  AND  EXTRAGENITAL   CHANCRES  IN   WOMEN.       567 

Gardillon,^  in  his  thesis,  reports  four  cases,  in  one  of  which  the  chancre 
was  on  the  posterior  wall  well  up.  A  very  interesting  case  is  reported  by 
Bockhart,^  in  which  the  chancre  was  seated  in  the  middle  of  the  posterior 
wall.  The  lesion  Avas  contracted  from  a  syphilitic  man  who  used  a  so- 
called  stimulating  condom,  which  so  excoriated  the  vaginal  wall  that  infec- 
tion took  place.  In  all  probability,  the  thickness  and  density  of  the 
vaginal  epithelium  in  most  cases  offer  a  barrier  to  syphilitic  infection. 
Two  interesting  cases  of  vaginal  chancre  are  reported  by  Binet.^ 

The  diagnostic  points  in  these  chancres  are — their  round  or  oval 
form,  their  limited  area,  their  sombre  color,  their  sharply-defined  bor- 
ders, which  are  usually  slightly  elevated,  never  punched  out,  as  is  a 
chancroidal  ulcer,  their  parchment-like  induration,  indolent  character 
and  painlessness,  and  their  scanty  secretion.  If  these  features  are 
borne  in  mind,   a  diagnosis  may  generally  be  made. 

Chancres  of  the  Os  Uteri. 

The  appearances  and  clinical  history  of  these  chancres  are  now  quite 
clearly  understood.  They  are  now  more  carefully  looked  for,  hence  they 
are  no  longer  so  rare  as  they  were  supposed  to  be.  Their  occurrence, 
however,  is  far  from  common. 

They  are  seated  either  on  the  anterior  or  the  posterior  lip  of  the 
uterus,  perhaps  more  frequently  on  the  former  than  the  latter.  On  these 
sites  they  may  extend  up  the  inner  surface  of  a  lip,  even  into  the  uterine 
cavity.  In  some  cases  the  chancre  surrounds  the  os  and  involves  a 
portion  of  the  inner  surface  of  the  lip. 

As  a  rule,  but  one  chancre  is  found,  and  rarely  are  two  seen.  (See 
Fig.  4,  Plate  IV.) 

The  chancre  of  the  os  appears  as  a  round,  an  oval,  or  clover-leaf-like 
excoriation  or  elevated  papule  or  nodule.  In  many  cases  the  lesion  is 
the  chancrous  erosion  or  its  exaggeration,  the  ulcus  elevatum. 

The  surface  of  the  chancre  is  in  accord  with  the  anatomical  con- 
formation of  the  parts.  It  is  usually  smooth,  sometimes  slightly  granu- 
lar, and,  when  the  lesion  is  old,  its  surface  may  be  decidedly  mammil- 
lated.  There  may  be  no  distinct  line  of  margination,  and  then,  again, 
a  sharply-defined  ring  of  circumvallation  may  be  seen.  While,  in  many 
cases,  these  chancres  appear  decidedly  like  erosions,  in  some  they  may 
be  covered  with  a  distinct  false  membrane,  which  may  be  of  a  greenish- 
cream  color,  of  a  deep-green,  or  a  greenish-brown,  or  even  of  a  light- 
brown  color.  This  membrane  may  be  smooth  and  of  seemingly  uniform 
structure,  and  then,  again,  it  seems  as  if  composed  of  minute  meshes  of 
tissue. 

The  secretion  is  usually  scanty  and  serous,  but  in  some  cases,  par- 
ticularly in  those  of  a  damaged  and  inflamed  os,  it  may  be  sero-purulent. 

The  lesion  runs  an  indolent  course,  and  is  unattended  with  pain  or 
any  discomfort.  Fournier,  however,  speaks  of  one  case  in  which  supra- 
pubic pain  seemed  to  be  symptomatic  of  a  chancre  of  the  os.  The  same 
author  noted  in  five  cases  of  chancre  of  the  os  vulvar  and  perivulvar 

^  Esaai  sur  le  Chancre  du  Vagin,  etc.,  Paris,  ]881. 

^  Monatshefte  fiir  Prakt.  Dermatologie,  No.  12,  1885,  pp.  417  et  seq. 

°  La  France  medicale,  p.  38,  1881. 


568  SYPHILIS. 

herpes,  and  he  thinks  that  the  presence  of  these  lesions  should  always 
suggest  the  possible  syphilitic  character  of  the  uterine  ulcer. 

Enlargement  of  the  inguinal  ganglia  is  usually  a  concomitant  of  the 
development  of  this  form  of  chancre. 

Owing  to  the  inaccessible  position  of  the  uterus,  the  utmost  difficulty 
is  often  experienced  in  palpating  and  examining  chancres  of  the  os. 
In  some  cases,  however,  the  organ  hangs  low  in  the  pelvis,  and  the 
lesion  can  be  reasonably  well  palpated  by  the  finger-tips.  Even  when 
thus  accessible,  it  is  often  difficult,  owing  to  the  density  of  the  uterine 
tissue,  to  say  positively  that  the  syphilitic  lesion  is  indurated.  In  some 
cases,  however,  induration  of  a  decided  character  can  be  made  out, 
though  it  may  be  very  difficult  to  determine  its  exact  extent.  In  the 
classical  case  reported  by  Ricord,  in  which  a  hard  chancre  was  seated 
on  the  OS  of  a  much-prolapsed  uterus,  examination  was  as  easily  made 
as  upon  the  penis  of  a  man ;  and  that  surgeon  says  that  it  was  chondroid 
or  ligneous  in  structure. 

As  a  rule,  chancres  of  the  os  run  a  slow,  aphlegmasic  course,  and 
disappear  very  slowly.  Rassumow,^  who  saw  117  uterine  chancres  in 
1374  cases  of  venereal  sores  on  various  portions  of  the  pudenda  of 
women,  found  their  cure  was  more  protracted  than  any  other  form  of 
venereal  sore.  On  the  other  hand,  in  somewhat  exceptional  cases,  as 
Fournier  remarks,  the  duration  of  this  chancre  is  very  short,  and  in  a 
little  time  all  localized  traces  of  it  are  lost.  The  duration  of  uterine 
chancres,  like  that  of  similar  lesions  of  the  lip,  penis,  and  vulva,  often 
depends  largely  upon  the  extent  and  depth  of  the  infiltration. 

Thus  the  new  growth  may  be  scanty  and  superficially  developed, 
involving  the  mucous  and  submucous  tissues  only,  and  then  it  may 
disappear  rather  precociously.  Then,  again,  the  neoplasm  may  be  ex- 
uberant, infiltrating  the  tissues  down  to  and  into  the  muscular  structure,^ 
in  which  case  there  is  a  Avell-marked  extensive  lesion  which  will  persist 
for  a  long  time  in  an  indolent  manner. 

Uterine  chancres  are  sometimes  accompanied  by  hard  oedema,  by 
which  the  neck  of  the  organ  may  be  much  hypertrophied.  In  this 
feature  of  hypertrophy  these  chancres  resemble  particularly  some  of 
those  of  the  lip,  vulva,  and  penis.  Then,  again,  the  new  growth  may 
be  well  circumscribed,  in  which  event  the  os  uteri  is  not  much  enlarged. 

As  a  result  of  this  involution  of  these  chancres,  in  some  cases  cica- 
tricial bands  or  masses  of  the  os  uteri  are  left,  and  the  sclerotic  condi- 
tions may  give  rise  to  dystocia  of  various  degrees. 


Chancres  of  the  Breast. 

Chancres  are  found  upon  the  female  nipple,  upon  its  areola,  and 
rarely  upon  the  integument  beyond  the  areola.  These  chancres  are 
particularly  interesting  both  as  to  their  mode  of  origin  and  their  clini- 
cal history  and  the  consequences  they  may  entail. 

^  "  Zur  Statistik  der  Schanker  der  Vaginal-portion,"  Vierteljahresschrift  fiir  Dei-m.  und 
Syphilis,  vol.  xii.,  1880,  pp.  517  et  seq. 

^  The  pathological  anatomy  of  a  hard  chancre  of  the  uterus  is  described  and  pictured 
by  Mracek :  "  Ueber  die  syphilitische  Initialerkrankungen  der  Vaginal-portion,"  ibid., 
vol.  xiii.,  1881,  pp.  47  et  seq. 


GENITAL  AND  EXTRAGENITAL   CHANCRES  IN  WOMEN.      569 

These  chancres  are  of  the  erosive  and  incrusted  types,  and  sometimes 
they  exist  as  indurated  fissures. 

Upon  the  nipple  the  chancre  forms  a  flat  plaque  of  varying  size  or  a 
distinct  nodule  involving  part  or  all  of  the  appendage.  When  the  wo- 
man does  not  give  the  breast  to  her  child,  the  chancre  shows  a  tendency 
to  become  incrusted,  but  during  nursing  moisture  keeps  the  parts  in  an 
eroded  condition. 

Chancres  very  commonly  form  in  the  furrow  at  the  base  of  the  nipple, 
and  then  they  assume  shapes  resembling  segments  of  circles,  and  some- 
times they  are  completely  circular  in  form.  These  chancres  are  most 
oommonly  of  the  incrusted  variety. 

Chancres  of  the  areola  are  usually  small  round  or  oval  erosions,  some- 
times flat,  again  elevated,  or  they  may  be  saucer-shaped  and  slightly 
depressed  below  the  normal  plane.  Very  rarely  do  these  chancres  be- 
come incrusted.  In  this  situation  it  is  rather  more  common  to  find 
several  chancres  than  one.  There  may  be  six  or  eight,  or  even  as 
many  as  sixteen,  of  these  chancres.  In  some  cases  these  lesions  are 
found  on  both  breasts. 

The  indurated  fissure  is  not  commonly  seen.  It  is  really  the  nipple 
chancre  complicated  with  one  or  more  very  well-marked  fissures. 

In  the  majority  of  cases  of  chancres  of  the  breast  the  infection  is 
derived  from  hereditarily  syphilitic  children,  in  whose  mouths  mucous 
patches  are  seated.  This  mode  of  infection  occurs  chiefly  in  hospitals 
and  in  lying-in-asylums,  in  which  vigorous  and  healthy  lactating  women 
are  made  to  nurse  one  or  more  children  besides  their  own.  Owing  to  care- 
lessness in  examination  on  the  part  of  the  visiting  staff  or  of  the  internes 
of  these  institutions,  the  buccal  lesions  of  syphilis  in  some  nurslings  are 
overlooked  or  wrongly  diagnosticated  as  of  simple  nature,  and  as  a  result 
some  luckless  woman  whose  duty  it  is  to  nurse  these  infants  becomes  in- 
fected with  syphilis.  I  had  under  observation  many  years  ago  the  case 
of  a  woman  who  was  thus  infected  in  one  of  our  city  institutions,  and  in 
the  essay  ^  in  which  it  is  narrated  I  considered  the  subject  in  all  of  its 
phases.  Many  other  similar  cases  have  been  reported  by  Continental 
authors.^ 

Another  mode  of  infection  of  the  breast  with  syphilis  is  from  the 
secretion  of  hard  chancres  in  the  mouth  of  nursing  infants.  These  cases 
are  usually  met  with  in  private  practice.  The  child  is,  as  a  rule,  infected 
by  some  relative,  friend,  or  chance  acquaintance,  who,  having  mucous 
patches  in  their  mouths,  implant  the  virus  on  the  child's  lip  or  lips.  In 
due  time  the  chancre  appears  (and  it  is  commonly  not  large  or  much  indu- 
rated), and  by  it  the  child's  mother  or  nurse  is  infected  at  the  breast.^ 

^ "  The  Dangers  of  the  Transmission  of  Syphilis  between  Nursing  Children  and  Nurses 
in  Infant  Asylums  and  in  Private  Practice,"  Am.  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children,  vol.  viii.,  Nov.,  1875. 

^Audoynaud,  "Etude  sur  la  Syphilis  communiqu^e  par  I'Allaitment,"  Thhe  de  Paris, 
1869;  and  Appay,  "  Transmission  de  la  Syphilis  entre  Nourrices  et  Nourrissons  syph- 
ilitiques  et  notamment  dans  rAUaitment  avec  Consideratious  m^dico-legales,"  These  de 
Paris,  1875  ;  also  Fournier,  op.  cit.,  pp.  117  et  seq. 

*Such  instances  of  syphilitic  infection  are  not  uncommon.  I  recall  three  cases  within 
recent  years,  besides  others  seen  years  ago.  In  one  case  the  infection  was  derived  from 
the  child's  aunt,  in  the  second  from  its  nurse,  and  in  the  third  the  child  was  in  all  prob- 
ability infected  by  a  woman  wlio  was  attracted  to  it  in  the  streets  by  reason  of  its  beauty, 
and  wlio  kissed  and  fondled  it  gushingly  with  the  nurse's  permission. 


570  SYPHILIS. 

In  this  way  syphilis  is  often  introduced  into  a  family,  and  all  its  mem- 
bers may  become  its  victims.  Further  on  in  this  section  another  mode 
of  infection  of  the  infant  is  described. 

Chancres  of  the  female  breast  are  not  infrequently  seen  which  have 
been  acquired  in  kissing  from  the  infected  mouths  of  lovers  and  husbands. 

Then,  again,  men  are  sometimes  infected  on  the  nipple  from  the  kiss- 
ing and  dalliance  of  women  with  infectious  mouths.  I  have  seen  two 
such  cases. 

Chancres  of  the  breast  appear  as  chancrous  erosions,  as  incrusted  or 
ecthymatous  chancres,  and  as  indurated  nodules  and  fissures. 

In  many  cases  but  one  chancre  is  present :  this  is  particularly  true 
when  the  nipple  alone  is  involved.  Out  of  fifty-six  chancres  of  the 
breast  seen  by  Fournier,  in  thirty  cases  there  was  but  one  chancre  and  in 
twenty-six  there  were  several. 

When  seated  on  the  areola  there  may  be  but  one  chancre,  sometimes 
several,  and  occasionally  many.  I  have  seen  sixteen  in  this  situation, 
and  Fournier  speaks  of  a  case  on  which  there  were  sixteen  chancres  on 
the  right  and  seven  on  the  left  mammary  areola. 

One  or  both  breasts  may  be  infected.  According  to  the  statistics  of 
Audoynaud,^  out  of  51  cases  both  breasts  were  infected  in  24,  but  one 
was  infected  in  24,  and  in  them  the  details  are  wanting.  This  would 
show  that  the  occurrence  of  chancres  on  one  breast  was  as  frequent  as 
the  occurrence  of  these  lesions  on  both. 

According  to  Fournier — and  I  am  in  accord  with  him — chancres  are 
found  most  frequently  at  the  base  of  the  nipple,  in  the  groove  between 
it  and  the  areola.  Next  in  order  is  the  nipple  itself,  and  after  that  the 
areola.  The  integument  beyond  the  areola  is  not  very  frequently  in- 
volved. 

Chancres  of  the  breast  are  usually  not  seen  until  they  are  fully  devel- 
oped or  are  on  the  road  to  absorption  or  cicatrization.  I  have  seen  a  suf- 
ficient number  in  these  early  states  to  enable  me  to  describe  them  mi- 
nutely. 

The  erosive  chancre  of  the  nipple  begins  as  a  small,  slightly  red, 
somewhat  elevated  papule  or  patch,  with  a  smooth,  velvety,  excoriated 
surface,  from  which  a  little  serum  exudes.  In  this  form  the  lesion  in- 
creases in  area  and  depth,  the  surface  remaining  smooth  and  shining, 
while  the  peripheral  increase  and  depth  may  give  it  a  nodular  structure. 
The  induration  may  be  moderate,  but  is  sometimes  well  marked.  I  have 
seen  it  here  of  the  parchment  variety.  The  chancrous  erosion,  or  later 
the  chancrous  nodule,  may  involve  more  or  less  of  the  nipple,  sometimes 
its  whole  structure. 

When  women  nurse  children,  owing  to  the  moisture  of  the  parts  the 
chancre  usually  remains  in  an  erosive  condition,  but  when  the  parts  are 
dry,  as  in  non-nursing  women,  the  secretion  is  apt  to  form  crusts,  and 
then  there  is,  as  a  result,  an  incrusted  lesion. 

In  some  cases  ulceration  takes  place  in  the  chancres  of  the  nipple, 
and  more  or  less  tissue  is  lost  and  the  symmetry  of  the  organ  destroyed. 
When  ulceration  attacks  chancres  of  the  nipple,  the  part  may  be  the  seat 
of  pain.  I  have  seen  several  cases  in  which  pain  lasted  for  years  after 
the  cicatrization  of  the  chancre. 

^  Loc.  cit. 


GENITAL  AND  EXTRAGENITAL   CHANCRES  IN  WOMEN.      571 

The  ecthymatous  chancre  of  the  nipple,  sometimes  unique  and  again 
multiple,  appears  like  an  indolent  incrusted  patch  or  papule,  involving 
all  or  a  portion  of  the  appendage.  The  crust  is  of  a  yellow  color,  or  it 
may  be  deeper,  of  a  greenish-brown  tint.  It  can  usually  be  readily 
removed,  and  then  the  smooth,  varnished-like  surface  of  the  chancrous 
erosion  is  exposed. 

The  indurated  fissure  of  the  nipple  is  an  indolent  lesion  of  considerable 
density,  of  pinkish  or  grayish-red  tint,  and  its  surface  resembles  that  of 
the  chancrous  erosion.  It  is  usually  painless,  though  perhaps  a  little 
sensitive,  and  in  this  particular  differs  widely  from  simple  cracked  nipples. 
There  may  be  one  fissure  or  there  may  be  several  of  them.  The  lesion 
is  really  an  induration  traversed  by  one  or  more  fissures.  This  form  of 
chancre  may  also  become  more  or  less  incrusted. 

Chancres  of  the  areola  are  of  the  incrusted  or  erosive  variety.  In 
some  cases  the  lesion  is  limited  to  the  furrow  at  the  base  of  the  nipple, 
which  it  enlarges  to  a  greater  or  less  extent,  being  of  the  form  of  a  seg- 
ment of  a  circle.     This  may  be  incrusted  or  eroded. 

Upon  the  areola  we  frequently  find  many  small  round  or  oval  chancres, 
which  may  be  incrusted  or  of  the  erosive  type.  These  chancres  are 
usually  but  moderately  indurated,  and,  as  before  stated,  as  many  as  twelve 
to  sixteen  may  be  seated  on  the  areola  of  one  breast.  It  is  very  probable 
that  the  starting-point  of  these  areolar  chancres  is  the  sebaceous  glands, 
which  are  here  so  numerous. 

Chancres  of  the  integument  of  the  breast  beyond  the  areola  are  very 
rare.  When  seen  they  will  be  found  to  be  of  the  erosive  or  incrusted 
types,  presenting  the  usual  appearances  of  chancre  of  the  skin.  They 
are  more  or  less  indurated,  and  sometimes  form  a  distinct  hard  nodule. 

In  all  cases  of  chancre  of  the  breast  there  is  concomitant  indolent 
enlargement  of  the  ganglia.  In  some  cases  those  at  the  edge  of  the  great 
pectoral  muscle  are  aifected,  in  others  those  of  the  axilla,  and  in  many 
cases  both  classes  are  much  swollen. 

It  is  well  to  bear  in  mind  the  possibility  of  wet-nurses  being  the  bearers 
of  chancre  of  the  breast,  and  physicians  cannot  be  too  careful  in  their 
examination  of  these  women.  A  woman  having  a  sore  in  the  least  degree 
suspicious  should  never  be  allowed  to  nurse  a  healthy  infant.  Careful 
inquiry  should  be  made  as  to  the  condition  and  history  of  children  nursed 
within  at  least  the  last  month.  Indeed,  if  it  is  possible,  such  children 
should  be  very  carefully  examined.  A  woman  who  has  nursed  a  child 
with  sore  mouth  or  snuffles,  eruptions,  marasmus,  or  osseous  lesions  should 
be  suspended  for  from  four  to  six  weeks,  during  which  time,  if  she  has 
been  infected  with  syphilis,  the  initial  lesions  will  appear  on  her  breast. 
If  these  precautions  and  restrictions  are  not  observed,  the  nurse  during 
her  first  period  of  incubation,  while  her  breast  is  yet  seemingly  healthy, 
may  take  charge  of  another  nursling.  While  nursing  the  child  her 
chancre  appears,  and  in  all  probability  her  little  charge  will  become 
infected. 

In  some  cases,  further  complications,  as  long  ago  pointed  out  by  Dron,* 
may  grow  out  of  these  circumstances.     The  nurse,  knowing  nothing  of 

^  "Mode  particulier  de  Transmission  de  la  Syphilis  au  Nonrrisson  par  la  Nourrice 
dans  I'Allaitment,"  Annales  de  Derm,  el  de  Syphiligmphie,  vol.  ii.,  1869  and  1870,  pp.  161 
et  seq. 


572  SYPHILIS. 

the  mode  of  development  of  syphilis,  and  finding  her  nipple  sore,  and 
later  on  her  body  covered  with  an  eruption,  naturally  may  settle  upon  the 
second  and  healthy  child  as  the  cause  of  her  infection.  She  may  then 
demand  damages  in  money  or  go  to  law.  Therefore  it  is  very  important 
in  these  cases  that  the  physician  should  be  thoroughly  acquainted  with  all 
the  phases  and  circumstances  incident  to  infection  of  the  nurse  by  the 
infant  and  of  the  infant  by  the  nurse. 


CHAPTEK    LVL 

HYPERPLASIA  OF  THE  GANGLIA  AND  PERIVASCULAR  SPACES.— 
ADENITIS  AND  LYMPHANGITIS. 

In  every  case  of  hard  chancre  the  neighboring  ganglia  become  indo- 
lently enlarged,  and  in  many  instances  the  lymphatic  vessels  are  involved 
in  a  similar  change.  The  enlargement  is  sometimes  appreciable  as  early 
as  the  fifth  day  after  the  appearance  of  the  sore,  and,  as  a  rule,  between 
the  seventh  and  the  tenth  days.  In  rather  exceptional  cases  well-marked 
induration  may  not  be  felt  until  the  fourteenth  day,  rarely  later.  At  first, 
it  is  usually  more  pronounced  on  the  same  side  as  the  chancre.  Later  on, 
both  sides  are  involved,  though  the  enlargement  is  sometimes  unilateraL 
The  hardness  of  the  ganglia  is  peculiar  in  its  density  and  painlessness. 
They  are  freely  movable,  and  feel  under  the  skin  like  almonds  or  little 
round  tumors,  which  do  not  usually  adhere  to  one  another  or  to  the  over- 
lying integument.  Sometimes  one  ganglion  becomes  much  larger  than 
the  rest,  and  exceptionally  a  number  become  blended  into  an  indolent 
mass.  In  somewhat  rare  cases  one  ganglion  in  a  chain  seems  to  be  spared ; 
thus  in  chancres  of  the  finger  the  epitrochlear  may  not  be  appreciably 
enlarged,  w^hile  the  axillary  ganglia  may  be  much  swollen. 

In  the  following  table,  prepared  by  Fournier,  the  seat  of  chancre  and 
the  situation  of  the  indurated  ganglia  in  anatomical  relation  with  them 
are  given : 

Seat  of  the  Chancre.  Corresponding  Indolent  Adenitis 

in  the — 

Chancres  of  the  genital  organs— f.  e.  of  Inguinal  ganglia, 

the  penis,  the  scrotum,  the  labia  majora 
and  minora,  the  fourchette,  the  meatus 
urinarius,  the  urethra,  the  entrance  of  the 
vagina,  etc. 

Perigenital  chancres  (those  of  the  peri-  Inguinal  ganglia, 

neum,  the  genito-crural-folds,  the  mons 
Veneris,  the  thighs,  the  buttocks,  etc.). 

Chancre  of  the  anus  and  the   margin  Inguinal  ganglia, 

of  the  anus. 

Chancres  of  the  lips  and  of  the  chin.  The  submaxillary  ganglia. 

Chancres  of  the  tongue.  The  subhyoidian  ganglia. 

Chancres  of  the  eyelids.  The  pre-auricular  ganglia. 


HYPERPLASIA   OF  THE  GANGLIA,  ETC.  573 

Chancres  of  the  fingers.  The    epitrochlear     and     the    axillary 

ganglia. 

Chancres  of  the  arm.  The  axillary  ganglion. 

Chancres  of  the  breast.  The  axillary  ganglia,  and  sometimes 

the  subpectoral  ganglia. 

Chancres  of  the  uterine  neck.  Theoretically,  the  pelvic  ganglia.   Gen- 

erally nothing  is  found  in  the  groins ; 
exceptionally  an  inguinal  bubo. 

Seat. — As  already  stated,  the  ganglia  affected  are  those  in  direct  ana- 
tomical connection  with  the  initial  lesion  or  chancre.  Since  a  chancre  is 
most  frequently  situated  upon  the  genital  organs,  induration  of  the  ganglia 
is  commonly  found  in  the  groins.  Chancres  of  the  interior  of  the  urethra 
in  both  sexes,  of  the  perineum,  of  the  anus,  of  the  cervix  uteri,  of  the 
buttocks,  of  the  lower  portion  of  the  abdomen,  and  of  any  point  of  the 
lower  extremities  will  likewise  manifest  their  presence  by  induration  of 
the  inguinal  ganglia. 

With  chancres  upon  the  fingers  the  situation  of  the  indurated  ganglia 
varies.  More  frequently  in  these  cases  the  ganglion  on  the  internal  side 
of  the  elbow  or  those  in  the  axilla  are  involved.  Again,  ganglia  between 
the  points  mentioned — the  hand  and  elbow  or  the  elbow  and  axilla — 
may  become  indurated.  Chancres  of  the  breast  also  affect  the  axillary 
ganglia. 

Chancres  upon  the  lips,  both  upper  and  lower,  upon  the  tongue,  and 
upon  the  chin  cause  induration  of  the  submaxillary  ganglia ;  those  upon 
the  eyelids,  induration  of  a  ganglion  situated  directly  in  front  of  the  ear. 
Fournier  mentions  a  case  of  a  chancre  occupying  the  palatine  arch,  in 
which  a  large  ganglion  was  present  in  the  thickness  of  the  cheek  ;  also 
another  case  in  which  infection  was  "very  certainly  "  the  result  of  cathe- 
terization of  the  Eustachian  tube,  and  in  which  there  were  two  voluminous 
ganglia  in  the  parotid  region,  one  directly  below  the  ear  and  the  other 
somewhat  beneath  it  under  the  ramus  of  the  jaw. 

Thus  the  situation  of  ganglionic  induration  points  to  the  approximate 
seat  of  a  chancre,  even  after  the  latter  has  disappeared,  and  may  be  of 
essential  service  in  unravelling  the  history  of  obscure  venereal  cases- 
It  will  generally  be  found  that  those  ganglia  in  immediate  anatomical 
relation  with  the  seat  of  the  chancre  are  usually  the  ones  which  are  most 
swollen.  Induration  of  the  inguinal  ganglia  may  affect  one  or  both 
sides.  In  the  former  case  it  is  usually  the  side  upon  which  the  chancre 
itself  is  situated,  although  occasionally  this  rule  is  reversed,  as  with 
buboes  attendant  upon  a  chancroid. 

Wherever,  as  in  the  groin,  a  number  of  ganglia  form  a  group,  most  of 
them,  at  least,  are  usually  involved,  but  to  an  unequal  extent.  A 
"pleiad,"  as  it  has  been  called,  or  a  rosary-like  arrangement,  of  small 
olive-shaped  or  globular  tumors,  is  felt,  cartilaginous  in  hardness,  freely 
movable  upon  each  other  and  the  surrounding  tissues,  and  without 
attachment  to  the  overlying  integument.  One  is  commonly  developed 
more  than  the  rest,  and  attains  about  the  size  of  an  almond ;  the 
others,  as  large  as  a  bean  or  cherry,  surround  it  like  satellites. 

There  are  no  symptoms  of  acute  inHanimation.  The  change  has 
taken  place  insidiously  and  often  without  the  patient  knowing  it.  The 
skin  is  not  altered  either  in  color  or  temperature.  Firm  pressure  some- 
times  reveals   slight   tenderness,    but    rarely    excites   severe   pain,  and 


574  SYPHILIS. 

motion  is  usually  not  impeded.  Indolence  is  one  of  tlie  chief  character- 
istics of  the  wrongly-called  syphilitic  bubo. 

Less  frequently,  only  a  single  tumor  is  felt  in  the  groin,  varying  in 
size  and  shape  in  different  cases :  sometimes  it  may  be  compared  to  a 
good-sized  plum,  while  at  other  times  it  is  elongated,  about  the  thickness 
of  the  finger,  and  corresponds  in  direction  to  the  inguinal  fold.  In 
some  instances  as  the  tumor  subsides  it  resolves  itself  into  several,  show- 
ing that  it  was  composed  of  a  number  of  coherent  ganglia  held  together 
by  a  mildly  proliferative  periadenitis.. 

When  a  chancre  is  situated  at  a  distance  from  any  group  of  ganglia, 
as  upon  the  fingers  or  face,  only  one  or  two  of  these  bodies  are  usually 
involved. 

Induration  of  the  ganglia  usually  reaches  its  full  development  in  the 
course  of  a  week  or  fortnight.  If  mercury  be  given  for  the  primary 
sore,  it  may  somewhat  diminish  for  a  time,  but  commonly  undergoes  a 
recrudescence  upon  the  evolution  of  secondary  symptoms.  It  is  usually 
more  persistent  than  the  latter,  but  its  ultimate  duration  varies  in  differ- 
ent cases  from  several  weeks  to  five  or  six  months  or  even  longer. 

Resolution  without  suppuration  is  almost  the  constant  termination  of 
syphilitic  induration  of  the  ganglia.  When,  however,  the  chancre  has 
been  attacked  by  pyogenic  microbes — and  this  is  more  common  when 
phimosis  has  been  produced — a  suppurative  adenitis  sometimes  results, 
which  may  be  chronic  or  it  may  be  very  acute  and  present  the  same 
features  as  chancroidal  bubo.  It  is  not  uncommon  in  suppurating 
syphilitic  adenitis  in  the  groin  to  find  a  diffuse  bed  of  suppuration  in 
which  are  scattered  many  hyperplastic  and  much-swollen  ganglia.  It  was 
formerly  claimed,  when  syphilitically  engorged  ganglia  suppurated  and 
broke  down,  that  it  was  an  evidence  of  a  strumous  tendency.  A  de- 
praved condition  of  the  system  may  render  the  course  of  such  a  suppurating 
bubo  more  active  and  severe,  but  it  is  not  the  genetic  cause  of  the  sup- 
puration, which  resides  in  the  poisons  secreted  by  the  pyogenic  process. 

Diagnosis. — In  general,  the  diagnosis  of  syphilitic  adenitis  is  very 
easy  when  this  condition  is  studied  in  connection  with  the  chancre.  It 
is  sometimes  observed  that  a  man  has  a  sore  of  doubtful  appearance  and 
with  indistinct  history,  and  in  connection  therewith  there  is  indolent 
enlargement  of  the  inguinal  ganglia,  perhaps  bilateral,  which  the  patient 
claims  has  been  present  for  years.  In  such  instances  a  prompt 
diagnosis  cannot  be  made,  but  in  the  course  of  a  week  or  two  the  nature 
of  the  affection  can  be  determined. 

In  some  very  fat  subjects  it  is  often  very  difficult  to  clearly  make  out 
the  condition  of  the  inguinal  ganglia.  This  same  experience  may  also 
be  observed  in  some  rare  cases  in  which  the  fascia  and  connective  tissues 
are  so  compact  and  unyielding  that  thorough  palpation  cannot  be  prac- 
tised. 

In  forming  estimates  of  the  condition  of  the  inguinal  ganglia  it  is 
always  well  to  remember  that  other  morbid  conditions  besides  syphilis 
may  cause  them  to  become  indolently  swollen.  Thus,  after  the  subsidence 
of  gonorrhoeal  adenitis  the  ganglia  may  remain  hard,  firm,  and  more  or 
less  enlarged.  Eczema,  psoriasis,  phtheriasis,  and  all  inflammatory  dis- 
eases of  the  skin,  when  they  attack  the  legs  lead  to  painless  or  painful 
enlargement   of    the    inguinal   ganglia.       Cuts,   abrasions,   traumatisms, 


HYPERPLASIA   OF  THE  GANGLIA,  ETC.  575 

lesions  of  the  nails,  the  heels,  and  in  some  cases  the  small  or  large  inflam- 
matory nodules  which  result  from  the  bites  of  insects,  may  give  rise  to 
ganglionic  swelling.  All  the  foregoing  conditions  should  be  borne  in 
mind  when  examining  a  case  of  supposed  chancre  and  in  exploring  the 
inguinal  region.  I  have  known  many  an  instance  in  which  a  benign 
lesion  of  the  penis  was  unqualifiedly  pronounced  to  be  syphilitic  in  conse- 
quence of  the  presence  of  swollen  lymphatic  ganglia,  which  had  become 
subacutely  and  chronically  inflamed  in  consequence  of  the  operation  of 
one  or  more  of  the  causes  just  detailed. 

Induration  of  the  Lymphatics. 

Though  for  brevity,  and  largely  on  account  of  its  general  acceptance, 
I  use  the  above  term,  it  is  well  to  remember  that  in  syphilis  the  chancre 
is  first  formed,  and  from  this  focus  the  infection  promptly  travels  up  the 
perivascular  lymph-spaces  which  surround  the  vessels.  Therefore,  to  be 
strictly  and  scientifically  accurate,  this  condition  is  a  syphilitic  hyper- 
plasia of  the  perivascular  lymph-spaces,  a  periphlebitis,  and  a  periar- 
teritis. 

As  both  the  simple  and  virulent  bubo  have  their  occasional  concomi- 
tants in  simple  and  virulent  lymphangitis,  so  has  glandular  induration  its 
accompanying  induration  of  the  lymphatics. 

Specific  enlargement  of  the  lymphatics  is  characterized  by  three 
important  symptoms — viz.  induration,  absence  of  inflammation,  and 
persistency. 

The  indurated  vessel  feels  like  a  hard  cord  running  from  the  neigh- 
borhood of  the  chancre  toward  the  pubes  along  the  upper  surface  of  the 
penis  in  the  course  of  the  dorsal  vein  and  artery,  or,  in  a  few  instances, 
it  occupies  the  side  of  this  organ.  It  is  generally  single,  but  sometimes 
multiple ;  of  the  size  of  a  crow-  or  goosequill ;  in  some  cases  of  uniform 
diameter,  when  it  communicates  to  the  fingers  a  sensation  like  that  of  the 
vas  deferens,  while  in  others  it  is  swollen  at  regular  intervals  like  a  neck- 
lace, or  is,  as  botanists  would  say,  moniliform.  The  distal  extremity 
arises  in  the  induration  surrounding  the  chancre,  and  the  cord  can  gen- 
erally be  traced  for  two  or  three  inches  toward  the  pubes,  sometimes  to 
the  base  of  this  prominence,  but  rarely  as  far  as  the  indurated  ganglia  in 
the  groin, 

I  have  had  under  my  care  recently  a  case  in  which  the  lymphatic  cord 
began  at  the  coronal  sulcus,  ran  up  the  penis,  and  near  the  root  became 
as  large  as  one's  finger,  and  thus  remained  after  turning  at  right  angles 
at  the  pubis,  and  ended  in  a  mass  of  engorged  ganglia  of  the  groin. 

Induration  of  the  lymphatics  is  most  frequently  observed  upon  the 
penis,  but  is  not  limited  to  this  region.  Bassereau  relates  a  case  of 
chancre  upon  the  cheek  in  which  a  hard  cord  could  be  traced  from  the 
indurated  base  of  the  sore  to  an  indurated  ganglion  beneath  the  angle  of 
the  jaw. 

Induration  of  the  lymphatics  appears  about  the  same  time  and  in  the 
same  manner  as  that  of  the  base  of  the  chancre,  and  the  two  generally 
correspond  in  degree  of  development.  The  former  is  less  constant  than 
the  latter,  but  if  sought  for  may  be  found  in  a  large  proportion  of  cases. 

Induration  of  the  lymphatics  usually  undergoes  resolution  about  the 


576  SYPHILIS. 

same  time  as  that  of  the  chancre,  but  in  a  few  rare  instances  it  becomes 
inflamed  and  terminates  in  suppuration,  when  fistulous  openings  may 
form  along  the  course  of  the  vessel.  In  these  cases  there  is  usually  a 
complicating  infection  of  the  chancre  by  pus-microbes,  and  an  active 
suppurating  process  results  Avhich  spreads  to  the  lymph-spaces. 

It  is  always  well  to  cause  patients  to  rub  mercurial  ointment  into 
hyperplastic  syphilitic  ganglia  as  soon  as  general  manifestations  show 
themselves.  Such  a  course  materially  aids  in  curing  the  syphilis.  In 
case  the  lymphatics  are  swollen,  lint  smeared  with  mercurial  ointment 
should  be  wrapped  around  the  penis  and  kept  there  night  and  day  if 
practicable. 


CHAPTER    LVIL 

GENERAL  OUTLINE  OF  THE  SYMPTOMS  AT  THE  EVOLUTION  OF 
THE  SECONDARY  STAGE. 

At  the  expiration  of  the  secondary  period  of  incubation,  which  may 
be  as  short  as  forty-five  days,  and  exceptionally  as  long  as  seventy, 
eighty,  or  ninety  (rarely  longer)  days,  the  secondary  period  of  syphilis 
begins.  This  stage  of  the  disease  is  also  called  the  period  of  general  or 
constitutional  manifestations,  and  also  the  condylpmatous  stage.  The 
teachings  of  pathological  anatomy  show  very  clearly  that  in  the  secondary 
period  of  incubation  the  infection  of  the  whole  system  is  going  on  slowly, 
insidiously,  but  effectively,  until  in  the  end  the  acme  is  reached,  Avhen 
general  systemic  manifestations  and  symptoms  are  developed. 

There  is  a  remarkable  variation  in  the  amount  of  systemic  disturbance 
at  the  beginning  of  the  secondary  period.  In  many  subjects  no  devia- 
tion whatever  from  the  healthy  standard  is  observed  to  mark  the  com- 
mencement of  the  secondary  stage,  and  the  dermal  lesions  are  the  only 
evidences  of  syphilis.  These  very  often  pass  away  unobserved,  and  as  a 
result  a  hiatus  in  the  patient's  medical  history  is  produced.  In  other 
cases,  however,  particularly  in  women,  much  and  varied  constitutional 
disturbance  takes  place.  In  some  cases  syphilis  comes  on  abruptly,  and, 
we  may  say,  it  explodes. 

Perhaps  the  most  constant  morbid  symptom  is  fever,  which,  though 
absent  in  many  cases,  is  present  in  most  in  varying  degrees  of  intensity. 
In  some  cases  there  is  an  elevation  of  temperature  of  from  one  to  three 
degrees,  commonly  with  a  corresponding  mild  nocturnal  exacerbation.  In 
other  cases  the  febrile  movement  is  well  marked,  the  morning  temperature 
beino-  from  101°  to  102°  Fahr.,  and  in  the  evening  104°  Fahr.,  and  in 
rather  exceptional  instances  higher,  even  to  107°  Fahr.,  particularly  in 
women.  Besides  the  elevation  of  temperature  there  is  a  corresponding 
acceleration  of  the  pulse,  and  the  respiration  ratio  is  increased.  The 
tissue-metamorphoses  are  present  in  the  urine  in  proportion  to  the  inten- 
sity of  the  fever. 


GENERAL    OUTLINE  OF  THE  SYMPTOMS,   ETC.  577 

Various  neuralgic  pains  are  also  complained  of  by  patients,  the  peculi- 
arity of  which  is  their  quite  constant  occurrence  toward  dark  and  at 
nio-ht.  Nocturnal  headache  is  frequently  experienced,  which  varies  in  se- 
verity from  a  mild  and  endurable  form  to  one  in  which  the  patient's  suffer- 
ings are  agonizing,  in  Avhich  he  or  she  is  tortured  by  pain  during  the 
nio-ht,  and  is  prostrate,  worn  out,  and  suffering  during  the  day,  when  it  may 
not  wholly  cease.  Such  patients  say  that  their  heads  feel  as  if  they  were 
being  crushed  as  by  a  vise,  or  as  if  a  nail  were  driven  into  their  skulls. 
Sometimes  the  pain  seems  to  be  superficial,  and  may  affect  the  temporal, 
frontal,  or  occipital  regions.  In  many  cases  these  pains  are  so  excrucia- 
ting that  the  sufferer  is  an  object  of  pity.  These  pains  in  the  head 
may  occur  at  the  date  of  onset  of  general  manifestations  and  at  later 
periods. 

Intense  neuralgic  pains,  affecting  the  cranial  nerves,  the  fifth  in  par- 
ticular, also  seated  in  the  intercostal  nerves,  in  the  sciatic  and  its  branches, 
and  in  the  anterior  crural,  are  not  uncommon.  Persons,  who  have  previ- 
ously suffered  from  neuralgia  of  any  part  are  especially  liable  to  exacerba- 
tions during  the  eruptive  stage  of  syphilis,  and,  in  fact,  at  any  time  during 
the  activity  of  the  diathesis. 

Insomnia  is  a  symptom  sometimes  complained  of  by  syphilitic  patients^ 
who  can  give  no  reason  for  it  whatever,  since  in  many  cases  there  is  no 
physical  suffering.  It  is  peculiar  in  the  fact  that  it  is  not  readily  influ- 
enced by  soporifics,  but  gradually  ceases  with  the  disappearance  of  the 
exanthematic  symptoms  under  mercurial  treatment. 

In  some  exceptional  cases,  particularly  in  women,  a  mild  and  tem- 
porary aberration  of  the  mind  is  observed  in  the  form  of  hysteria,  emo- 
tional disturbances,  hallucinations,  delusions,  and  morbid  impulses.  In 
men  there  may  be  present  mild  or  severe  stupor,  delirium,  and  even 
mania.  Pains  in  the  muscles  and  joints  simulating  rheumatism  and 
occurring  at  night  are  most  constant  at  the  evolution  of,  and  during,  the 
secondary  period.  These  are  sometimes  so  severe  that  they  produce  dis- 
ability of  the  member  affected. 

Disturbances  of  the  sympathetic  nervous  system  are  sometimes  strongly 
marked,  particularly  in  anaemic  and  thin  persons  and  in  women.  Suck 
patients  complain  of  cold  feet,  and  their  hands  feel  like  marble  or  ice^ 
and  they  are  chilled  by  the  slightest  draft. 

The  tendency  to  anaemia  in  early  secondary  syphilis  in  many  cases  is- 
well  marked.  The  diminished  nutritive  qualities  of  the  blood,  Avhichi 
loses  in  red  corpuscles  and  contains  a  marked  increase  in  leucocytes,  and. 
the  impairment  of  the  nutrition  of  the  tissues  are  shown  in  the  pale^ 
shallow,  and  emaciated  facies,  in  the  palpitations  and  the  small  thready 
pulse  and  shortness  of  breath,  in  the  want  of  appetite  and  energy,  and  in 
the  nervousness,  restlessness,  apprehensiveness,  and  great  languor  amount- 
ing often  to  dejection. 

While  in  most  cases  this  formidable  combination  of  symptoms  is  gradu- 
ally dispelled  by  treatment,  and  a  healthy  tone,  mental  and  physical,  is 
restored,  in  many,  particularly  in  persons  of  poor  fibre,  in  those  suffering 
from  visceral  diseases  and  from  adynamic  conditions  and  other  morbid 
states  of  the  system,  this  cachexia  and  asthenia  may  persist,  and  require 
the  most  intelligent  management,  therapeutical,  hygienic,  and  climatic,  to- 
successfully  combat  it. 
37 


578  SYPHILIS. 

Relapses  of  anaemia,  cachexia,  and  asthenia  are  common  during  the 
whole  course  of  the  infection. 

The  course  of  syphilis  is  remarkably  uncertain,  the  disease  being  seen 
in  all  degrees  of  mildness  and  in  every  form  of  severity.  Constitutional 
peculiarities,  habits,  and  surroundings  are  at  the  bottom  of  this  morbid 
action.  Some  patients  suffer  very  mildly  from  syphilis,  even  when  they 
do  not  follow  treatment,  while  others,  again,  are  sorely  punished.  In  the 
majority  of  cases  patients  otherwise  healthy  experience  very  little  trouble 
from  syphilis,  provided  they  pursue  a  proper  treatment  for  a  sufficient 
length  of  time,  avoid  alcoholics,  husband  their  strength,  and  exercise 
watchfulness  of  their  general  well-being.  It  is  said  that  patients  of  light 
complexion  and  reddish  hair  suffer  more  severely  than  those  of  dark  com- 
plexion— a  statement  which  is  in  the  main  correct.  But  although  the 
epithelial  tissues  and  the  integument  of  these  patients  are  so  frequently"-^ 
and  we  may  perhaps  say  persistently — attacked,  the  prognosis  is  good  if 
their  bodies  are  otherwise  sound  and  healthy. 


CHAPTER    LVIII. 

THE  VARIOUS   MORBID  CONDITIONS  AND  AFFECTIONS  OF  THE 

SECONDARY  STAGE. 

It  is  necessary  for  completeness  of  description  to  trace  the  course  of 
the  infection  in  the  various  tissues  and  organs,  and  to  study  in  greater 
detail  the  symptomatology  of  the  second  stage  of  syphilis. 

Since  the  perivascular  lymph-spaces  and  lymphatic  ganglia  are  so 
constantly  and  extensively  involved  in  syphilitic  infection,  it  is  import- 
ant that  their  condition  should  be  clearly  studied. 

Generalized  Hyperplasia  of  the  Superficial  and  Deep  Lymphatic 

Ganglia. 

With  the  generalization  of  the  syphilitic  infection  the  superficial  and 
deep  lymphatic  ganglia  of  the  whole  body  become  indolently  and  pain- 
lessly swollen.  Though  this  condition  is  spoken  of  as  essentially  belong- 
ing to  the  secondary  period,  there  is  no  doubt  that  the  tissue-changes 
which  take  place  in  the  ganglia  begin  quite  early  in  the  secondary  period 
of  incubation,  and  they  become  mature  at  the  time  of  onset  of  other 
secondary  lesions.  The  ganglia  which  are  most  accessible,  and  there- 
fore important  in  a  diagnostic  point  of  view,  are  the  anterior  and  pos- 
terior cervical  ganglia,  situated  anteriorly  and  posteriorly  to  the  sterno- 
cleido-mastoid  muscle,  the  occipital  ganglia,  those  over  the  clavicle  (on 
either  end)  and  on  the  margin  of  the  pectoral  muscles,  the  anterior  and 
posterior  auricular  or  the  mastoid  ganglia,  the  epitrochlear  at  the  elbow- 
joint  above  the  internal  condyle,  and  the  axillary  ganglia.    All  of  these 


VARIOUS  MORBID   CONDITIONS  AND  AFFECTIONS,   ETC.       579 

ganglia  become  swollen  in  secondary  syphilis  as  a  result  of  the  essential 
hyperplastic  process  produced  by  the  virus.  In  some  cases  the  ganglionic 
reaction  is  rendered  more  intense  by  the  presence  of  irritated  syphilitic 
lesions  or  by  inflammatory  skin  lesions  which  may  be  developed  on  the 
regions  of  the  body  in  which  lymphatic  radicles  take  their  origin. 

In  this  way  the  lymphatic  ganglia  of  the  neck,  of  the  axillae,  and 
groin  may  become  more  or  less  acutely  swollen,  and  may  then  be  the 
seat  of  pain.  Whenever  any  of  these  ganglia  go  on  to  suppuration,  it 
is  certain  that  a  nearby  pus-focus  has  supplied  the  irritating  secretions 
or  the  microbes. 

While  hyperplasia  of  the  superficial  ganglia  occurs,  as  a  rule,  in  early 
secondary  syphilis,  this  condition  also  may  be  observed  in  exceptional 
cases  in  late  syphilis,  particularly  in  persons  whose  nutrition  has  been 
lowered  and  whose  constitutions  have  by  any  means  been  impaired. 

Deep  Lymphatic  Ganglia. — It  is  now  generally  conceded  that  the 
changes  in  these  ganglia  are  among  the  most  frequent  and  most  constant 
of  the  effects  of  tertiary  syphilis.  They  bear  the  same  relation  to  syphilis 
of  the  viscera  that  adenopathy  of  the  subcutaneous  lymphatic  glands 
does  to  syphilis  of  the  skin ;  in  other  words,  they  are  its  constant 
accompaniment.  The  aifection  of  the  deep  lymphatic  glands  may,  how- 
ever, exist  without  any  lesion  of  the  viscera,  just  as  the  post-cervical 
and  epitrochlear  glands  may  be  enlarged  without  any  eruption  upon  the 
scalp  or  arms. 

The  glands  most  frequently  affected  are  the  prevertebral,  lumbar, 
iliac,  and  femoral ;  the  mesenteric  glands  and  those  of  the  extremities 
are  rarely  involved.  The  changes  are  various.  Most  frequently  there 
is  hyperplasia  of  the  glandular  elements ;  the  gland  is  increased  in 
length  rather  than  in  breadth,  is  friable,  of  soft  consistency,  of  a  red- 
dish- or  yellowish-gray  color,  its  surface  injected,  and  its  substance 
cheesy.  In  other  cases  the  connective  tissue  of  the  gland  appears  to 
be  the  chief  seat  of  the  lesion,  and  this  body  becomes  indurated.  Sup- 
puration is  never  present,  which  is  an  important  diagnostic  sign  between 
this  and  the  affections  of  the  glands  in  typhoid  fever  and  in  tubercu- 
losis. 

Two  forms  of  syphilitic  adenitis  are  described  by  Cornil — the  sec- 
ondary, and  the  other  of  the  tertiary  stage  of  syphilis.  In  the  former 
the  microscope  shows,  besides  the  lymph-corpuscles,  large  spheroidal 
cells,  more  numerous  in  the  cavernous  than  in  the  follicular  structure  of 
the  gland.  The  cells  contain  several  nuclei,  the  larger  of  which  enclose 
nucleoli.  There  is  also  slight  increase  of  the  connective  tissue,  so  that 
there  exists  cell-proliferation  combined  with  a  moderate  degree  of  sclero- 
sis. In  tertiary  adenitis  the  swollen  ganglia  form  soft  Avhitish  masses 
of  a  medullary  appearance.  Round  and  granular  lymph-corpuscles  and 
large  multinucleated  cells  crowd  the  cavernous  tissue  and  the  lymph- 
passages  of  the  ganglia.  This  is  therefore  a  kind  of  catarrhal  inflam- 
mation. Two  forms  of  tertiary  adenitis  have  been  recognized  and  made 
the  subject  of  a  thesis  by  Gonnet,^  who  calls  them  sclerous  and  gum- 
matous adenitis.  He  says  they  may  occur  together,  and  the  former  may 
be  converted  into  the  latter. 

'  "  L'adenopathie  syph.  tertiaire,"  These  de  Paris,  1878. 


580  SYPHILIS. 

Syphilitic  Fever. 

According  to  my  observations,  fever  occurs  in  secondary  syphilis  in 
the  majority  of  cases.  It  may  be  transitory  or  persistent;  it  may  be  so 
mild  as  to  escape  notice,  or  it  may  be  moderately  intense.  It  presents 
'two  forms  :  in  one  the  febrile  condition  is  continuous,  in  the  other  it 
shows  distinct  remissions. 

Let  us  first  consider  the  continuous  fever  which  accompanies  the 
evolution  of  syphilis,  Avell  named  by  the  Germans  the  "  eruption  fever." 
It  seldom  occurs  before  the  thirtieth  day  of  the  secondary  period  of  incu- 
bation— that  is,  ten  days  prior  to  the  evolution  of  secondary  symptoms. 
In  at  least  half  the  cases  of  syphilis  there  is  no  febrile  reaction  until 
within  three  or  four  days  of  the  first  evidence  of  constitutional  infection. 
In  rare  cases  the  temperature  may  reach  103°,  or  even  105°  F.,  within 
twenty-four  or  forty-eight  hours.  Frequently  it  does  not  exceed  101°, 
remaining  at  that  point  until  the  eruption  appears,  when  it  again  rises, 
possibly  to  105°.  It  then,  as  a  rule,  falls  gradually  or  abruptly  to  about 
102°.  In  almost  all  cases  there  is  a  difference  of  about  one  degree  be- 
tween the  morning  and  evening  temperatures.  In  other  cases  a  tempera- 
ture of  105°  is  observed  ten  or  twelve  days  before  the  end  of  the  secondary 
period  of  incubation,  and  continues  without  remission  until  the  eruption, 
appears,  when  it  falls  abruptly  to  102°,  where  it  may  remain  for  several 
days.  In  the  majority  of  our  cases  102°  has  been  about  the  average 
temperature. 

Some  observers  consider  the  febrile  reaction  a  reliable  indication  of 
constitutional  infection,  but  in  some  cases  the  eruption  precedes  the  fever 
by  an  interval  of  a  week  or  ten  days. 

The  remarkable  effect  of  mercury  upon  the  temperature  has  been 
noticed.  Its  use  causes  a  reduction  nearly  or  quite  to  the  normal 
standard  in  some  cases  within  ten  days,  whereas  without  it  the  febrile 
condition  may  persist  for  several  months. 

Early  in  the  secondary  period  the  fever  is  prone  to  relapse,  possibly 
at  the  same  time  with  a  recurrence  of  general  or  special  syphilitic  symp- 
toms.     In  these  cases  the  temperature  rarely  goes  above  102°. 

When  phagedena  attacks  the  initial  lesion  and  syphilitic  cachexia 
appears  early,  the  fever  is  likely  to  be  excessive  and  prolonged.  In 
weak  and  sickly  persons  the  elevation  is  notably  greater  than  in  the 
robust,  and  in  women  it  is  higher  than  in  men.  The  febrile  reaction 
accompanying  an  erythematous  syphilide  is  often  as  extreme  as  in  a 
simple  eruptive  fever.  In  most  cases  of  papular  eruption  the  fever  is- 
moderate.  In  cases  of  pustular  eruption  and  of  iritis  accompanying 
general  secondary  symptoms  it  is  more  marked.  In  general  the  febrile 
reactions  of  the  early  years  of  syphilis  are  more  intense  than  those 
occurring  later.  Indeed,  lesions  of  much  gravity  may  occur  after  the 
lapse  of  years,  unaccompanied  by  fever.  On  the  other  hand,  it  may 
coexist  with  the  various  nervous  and  visceral  affections  of  the  tertiary 
stage. 

Syphilitic  fever  not  infrequently  presents  a  distinctly  remittent 
type — a  peculiarity  which  may  be  noticed  in  the  early  period,  but  is 
generally  not  observed  until  late  in  the  course  of  syphilis.  I  have 
seen  but  two  cases  in  which  the  fever  began  in  a    remittent    form  ten 


VARIOUS  3I0RBID   CONDITIONS  AND  AFFECTIONS,  ETC      581 

days  before  the  general  outbreak,  and  retained  its  character  for  nearly 
three  weeks.  When  remittent  fever  occurs  early  it  usually  accompanies 
the  development  of  constitutional  symptoms.  It  is  never  very  protracted. 
The  exacerbations  occur,  as  a  rule,  daily  and  toward  night,  beginning, 
perhaps,  between  six  and  eight  o'clock  Avith  a  general  cold  sensation, 
soon  followed  by  fever.  The  chilly  feeling  may  be  insignificant  or  it 
may  be  quite  marlced,  and  may  last  for  an  hour  or  more,  being  accom- 
panied by  a  feeling  of  lassitude  and  soreness,  and  perhaps  by  headache 
more  or  less  severe.  Thirst  seems  to  be  less  than  in  other  forms  of 
fever.  The  sweating  stage  is  incomplete,  there  frequently  being  only 
slight  moisture  of  the  surface.  It  thus  differs  from  malarial  fever  in  this 
respect,  as  well  as  in  the  fact  that  the  stages  are  neither  of  them  clearly 
defined,  that  of  heat  being  most  marked.  The  elevation  of  temperature 
varies  from  102°  to  105°  F.  The  pulse-rate  is  not  proportionately 
increased.  Relapses  are  quite  common,  even  after  long  intervals.  The 
gravity  of  the  fever  is  greatest  in  cachectic  subjects,  in  whom  it  may 
assume  a  typhoid  type. 

This  form  of  fever  occurs  most  frequently  in  the  secondary  period 
during  the  first  two  years  of  infection,  yet  it  may  appear  in  the  tertiary 
period,  possibly  coexisting  with  lesions  peculiar  to  that  stage. 

The  prognosis  depends  Avholly  on  that  of  the  associated  syphilitic 
diathesis. 

Quinine  has  been  found  ineffective,  but  the  remittent  as  well  as  the 
continuous  form  is  strikingly  amenable  to  mercury.  The  curious  fact  is 
reported  by  Jullien  to  have  been  observed  by  Domenico  Copozzi,  that 
in  one  instance  the  salts  of  quinia  converted  a  quotidian  syphilitic  fever 
into  a  tertian,  and  then  to  a  double  tertian,  when  it  relapsed  to  a 
quotidian,    which   finally   yielded  to   mercury. 

Cachexia,  Chloro-ansemia,  and  Asthenia. 

At  certain  periods  during  its  course  syphilis  produces  an  adynamic 
condition  of  the  system  called  "syphilitic  cachexia."  These  periods  are 
at  or  just  before  the  evolution  of  the  disease  during  its  secondary  stage 
and  toward  the  close  of  its  tertiary  stage. 

In  these  cases  there  may  be  ol3served,  soon  after  the  onset  of  the 
secondary  stage,  loss  of  appetite  and  strength,  emaciation,  and  a  pale, 
sallow  appearance.  The  pulse  becomes  rapid,  weak,  and  small,  and  the 
temperature  rises.  The  patient  feels  dejected,  nervous,  and  apprehensive. 
The  condition  becomes  graver  in  proportion  to  the  extent  of  the  numerous 
functional  disorders  which  accompany  the  inauguration  of  the  secondary 
stage.  Headache,  neuralgic  or  rheumatoid  pains,  with  severe  nocturnal 
exacerbations,  may  torment  the  unfortunate  sufferer. 

The  cachexia  of  the  secondary  period  of  syphilis  also  may  begin  a 
few  months  after  the  onset  of  the  disease.  It  is  seen  chiefly  in  weakly 
persons  oftener  than  in  the  robust,  and,  again,  more  frequently  in  those 
who  have  had  imperfect  or  no  treatment  whatever  ;  hence  we  have  reason 
to  infer  that  early  and  adequate  treatment  will  prevent  its  occur- 
rence. The  general  symptoms  of  cachexia,  already  given,  are  repeated 
in  this  stage  of  syphilis  in  a  milder  form.  Frequently  notliing  can  be 
found  to  account  for  the  condition,  and  the  only  suspicious  feature  of  the 


582  SYPHILIS. 

case  is  the  occurrence  of  headache  or  pain,  due  to  a  low  grade  of 
inflammation  in  bony  or  fibrous  tissue,  and  which  are  more  severe  at 
night. 

In  most  instances  there  is  no  reason  to  anticipate  an  unfavorable 
result,  but  in  others  these  vague  symptoms  are  so  alarming  as  to  suggest 
serious  visceral  lesions.  I  have  sometimes  found  slight  enlargement 
and  tenderness  of  the  liver,  and  often  marked  splenic  hypertrophy.  The 
urine  in  uncomplicated  cases  is  usually  of  very  low  specific  gravity  and 
deficient  in  mineral  ingredients. 

In  spite  of  the  serious  nature  of  the  case,  gradual  restoration  to 
health  may  be  expected  under  appropriate  treatment. 

Fournier  thinks  that  the  female  is  usually  more  seriously  affected  than 
the  male  sex.  He  has  observed  that  syphilis  produces  in  the  former  two 
conditions — one  "  chloro-angemia,"  and  another,  more  severe,  "asthenia. 

The  chloro-anaemic  woman  has  a  pale,  leaden  color  slightly  tinged 
with  yellow,  is  emaciated,  weak,  and  subject  to  palpitations  on  slight 
exertion.  Frequently  an  ansemic  bruit  may  be  heard  in  the  large  vessels. 
The  patient  complains  of  muscce  voUtantes,  of  vertigo,  and  of  excessive 
nervousness.  The  appetite  may  be  impaired  or  it  may  be  ravenous, 
large  quantities  of  food  being  taken  and  not  assimilated.  Fournier 
terms  this  '■'■  boulimie,''  or  a  temporary  exaggeration  of  the  appetite. 
While  admitting  its  occurrence  in  those  Avho  present  many  nervous 
symptoms,  he  insists  on  its  specific  origin.  It  is  probable  that  "  bou- 
limie  "  and  the  unnatural  thirst  termed  "polydipsia,"  which  are  often 
associated  together,  are  hysterical  symptoms  resulting  from  the  depress- 
ing influence  of  syphilis. 

The  condition  of  asthenia  is  regarded  by  Fournier  as  totally  distinct 
from  chloro- anaemia,  since  those  women  who  are  the  subjects  of  it  show 
no  evidence  of  anaemia  in  the  countenance.  They  complain  of  great 
weakness  and  prostration,  and  are  low-spirited  and  indisposed  to  any 
kind  of  exertion,  and  even  gentle  exercise  induces  fainting.  Fournier 
says  that  the  debility  is  greater  than  is  observed  in  cases  of  profuse 
hemorrhage  or  in  convalescence  from  adynamic  fevers.  The  pulse  is 
weak,  respiration  is  slow,  digestion  is  deranged,  and  nutrition  is  imper- 
fect. Nervous  depression  is  indicated  by  dulness  of  hearing  and  sight, 
and  by  inability  to  sustain  prolonged  mental  effort. 

This  condition  is  often  combined  with  chloro-anaemia,  and,  like  the 
latter,  varies  greatly  in  severity  and  is  amenable  to  proper  treatment. 

The  danger  in  each  of  these  conditions  is  from  the  diminished  resist- 
ance of  the  system,  which  lends  a  malignant  feature  to  any  intercurrent 
affection  that  may  attack  the  patient. 

The  Typhoidal  Condition. 

In  the  early  months  of  syphilis  certain  grave  adynamic  conditions 
sometimes  supervene,  which  may  very  properly  be  termed  the  syphilitic 
typhoidal  state,  or,  as  Fournier  calls  it,  typhose  si/philitique.  This  con- 
dition, which  is  not  common,  is  usually  seen  in  weakly  and  overworked 
or  under-fed  individuals,  m  males  more  frequently  than  in  females. 
Malaria  and  a  neuropathic  tendency  are  sometimes  contributory  causes. 
It  may  occur  quite  early  in  the  infection  coincidently  with  the  develop- 


VARIOUS  MORBID   CONDITIONS  AND  AFFECTIONS,  ETC.      583 

ment  of  the  general  manifestations,  and  at  any  time  during  the  first  year. 
It  may  supervene  in  some  subjects  in  whom  the  treatment  has  been  inef- 
ficient or  wanting,  and  also  as  a  result  of  excesses,  sexual  and  alcoholic, 
and  of  severe  bodily  and  mental  strain. 

The  patient  may  or  may  not  complain  of  headache  at  first,  but  he 
experiences  a  feeling  of  great  weakness  which  soon  develops  into  utter 
prostration.  He  has  a  mild  continuous  fever  and  dull  frontal  headache, 
and  his  pulse  is  rapid  and  small.  He  becomes  pale  and  sallow,  has  nO' 
energy,  and  desires  to  lie  down.  All  his  senses  grow  to  be  impaired  and 
dull,  and  he  becomes  somnolent  and  torpid.  He  has  confusion  of  thought, 
vertigo,  and  sometimes  photophobia.  His  appetite  leaves  him,  and  his 
bowels  are  usually  slow ;  exceptionally  there  is  diarrhoea.  In  this  condi- 
tion he  will  lie  in  bed  indifferent  to  all  around  him,  not  caring  for  food, 
and  sometimes  having  great  distaste  for  it.  In  this  lethargic  condition 
he  may  become  mildly  or  severely  delirious,  and  in  some  bad  cases  mani- 
acal. It  will  be  observed,  however,  as  a  rule,  that  the  peculiar  dull, 
earthy  tint  of  the  face  so  constantly  seen  in  typhoidal  patients  is  not  well 
marked  in  syphilitic  subjects.  But  there  is  the  same  typhoidal  facies, 
as  shown  in  the  utter  loss  of  tone  of  the  facial  muscles. 

Though  the  condition  is  a  very  rare  one,  it  does  not  commonly  lead  to 
death,  and  it  may  be  relieved  by  antisyphilitic  treatment,  together  with 
good  care  and  nursing  and  nutritious  food.  The  convalescence,  however, 
is  rather  slow,  and  several  months  may  elapse  before  the  patient  begins  to 
gain  in  weight  and  acquires  his  normal  physical  strength  and  mental  bal- 
ance. In  this  condition,  however,  hemiplegia,  aphasia,  and  epilepsy  may 
supervene,  and  then  the  gravity  of  the  case  is  much  enhanced. 

The  diagnosis  of  this  condition  is  usually  easy  if  the  medical  history  of 
the  patient  is  knoAvn.  The  absence  of  diarrhoea,  of  abdominal  tenderness, 
and  of  gurgling  in  the  right  iliac  fossa,  and  of  the  typically  pronounced 
typhoidal  facies,  will,  when  carefully  studied,  lead  the  physician  to  a  cor- 
rect interpretation  of  the  nature  of  the  case. 

Hysteria. 

In  men,  and  particularly  in  women,  a  condition  of  more  or  less  pro- 
nounced hysteria  may  be  developed  in  the  eaily  months  of  syphilis.  This 
condition  can  be  comprehensively  portrayed  by  the  recital  of  a  case  of  a 
syphilitic  woman  which  brings  out  its  salient  features  :  After  the  onset  and 
cessation  of  roseolar  and  papular  eruptions,  pains,  and  iritis,  a  woman  twenty- 
two  years  old  began  to  suffer  from  continuous  supraorbital  pain  and  quite 
permanent  dizziness.  In  walking  her  steps  became  unsteady,  and  on  occa- 
sions a  sensation  as  if  she  would  inevitably  fall  backward  was  felt,  but  w.a& 
always  controlled  by  a  forced  mental  effort.  She  was  emaciated,  and, 
instead  of  being  cheerful,  as  she  was  naturally,  she  was  sad  and  despond- 
ent. Her  appetite  was  poor,  but  not  capricious  ;  the  boAvels  moved  regu- 
larly, and  urine  was  normal  in  quantity  and  as  to  constituents,  and  her 
menses  were  regular.  Her  pulse  was  60  and  small,  and  the  temperature 
normal.  It  was  noticed  that  she  was  more  irascible  than  usual,  and  after 
such  spells,  which  were  of  frequent  occurrence,  she  often  wept  copiously. 
After  this  she  would  remain  for  hours  in  a  condition  of  abstraction,  not 
appearing  sensible  or  cognizant  of  things  passing  around  her.     She  would 


584  SYPHILIS. 

go  away  from  the  table  when  eating,  imagining  that  she  was  not  good 
enough  to  be  in  company  with  others.  At  other  times  she  would  become 
very  suspicious,  and  would  imagine  that  her  friends  were  conspiring 
against  her  or  that  they  were  laughing  at  her  and  making  sport  of  her. 
Under  this  impression  she  would  become  very  nervous,  and  would  shrink 
away  and  cry,  and  would  perhaps  sit  hours  without  moving ;  and  if  any 
one  came  near  her  she  would,  as  it  were,  awaken  from  her  lethargy  greatly 
fi'ightened  and  be  much  agitated.  When  spoken  to  she  recognized  those 
around  her  very  readily,  and  was  pleased  to  see  them,  and  she  said  she 
felt  a  queer  sensation  in  the  head.  When  asked  if  she  felt  in  this  strange 
manner  continuously,  she  replied  that  there  were  intervals  in  which  she 
^as  comparatively  free  from  the  sensations,  and  that  she  tried  very  hard 
to  resist  them.  She  said  she  felt  quite  weak,  that  her  memory  was  very 
poor  in  comparison  to  what  it  had  been,  and  that  in  reading  a  book  or 
paper  she  very  often  forgot  when  she  got  through  what  she  had  read. 
This  fact  was  very  apparent,  for  she  was  fond  of  reading  the  sensational 
serials  in  the  weekly  papers,  but  her  memory  was  so  much  impaired  that 
she  could  not  keep  the  thread  of  the  narrative.  She  complained  of 
w^eakness  and  dimness  of  vision,  and  she  frequently  saw  musece  volitantes 
before  her  eyes.  She  said,  also,  that  her  sleep  was  very  much  disturbed, 
and  she  frequently  awoke  greatly  alarmed.  Upon  walking  a  sensation 
of  ataxia  was  noticed,  and  she  said  she  felt  uncertain  as  to  where  she  was 
placing  her  feet.  At  this  time  she  had  nocturnal  rheumatoid  pains  along 
the  tibige,  and  also  in  the  larger  joints.  There  was  also  a  loss  of  sensa- 
tion to  pain  or  analgesia  of  the  backs  of  the  hands.  In  this  case  it  will 
be  seen  that  there  were  troubles  of  intellectuation  and  of  the  special 
senses. 

Fournier  ^  recently  reported  the  case  of  a  man  who  in  the  secondary 
stage  of  syphilis  complained  of  voraciousness  of  appetite,  who  had  a  di- 
minished field  of  vision  of  the  left  eye  and  a  complete  sensitivo-sensorial 
bemiansesthesia  of  the  same  side.  This  condition  developed  in  eight 
■days. 

As  a  rule,  these  cases  respond  quite  promptly  to  general  and  special 
treatment,  and  a  good  prognosis  may  be  given. 

Analgesia. 

Syphilis  very  commonly  gives  rise  to  various  disorders  of  the  general 
sensibility,  especially  in  women.  The  most  frequent  of  these  is  a  loss  of 
the  perception  of  pain,  or  analgesia,  with  which  is  sometimes  combined 
the  absence  of  the  sense  of  touch  and  of  temperature.  In  such  cases, 
for  instance,  a  pin  may  be  thrust  deeply  into  the  flesh  without  the  patient's 
suffering  any  pain,  or  she  may  be  also  insensible  to  the  touch  of  the 
£ngers,  or  cannot  distinguish  between  hot  and  cold  substances. 

Syphilitic  analgesia  varies  in  degree  in  different  cases,  and  also  in 
the  extent  of  the  surface  affected.  In  some  instances  it  extends  from 
bead  to  foot,  in  others  it  is  confined  to  particular  regions,  when  the 
extremities  of  the  limbs,  as  the  hands,  the  lower  half  of  the  forearms, 
the  feet  and  ankles,  the  female  breasts,  are  almost  invariably  involved. 
The  back  of  the  hand,  over  the  dorsal  surface  of  the  metacarpus,  is  a 
'  "Hysteiie  secondaire  syphilitique,"  Annales  de  Derm,  et  de.  Syph.,  1895,  p.  23. 


VARIOUS  MORBID   CONDITIONS  AND  AFFECTIONS,  ETC.       585 

favorite  site,  where  it  is  likely  to  be  found  if  anywhere.  The  disorder 
occurs  during  the  early  secondary  period,  and  most  commonly  lasts  for 
several  months. 

Cases  of  this  affection  have  frequently  come  under  my  observation 
both  in  the  male  and  the  female  sex.  It  would  probably  be  found  oftener 
if  looked  for,  but  its  presence  is  of  no  special  value  either  in  the  way  of 
prognosis  or  treatment,  and  is  hence  for  the  most  part  neglected. 

Disturbance  in  the  Reflexes. 

In  some  cases  of  syphilis,  prior  to  the  onset  of  general  manifestations 
and  during  their  evolution,  an  exaggeration  of  the  reflexes  of  the  skin 
and  tendons  may  be  observed.  This  condition  may  develop  slowly  or  it 
may  appear  quite  suddenly.  Finger^  has  studied  this  subject  carefully, 
and  has  convinced  himself  that  the  increased  excitability  gradually 
ceases,  and  ends  in  a  corresponding  decrease  in  which  the  reflex  situa- 
tion is  considerably  below  normal.  Relapses  of  the  secondary  eruptions 
are,  according  to  Finger,  followed  by  a  decrease  in  the  normal  excitabil- 
ity of  these  tissues  and  parts.  Zabourine  ^  confirmed  Finger's  conclusions, 
having  used  in  his  observations  the  instrument  of  Alelekoff  and  Daniels 
designed  for  the  purpose.  This  observer  claims  that  this  symptom  occurs 
in  all  cases,  and  that  it  is  due  to  vascular  and  hyperaemic  conditions  of 
the  cord. 

According  to  Marx, ^  the  patellar  reflex  excitability  is  greater  in  syph- 
ilitic women  than  in  men,  and  is  particularly  acute  during  menstruation. 
Fatigue  and  alcoholism  tend  to  diminish  the  excitability  in  a  notable 
degree. 

Sjmovitis. 

Two  forms  of  synovitis  occur  during  the  course  of  syphilis — the  one 
simply  a  chronic  effusion  into  the  joint  Avithout  any  appreciable  change 
therein ;  the  other  an  affection  in  Avhich  there  is,  besides  the  effusion,  a 
thickening  of  the  synovial  membrane. 

Synovitis  of  the  Early  Stage. — This  begins  slowly  and  painlessly. 
The  patient  experiences  slight  stiffness  in  the  joint,  which  is  found  to 
be  swollen.  On  examination  the  usual  symptoms  of  effusion  are  found, 
which  vary  according  to  the  joint  attacked.  The  skin  covering  the  joint 
is  not  changed.  Firm  pressure  may  cause  slight  pain,  and  dull  pain  may 
often  be  felt  at  night,  but  the  articular  surfaces  may  be  crowded  together 
with  impunity.  The  amount  of  effused  fluid  varies :  in  some  cases  it  is 
very  slight,  in  others  copious.  A  peculiar  feature  of  this  affection  is  the 
intermittent  character  of  the  effusion.  For  example,  a  patient  may  have 
complained  of  a  moderate  effusion,  which  seemed  to  wholly  pass  away ; 
after  a  longer  or  shorter  period  it  returns  and  reaches  a  certain  stage, 
where  it  remains  for  a  time  ;  then  the  swelling  increases  ;  after,  it  decreases 
very  perceptibly,  and  again  increases  to  marked  proportions.    During  this 

^."  Ueber  eine  constante  nervnse  Storung  bei  florider  syphilis  der  secundiirperiode," 
Vurleljahr.Jilr  Derm,  unci  Syph.,  vol.  xiii.  pp.  255  et  seq. 

*  "  Le  reflexe  tendineux  du  (ienou  dans  rEniption  primitive  de  la  Syphilis,"  Annales 
de  Derm,  el  de  Syph.,  189.3,  pp.  840  ct  seq. 

^  "  Untersuchungen  iiber  Patellar-reflex  insbesondere  bei  Lues,"  Dermat.  Zeitschrifl, 
1894,  pp.  397  et  seq. 


586  SYPHILIS. 

whole  period  the  patient  has  suiFered  little  inconvenience,  except  a  slightly 
painful  stiflFness  of  the  joint  in  the  morning,  which  passes  away  in  an  hour 
or  two,  and  perhaps  a  slight  pain  at  night.  Not  infrequently  such  patients 
also  suffer  from  periosteal  pain  in  the  course  of  the  long  bones  or  from 
nocturnal  neuralgia.  The  effusion  may  remain  for  a  long  or  short  period. 
In  some,  particularly  those  who  are  subjected  to  treatment,  it  passes  slowly 
away,  and  the  joint  is  apparently  left  in  its  normal  condition.  In  other 
cases  the  affection  is  chronic  and  persistent,  and  the  effusion  disappears 
very  slowly.  In  these  cases  we  usually  find  the  whole  joint  somewhat 
enlarged  and  indurated,  and  subject  to  frequent  small  effusions.  There  is 
no  tendency  to  suppuration  or  destruction  of  the  joint. 

The  diagnosis  of  this  affection  can  be  generally  made  out  without 
difficulty.  The  history  of  the  case  and  the  slow,  painless,  intermittent, 
and  subacute  character  of  the  effusion  establish  its  distinct  nature  from 
the  synovitis  of  rheumatism  or  of  gonorrhoea. 


Precocious  Osseous  Affections. 

The  bones  may  be  attacked  in  the  early  months  of  syphilis,  although 
osseous  lesions  generally  develop  quite  late.  The  bones  most  liable  to 
early  affection  are  those  of  the  cranium,  the  ribs,  the  sternum,  the  clavicle, 
and'the  tibia.  According  to  Mauriac,  these  lesions  may  occur  even  before 
the  cutaneous  manifestations  of  syphilis.  I  have  observed  localized  pain 
in  the  bones  afthe  period  of  invasion,  but  never  distinct  swellings  much 
before  the  third  month  of  syphilis.  The  swellings  appear  quickly  and 
with  fixed  pain,  which  is  worse  at  night,  and  may  be  accompanied  by 
radiating  neuralgic  pains. 

Of  the  skull-bones,  the  frontal  and  parietal  are  most  commonly 
attacked.  The  swellings  vary  in  diameter  from  half  an  inch  to  an  inch 
and  a  half,  and  reach  a  height  of  half  an  inch.  They  are  round  and 
smooth,  and  if  slowly  developed  are  quite  hard.  They  may  be  single 
or  multiple,  unilateral  or  symmetrical.  I  have  now  under  observation 
a  patient  affected  six  months  ago  upon  whose  skull  there  are  thirteen 
of  these  nodes.  They  may  occur  at  the  angle  of  junction  of  the  frontal 
bone  with  the  orbital  plates  or  on  the  occipital  bone,  but  they  are  usually 
on  the  sides  of  the  skull.  Mauriac  states  that  they  are  sometimes  con- 
fluent. In  some  cases  cerebral  symptoms  indicate  that  similar  lesions 
exist  on  the  internal  surface  of  the  cranium. 

The  clavicle  is  usually  affected  at  its  sternal  extremity,  the  articula- 
tion sometimes  being  involved.  The  upper  third  of  the  sternum  is  more 
commonly  involved  than  the  lower  third.  Occasionally  its  borders  are 
attacked  with  portions  of  the  costal  cartilages,  when  the  patient  may 
complain  of  severe  dyspnoea  and  pain  on  deep  inspiration.  In  such  a 
case  a  localized  pleurisy  has  probably  been  excited.  In  severe  cases  the 
ribs  themselves  may  be  invaded,  especially  their  anterior  portions.  Its 
subcutaneous  surface  is  the  portion  of  the  tibia  most  frequently  the  seat 
of  these  tumors.  They  vary  in  size  and  number,  but  are  usually  not  as 
salient  as  similar  swellings  of  other  bones.  The  radius  and  the  ulna  are 
also  sometimes  attacked.  The  swellings  are  usually  near  the  joint,  the 
wrist  more  commonly  than  the  elbow. 


VARIOUS  MORBID   CONDITIONS  AND  AFFECTIONS,   ETC.       587 

These  tumors  often  attain  a  large  size  in  one  or  two  weeks.  The  pain, 
which  is  always  present,  is  aggravated  by  pressure  and  is  worse  at  night. 

The  lesion  is  undoubtedly  due  to  hypersemia  of  the  periosteum  and  the 
formation  of  new  fibrous  tissue.  Gummy  infiltration  probably  does  not 
occur.  The  tumors  have  a  tendency  to  spontaneous  involution,  and  very 
rarely  break  down  and  form  ulcers.  If  left  to  themselves,  they  become 
converted  into  bony  nodes,  but  they  yield  readily  to  proper  treatment. 
In  but  one  case,  a  tumor  of  the  sternum,  have  we  seen  necrosis  take 
place.  The  ulcer,  which  resembled  a  gummatous  ulcer,  had  the  eroded 
bone  for  its  base  and  healed  slowly,  leaving  a  depressed  cicatrix.  Early 
treatment  prevents  deformity,  but  delay  may  result  in  superficial  atrophy 
of  the  bone. 

These  lesions  are  generally  accompanied  by  others  of  the  secondary 
stage ;  they  may  occur  even  before  the  disappearance  of  the  primary 
sore.  A  mild  form  of  hydrarthrosis  is  sometimes  induced  by  their  prox- 
imity to  a  joint. 

Treatment  should  be  both  local  and  internal.  Mercurial  ointment  well 
rubbed  in  twice  daily  and  kept  constantly  applied  to  the  parts  is  the  best. 
If  it  cause  irritation,  it  may  be  mixed  with  an  equal  quantity  of  oxide-of- 
zinc  ointment.     Internally  the  mixed  treatment  is  required. 

Rheumatoid  Pains  and  Rheumatism. 

Some  of  the  most  constant  symptoms  of  the  early  months  of  syphilitic 
infection  are  pains  in  the  muscles,  fasciae,  bones,  and  joints.  These  are 
termed  rheumatoid  pains,  articular  pains,  and  arthralgia ;  they  chiefly 
attack  the  larger  joints,  such  as  the  shoulder,  the  knee,  the  hip,  the 
ankle,  elbow,  and  wrist,  and  often  the  phalanges.  The  muscles  affected 
are  chiefly  those  of  the  extremities,  and  the  fasciae  of  these  parts  and 
of  the  large  joints  are  also  attacked.  Sometimes  a  single  muscle,  and 
again  groups  of  muscles,  may  be  attacked.  The  sensation  may  be  that 
of  simple  weakness  or  fatigue,  of  moderate  soreness,  and  even  of  a  dull 
or  severe  aching  pain.  The  pains  begin  generally  toward  evening,  and 
they  may  become  atrocious,  and  even  intolerable,  during  the  night.  To- 
ward morning  they  usually  cease,  and  leave  a  sensation  of  soreness  and 
stiffness  in  the  joint.  In  some  cases  the  irritative  process  is  so  severe  that 
a  joint  is  temporarily  rendered  nearly  immobile.  In  some  rare  cases  in 
the  early  secondary  stage  the  rheumatoid  pains  are  felt  on  the  surface  and 
in  the  continuity  of  the  long  bones. 

Acute  Articular  Rheumatism. 

As  a  very  exceptional  feature  in  secondary  syphilis  a  condition  resem- 
bling acute  articular  rheumatism  is  developed,  particularly  within  the 
early  months  of  the  infection.  The  joints  chiefly  attacked  are  the  large 
ones,  and  also  the  small  ones,  Avhich  become  swollen  and  very  painful, 
and  the  skin  over  them  coincidently  becomes  red  and  tender.  As  a 
rule,  the  process  is  quite  protracted  and  extends  over  several  weeks,  and 
even  as  long  as  two  or  three  months.  Usually  one  or  more  joints 
are  attacked  at  a  time,  and  whenever  the  inflammation  begins  it  shows 
a  tendency  to  stay.  It  is  not  common  in  acute  syphilitic  rheumatism  to 
see  the  inflammatory  process  cease  in  one  joint  and  then  jump  to  another, 


588  SYPHILIS. 

as  it  so  commonly  does  in  the  simple  form.  In  the  specific  rheumatism 
heart-complications  are  very  great  exceptions. 

The  fever  may  be  mild,  and  then  again  it  is  sometimes  of  quite  pro- 
nounced type.  In  the  milder  forms  the  morning  and  night  temperature 
may  vary  between  100°  F,  and  103°  F.,  whereas  in  the  severe  order  of 
cases  it  usually  oscillates  between  102°  F.  in  the  morning  and  105°  F.  in 
the  evening.  There  may  be  mild  sweating,  but  we  do  not  observe  the 
drenching  sour  sweat  of  acute  rheumatism.  In  the  syphilitic  form  of 
acute  rheumatism  there  also  may  be  sometimes  observed  periosteal  swell- 
ings on  the  shafts  of  some  of  the  long  bones,  the  tibia,  fibula,  and 
radius  and  ulna  chiefly.  In  one  instance  I  observed  periostitis  of  the 
cranial  bones. 

Though  this  form  of  rheumatism  is  often  quite  rebellious,  it  usually 
yields  in  a  few  weeks  to  careful  antisyphilitic  treatment. 

In  almost  all  cases  in  which  there  is  mild  or  severe  syphilitic  fever, 
whether  the  condition  be  typhoidal,  hysterical,  or  rheumatismal,  there  are 
usually  neuralgias  of  the  cranial,  intercostal,  sciatic,  or  anterior  crural 
nerves,  which  come  on  toward  night  and  are  usually  severe  at  that  period 
of  the  day. 


Hypersemia  and  Hyperplasia  of  the  Pharynx  and  Tonsils. 

In  many  cases  of  syphilis,  coincidentally  with  the  evolution  of  the 
secondary  manifestation,  a  diff"use  redness  and  thickening  of  the  pharynx 
and  a  swelling  of  the  tonsils  may  be  seen.  A^ery  often  patients  make  no 
complaint,  and  are  unaware  of  the  existence  of  this  local  trouble.  Then, 
again,  the  soreness,  stiffness,  and  pain  give  rise  to  much  sufiering  and 
inconvenience.  In  many  of  these  cases  there  is  no  superficial  lesion 
other  than  moderate  excoriation ;  in  some,  however,  mucous  patches  and 
condylomata  may  be  present.  This  pharyngeal  hypersemia  may  be  very 
persistent,  particularly  in  smokers,  and  in  some  patients  it  is  much 
increased  by  the  use  of  mercury  internally.  Local  treatment  is  very 
necessary  for  this  condition,  which  should  be  constantly  looked  for. 


Pleurisy. 

Recent  observations  have  conclusively  shown  that  the  pleura  may  be 
attacked  early  and  late  in  the  secondary  period  of  syphilis.  The  affection 
may  or  may  not  have  distinctive  characteristics.  In  some  cases  patients 
complain  of  pain  in  the  chest-wall,  which  is  usually  limited  to  a  space  of 
the  size  of  one  or  two  palms  of  the  hand.  It  is  not  at  all  uncommon  in 
dispensaries,  and  even  in  private  practice,  for  patients  to  come  who  are 
covered  with  an  erythematous  or  papular  rash,  and  to  see  on  them  one  or 
more  porous  plasters  placed  on  the  chest-wall,  usually  about  midway  from 
the  shoulders,  and  on  either  the  anterior  lateral  or  posterior  surface.  They 
may  complain  of  soreness,  stiffness,  or  even  pain  of  a  dull  and,  some- 
what rarely,  stabbing  character.  In  these  cases  there  may  be  no  fever  at 
all,  or  the  temperature  may  be  a  little  above  the  normal.  There  may  be 
slight  effusion  ;  rarely  is  it  copious.  In  some  cases  a  mild  friction-sound 
gives  evidence  of  moderate  fibrinous  exudation. 


VARIOUS  MORBID   CONDITIONS  AND  AFFECTIONS,  ETC.      589 

BroLisse  ^  and  Chantimesse  and  Widal  ^  have  observed  cases  in  Avhich 
there  were  successive  attacks  of  pleurisy  with  or  without  chills,  and 
perhaps  attended  with  pain  and  fever.  It  begins  quite  early,  and  may  be 
observed  through  the  whole  secondary  stage. 

Rochon  ^  claims  that  in  every  case  of  pleurisy  in  early  sj^philis  he 
found  hypertrophy  of  the  spleen.  Brousse  found  the  concomitant  condi- 
tion in  only  one  case. 

This  early  pleurisy  is,  as  a  rule,  readily  and  promptly  curable. 

Prsetorius  *  thinks  that  pleurisy  is  far  from  rare  in  syphilis — that  it 
develops  slowly  and  without  the  points  de  cotes  and  without  expectoration. 
According  to  his  observation,  it  attacks  the  apex  and  middle  parts  of  the 
lungs  in  the  secondary  and  tertiary  stage.  In  the  latter  it  is  more  insidi- 
ous than  in  the  early  stage.     It  may  or  may  not  give  rise  to  effusion. 

On  the  other  hand,  in  a  more  recent  essay  by  Monserat,^  who  has 
observed  several  cases  and  has  gone  over  the  literature  of  the  subject,  he 
claims  that  in  early  syphilis,  either  concurrently  or  not  with  eruptions, 
pleurisy  may  develop  with  severe  invasion  with  painful  points  ae  cote, 
intense  dyspnoea,  and  perhaps  with  marked  fever.  There  may  also  only 
be  mild  pleurodynia  and  febrile  movement.  There  may  be  moderate 
effusion  or  the  process  may  be  dry.  It  may  be  unilateral  or  both  sides  of 
the  chest  may  be  attacked. 

The  course  of  syphilitic  pleurisy,  according  to  this  observer,  is  irregu- 
lar, and  several  successive  attacks  may  occur. 

Pleurisy  is  often  coexistent  with  joint  lesions,  all  of  which  are  due  to 
subacute  irritative  processes. 

Nikulin  ^  observed  two  cases  of  pleurisy,  in  one  of  which  the  inflam- 
matory process  invaded  the  serosa  of  the  lung  by  extension  from  peri- 
ostitis of  the  ribs ;  in  the  other  it  was  primitive  in  the  pleura. 

The  first  case  was  that  of  a  man  forty-five  years  old,  and  syphilitic 
twelve  years.  For  three  months  he  lost  flesh,  was  much  debilitated,  and 
had  fever  which  was  influenced  by  antipyretics.  He  had  pain  in  right 
side,  a  dry  cough,  and  dyspnoea.  There  was  prominence  on  this  side 
of  the  size  of  an  octavo  sheet  of  paper,  and  dulness  on  percussion.  The 
patient  was  promptly  cured  by  the  use  of  iodide  of  potassium. 

In  the  second  case  the  man  was  forty  years  old,  and  had  been  syphilitic 
nineteen  years.  He  complained  of  pains  in  the  thorax,  a  sense  of  op- 
pression, fever,  and  sweats.  He  had  lost  much  flesh  and  w\as  very  weak. 
An  intense  friction-sound  was  heard  over  the  affected  part.  Blisters  failed 
to  give  any  relief,  which  promptly  followed  the  administration  of  the 
iodide  of  potassium. 

Thus  it  will  be  seen  that  there  are  two  forms  of  pleurisy  caused  by 
syphilis,  the  early  and  the  late  form.  The  first  is  readily  curable  by  mer- 
cury and   iodide   of  potassium   in   combination,   while   the  second   form 

^  "  Pleurisie  syphilitiqne  de  la  Periode  secondaire,"  Annales  de  Derm,  et  de  S>/ph.,  1894> 
pp.  965  et  seq. 

^  "Pleurisie  du  Stade  ros^olique  de  la  Syphilis,"  Bull,  de  la  Sociele  med.  de  Ilopilaux, 
Aug.  18,  1890,  and  Bulletin  medieal,  1891,  No.  66,  p.  791. 

*  "Des  Pleurisies  syphilitiques,"  I'lihe  de  Pari.%  1893. 

*  Annalea  de  Id  Sociere^de  med.  d'Avvers,  Sept.,  1891. 

*"  Contribution  a  I'Etude  de  la  Pleurisie  syphilitique  de  la  Periode  secondaire," 
These  de  Montpellier,  1894. 

^  "  Lues  der  Pleura,"  Berlin,  klin.  Wochenschr.,  No.  40,  1891,  pp.  981  et  seq. 


590  SYPHILIS. 

yields  quite  promptly  to  the  last  drug.  It  is  interesting  to  remember 
that  in  the  older  writings  the  iodide  of  potassium  was  by  many  strongly 
recommended  in  pleurisy. 

Angina  Pectoris. 

This  condition,  with  all  its  classical  symptoms,  is  in  rare  cases  seen  in 
secondary  and  tertiary  syphilis.  It  is  of  paroxysmal  occurrence,  and 
both  mild  and  severe  in  its  course,  and  sometimes  accompanied  by  ab- 
normal sensations  of  heat  and  cold  or  sweating  on  the  left  side  of  the 
body.     It  usually  yields  promptly  to  antisyphilitic  treatment. 

The  early  angina  pectoris  is  probably  due  to  irritative  lesions  in  the 
coronary  arteries,  and  perhaps  in  the  cardiac  plexus ;  the  late  form  gen- 
erally results  from  gummatous  aifections  of  the  heart.  Hallopean  ^  and 
Vitore^  have  published  interesting  clinical  essays  on  this  subject. 

Hypersemia  and  Hyperplasia  of  the  Spleen. 

With  the  evolution  of  secondary  manifestations  and  symptoms,  partic- 
ularly in  cases  of  anaemia  and  cachexia,  in  which  the  condition  of  the 
blood  is  much  deteriorated,  there  will  sometimes  be  found  decided  swell- 
ing of  the  spleen.  The  patients  complain  of  a  dull,  heavy  sensation  in 
the  splenic  region,  and  in  some  cases  a  mild  or  severe  pleuritic  pain  may 
be  felt.  This  condition  is  usually  ephemeral,  and  slowly  subsides  under 
antisyphilitic  treatment  and  when  the  general  nutrition  improves. 

In  an  essay  in  which  the  results  of  the  study  of  88  cases  are  given 
Quinquaud  and  Nicolle^  claim  that  in  the  majority  of  cases  of  acquired 
syphilis  enlargement  of  the  spleen  occurs.  It,  according  to  them,  usu- 
ally begins  after  the  appearance  of  the  chancre  and  the  adenopathies,  and 
before  the  onset  of  general  manifestations.  In  the  first  month  of  the 
secondary  stage  the  organ  becomes  and  remains  enlarged,  and  its  area  of 
dulness  may  be  four  inches  in  extent.  According  to  these  authors,  the 
enlarged  volume  of  the  organ  does  not  thus  early  appear  to  be  in  propor- 
tion to  the  intensity  of  the  symptoms,  and  the  morbid  process  is  not  then 
materially  modified  by  treatment.  At  the  end  of  the  first  year  the  splenic 
enlargement  begins  to  diminish  in  some  subjects.  It  wholly  disappears 
except  in  cases  of  malignant  course,  when  it  may  persist  even  into  the 
tertiary  stage. 

Quinquaud  and  Nicolle  think  that  splenic  hypertrophy  may  aid  in 
diagnosis  in  the  primary  period  when  there  is  doubt  as  to  the  nature  of 
the  chancre.  In  the  secondary  stage  also,  when  doubtful  manifestations 
are  present,  it  may  be  of  diagnostic  import,  and  they  call  this  a  perma- 
nent symptom  of  the  infection.  The  absence  of  splenic  enlargement, 
in  their  view,  shows  the  eradication  of  the  disease.  In  my  experience, 
vigorous  antisyphilitic  treatment  soon  (fauses  the  resolution  of  the  splenic 
hyperplasia. 

^  "  De  I'Angine  de  poitrine  d'Originesyphilitique,"  Annates  de  Derm,  et  de  Syph.,  1887, 
pp.  747  et  seq. 

'"'Un  caso  di  Angina  pectoris  per  sifilide,"  Bull,  di  Clin.,  Naples,  1886,  vol.  iii.  pp. 
185  et  seq. 

^"  Etude  clinique  sur  I'Hypertrophie  de  la  Rate  dans  la  Syphilis  acqnise,"  Bidl.  de 
la  Societe  /rang,  de  Derm,  et  de  Syph.,  vol.  iii.,  1892,  pp.  530  et  seq. 


VARIOUS  MORBID  CONDITIONS  AND  AFFECTIONS,  ETC.      591 

Colombini  ^  also  examined  the  spleen  in  eighty  cases  of  syphilitics, 
and  concludes  that  hypergemia  of  this  organ  is  one  of  the  first  of  the 
general  manifestations  of  the  infection.  This  author  thinks  that  prog- 
nostic and  therapeutical  indications  may  be  derived  from  a  study  of  the 
condition  of  the  spleen,  Avhich  he  thinks  remains  enlarged,  particularly 
during  the  first  year,  and  only  slowly  diminishes  in  size. 

Jaundice. 

In  early  secondary  syphilis  and  during  the  first  year  of  the  infection 
there  is  not  infrequently  seen  a  mild  and  ephemeral  form  of  jaundice. 
This  evidence  of  hepatic  derangement  may  consist  simply  of  moderate 
yellowness  of  the  skin  of  the  face,  or  there  may  be  a  dense  golden- 
yellow  discoloration.  In  case  of  jaundice  there  is  usually  chloro-ansemia 
or  asthenia. 

This  condition  is  probably  due  to  an  irritative  process  acting  upon  the 
common  bile-ducts,  and  not  to  any  structural  lesion. 

The  jaundice  of  secondary  syphilis  may  last  only  a  few  weeks,  and 
perhaps  in  severe  cases,  particularly  when  treatment  has  not  been  fol- 
lowed, it  may  last  two  or  three  months.  Under  the  influence  of  anti- 
syphilitic  treatment  and  good  regimen  the  yellowness  of  the  skin  disap- 
pears and  the  health  of  the  patient  becomes  restored. 

Lasch^  has  published  the  histories  of  three  cases  of  jaundice  in 
early  syphilis,  and  from  a  study  of  them  and  of  forty-six  reported  cases 
of  various  authors  concludes  that  syphilitic  icterus  develops  in  a  brusque 
manner  without  being  preceded  by  digestive  derangements.  Syphilitics 
thus  affected  may  have  good  appetite  and  digestion,  and  usually  are  not 
troubled,  as  patients  with  catarrhal  icterus  are,  with  inability  to  assimi- 
late fatty  food. 

In  cases  of  syphilitic  icterus  there  is  an  absence  of  any  etiological 
causes,  such  as  are  found  in  those  of  the  catarrhal  variety. 

The  jaundice  of  syphilis  is  more  frequently  found  in  women  than  in 
men.     It  is  usually  readily  amenable  to  specific  treatment. 

Albuminuria  and  Ephemeral  Nephritis. 

Much  has  of  late  been  added  to  our  previously  meagre  knowledge  of 
the  kidneys  and  their  condition  in  secondary  syphilis. 

There  can  no  longer  be  a  doubt  that  early  and  sometimes  rather  late 
in  the  secondary  stage  a  mild  or  more  severe  form  of  nephritis  may 
occur. 

It  is  thought  by  several  authors  that  the  early  or  precocious  nephritis 
of  syphilis  has  the  characteristics  of  the  same  condition  due  to  other  in- 
fectious fevers  and  diseases.  Negel,^  as  a  result  of  his  studies,  concludes 
that  the  syphilitic  affection  is  a  glomerulo-nephritis  comparable  to  that 
of  scarlatina. 

The  symptoms  of  early  renal  syphilis  may  be  entirely  wanting,  and 
the  diseased  condition  may  only  be  discovered  upon  examination  of  the 
urine.     Then,  again,  in  some  cases  there  is  oedema  of  the  lower  extremi- 

^  Giornale  Ital.  delle  Mai.  Ven.  e  della  Pelle,  vol.  xxx.  pp.  1  et  secj. 

"^  "  Icterus  Syphiliticus  priioox,"  Bed.  klin.  Wochenschr.,  1894,  pp.  906  et  seq. 

»  "  De  la  Syphilis  renale,"  Thhe  de  Paris,  1888. 


592  SYPHILIS. 

ties  and  of  the  face,  and  perhaps  there  may  be  moderate  or  copious  pleural 
or  abdominal  effusion. 

Furbringer '  has  studied  the  subject  in  more  than  200  cases,  and  he 
concludes  that  there  is  an  essential  syphilitic  nephritis,  and  that  mer- 
curial treatment  tends  to  cause  a  mild  and  ephemeral  form  of  the  affec- 
tion. In  100  untreated  cases  of  syphilis,  in  which  the  kidneys  were 
healthy,  he  found  8  cases  which  developed  albuminuria,  the  maxi- 
mum quantity  of  albumin  being  12  per  cent.  In  other  cases  external 
and  internal  treatment  produced  the  same  result.  In  syphilitic  albu- 
minuria Fiirbringer  found  renal  epithelium,  cylinders,  and  red  blood- 
corpuscles. 

Hudelo  ^  reports  the  case  of  a  man  who  in  the  fourth  month  of  sec- 
ondary syphilis  presented  evidence  of  Bright's  disease,  pulmonary  apo- 
plexy, with  pleural  and  pericardial  effusion.  At  the  autopsy  diffuse 
subacute  nephritis,  both  epithelial  and  interstitial,  with  a  tendency  to 
contraction  in  spots,  was  found  by  Darier.  In  another  case,  reported  by 
Hudelo  and  Darier,^  a  man  forty-nine  years  old  four  months  after  infec- 
tion presented  symptoms  of  Bright's  disease.  He  died,  and  at  the 
autopsy  a  diffuse  subacute  nephritis,  Avith  glomerulitis  and  fatty  degen- 
eration of  the  parenchyma,  was  found.  As  to  these  results  Darier 
says  :  "  In  these  cases  of  syphilis  there  were  no  post-mortem  appearances 
to  distinguish  these  kidneys  from  those  of  other  infectious  diseases. 
Tubercular  nephritis  is  comparable  to  that  of  syphilis." 

Horteloup  ^  lays  stress  on  the  curability  of  syphilitic  albuminuria  in 
secondary  syphilis,  particularly  when  treated  early,  even  if  severe 
oedema  and  intrathoracic  and  intra-abdominal  effusions  are  present. 
This  author  also  suggests  that  cold  may  be  a  factor  in  the  production 
of  nephritis. 

In  many  cases  this  nephritis  is  curable  by  antisyphilitic  treatment, 
aided  by  care  as  to  regimen  and  the  use  of  a  milk  diet.  In  some  cases, 
particularly  in  those  who  indulge  in  an  excess  of  alcoholic  liquors  and 
who  are  exposed  to  cold,  parenchymatous  changes  are  produced. 

The  ephemeral  nephritis  of  secondary  syphilis  is  to  be  feared,  for  the 
reason  that  it  may  lead  to  structural  changes  in  the  kidneys. 

Glycosuria. 

Tschistiakoff^  has  reported  the  case  of  a  man  whose  urine  at  the 
date  of  the  secondary  syphilitic  invasion  contained  |  per  cent,  of  sugar, 
which  disappeared  with  the  development  of  the  roseolous  eruption. 
The  fact  was  ascertained  that  the  patient  was  not  a  diabetic  before  he 
became  infected  with  syphilis.  This  author  thinks  that,  owing  to  dis- 
turbances in  metabolism  at  the  onset  of  secondary  syphilis,  a  benign 

^  "  Ueber  Albuminurie  durch  quecksilber  und  lues,"  Berlin,  klin  Wochenschrifi,  No.  21, 
1885,  pp.  343  et  seq. 

^  "  Mai  de  Bright  syphilitique  precoce,"  Bull,  de  la  Socieie  /rang,  de  Derm,  et  de  Syph., 
vol.  iv.,  1893,  pp.  125  et  seq. 

*  "Syphilis  renale  precoce,"  ibid.,  vol.  iv.  pp.  406  et  seq. 

*  "Note  sur  I'Albuminurie  syphilitique,"  Armales  de  Derm,  et  de  Syph.,  1886,  pp.  577 
et  seq.  Also  see  Wickham,  "  Note  sur  I'Albuminurie  Survenante,  dans  le  cours  d' Acci- 
dents secondaires  d'Origine  syphilitique,"  L'  Union  medicale,  1886,  vol.  xlii.  pp.  685  et 
seq. 

^  Vrach,  1894,  vol.  xv.  pp.  103  et  seq. 


HEMORRHAGIC  SYPHILIS  AND  HEMOGLOBINURIA.  593 

glycosuria,  characterized  by  the  small  amount  of  sugar  excreted,  by 
moderate  polyuria,  and  without  excessive  thirst  or  appetite  and  loss  of 
weight,  sometimes  occurs. 

Peptonuria. 

Impressed  with  the  fact  that  peptonuria  is  a  condition  found  in  the 
course  of  infectious  diseases,  Raymond^  searched  for  it  in  syphilis,  and 
found  that  it  is  of  rare  occurrence.  The  cases  in  which  peptonuria  was 
found  were  those  of  malignant  precocious  syphilis  and  phagedena. 


CHAPTER    LIX. 

HEMORRHAGIC  SYPHILIS  AND  H^MOaLOBINURIA. 

Any  of  the  secondary  eruptions  of  syphilis  may  be  accompanied  by 
hemorrhagic  effusion,  either  around  or  into  the  substance  of  the  lesion. 
It  may  occur  on  the  lower  extremities  of  those  whose  general  health  is 
unimpaired,  and  is  then  not  of  serious  import,  or  it  may  occur  on  various 
other  portions  of  the  body  of  broken-down  and  scorbutic  persons.  In 
all  of  these  cases  the  effusion  is  secondary  to  the  specific  process,  spon- 
taneous transudation  of  blood  into  the  skin  of  syphilitics  being  quite  a 
rare  occurrence.  A  case  of  much  interest  has  been  reported  by  Balz,^  as 
follows  :  A  man,  aged  twenty-five,  healthy,  but  having  had  typhus  fever, 
when  syphilitic  one  year  suddenly  and  without  premonition  became  cov- 
ered with  a  blood-red  exanthem.  This  was  composed  of  discrete  and 
confluent  spots  varying  in  size  from  a  millet-seed  to  a  silver  dollar.  The 
blood-red  color  rapidly  faded  and  left  slightly  scaly,  reddish-  and 
greenish-yellow  patches  similar  to  those  seen  in  scorbutus.  Coincidently 
he  had  swelling  of  the  joints  of  the  little  finger,  wrist,  right  elbow,  and 
both  feet,  due  to  intra-  and  periarticular  hemorrhagic  effusion.  The 
cheeks  and  eyelids  were  swollen,  but  the  gums  were  normal.  The  urine 
did  not  contain  blood.  Four  days  later  a  new  eruption  occurred  simul- 
taneously with  an  attack  of  pleuro-pneumonia.  For  the  latter  an  ice-bag 
was  applied  to  the  chest,  resulting  in  the  development  of  a  large  patch 
of  effused  blood,  which  slowly  subsided,  the  skin  being  oedematous  and 
sensitive.  A  second  application  of  the  ice-bag  produced  a  similar  result. 
Under  the  use  of  iodide  of  potash  the  patient  was  cured  in  four  weeks. 
Balz  thinks  that  syphilis  induced  in  tliis  case  a  hemorrhagic  diathesis. 
He  also  speaks  of  another  case  of  a  healthy  man  Avho,  a  short  time  after 
syphilitic  infection,  w^as  attacked  by  a  general  hemorrhagic  eruption, 
with  epistaxis,  bloody  urine,  bloody  stools,  and  febrile  reaction.      Several 

'  Annales  de  Derm,  el  de  Sypk.,  1890,  pp.  68  et  seq. 
^  "  Ueber  hsemorrhagische  Syphilis,"  Ai-ch.  d.  Heilk.,  Feb.,  1875. 
38 


594  SYPHILIS. 

days  later  a  papular  syphilide  appeared  among  the  patches  of  effusion,  and 
on  the  tenth  day  the  man  died. 

Horowitz^  reports  two  cases  of  men,  syphilitic  respectively  four  and 
five  months,  who  suffered  from  secondary  manifestations  of  the  skin.  The 
papules  became  hemorrhagic  and  surrounded  by  large  and  small  ecchy- 
motic  zones,  some  of  which  were  confluent.  In  these  cases,  as  in  several 
similar  ones,  there  had  been  icterus  at  an  earlier  date.  Horowitz  states 
that  he  also  has  seen  the  case  of  a  young  syphilitic  woman  who  died  in 
consequence  of  nasal,  uterine,  and  intestinal  hemorrhage,  but  whose 
eruptions  did  not  become  hemorrhagic. 

Hartmann  and  Pignot  have  published  an  essay  ^  in  which  the  history 
of  a  goodly  number  of  cases  of  hemorrhage  during  syphilis  is  given. 
These  observers  think  that  hemorrhage  is  due  to  specific  arteritis,  while 
others  think  that  in  some  cases  changes  in  the  blood  may  be  the  under- 
lying cause  of  its  extravasation  and  effusion. 

Hartmann  and  Pignot,  as  a  result  of  their  studies,  conclude  that  syph- 
ilis causes,  first,  cutaneous  hemorrhage  into  specific  eruptions ;  second,  a 
special  form  of  purpura ;  and,  third,  the  ordinary  purpura,  which  runs  its 
course  during  the  evolution  of  the  disease. 

I  have  also  seen  a  case  of  hemorrhagic  effusion  occurring  late  in  syph- 
ilis. The  patient,  a  man  forty-six  years  of  age,  had  suffered  severely 
from  various  lesions,  and  of  late  with  extensive  ulcerating  gumraata. 
Twelve  years  after  infection,  being  in  a  cachectic  state,  he  was  attacked 
by  a  general  but  not  copious  eruption  of  bullae.  These  when  first  seen 
contained  sero-pus,  but  soon  became  of  a  deep-red  color,  and  around  them 
a  wide  areola  of  effused  blood  appeared,  with  large,  slightly-raised  hemor- 
rhagic patches  between  them.  The  bullae  became  large,  foul  ulcers  ;  the 
effused  patches  grew  larger,  and  some  coalesced.  The  patient  finally 
passed  into  a  typhoid  condition  and  died.  In  this'  instance  the  hemor- 
rhagic condition  or  diathesis  was  probably  caused  by  syphilis. 

Much  future  study  upon  this  subject  is  necessary.  The  interesting 
question  arises  concerning  hemorrhages  in  syphilitics  whether  or  not  they 
are  in  some  cases  caused  by  intercurrent  infectious  processes. 

The  etiological  relation  between  syphilis  and  hsemoglobinuria  has  not 
as  yet  been  clearly  made  out,  but  there  is  distinct  evidence  that  syph- 
ilis acts  as  a  causative  factor  in  this  peculiar  form  of  blood-degen- 
eration. 

Murri,^  after  extensive  observation  of  many  cases  of  haemoglobinuria, 
in  fifteen  of  Avhich  the  existence  of  syphilis  was  clearly  demonstrated,  has 
reached  the  conclusion  that  this  infection  is  not  infrequently  the  etiological 
factor  in  that  morbid  condition  of  the  blood.  Hsemoglobinuria  may  occur 
in  both  early  and  late  syphilis.  The  syphilitic  form  presents  no  distin- 
guishing features  from  the  one  due  to  malaria.  Murri  thinks,  however, 
that  in  chronic  malaria  the  fever  gives  rise  to  the  hsemoglobinuria,  while 
in  syphilis  that  condition  causes  the  fever.  Murri  relates  the  case  of  a 
man  who  in  the  third  year  of  his  syphilis  suffered  from  hsemoglobinuria 
and  dermal  manifestations.     Mercurial  treatment,  after  some  disappoint- 

^  "  Zur  Kenntniss  der  Hfemorrhagischen  Syphilis,"  Vierteljah.  fur  Derm,  und 
Syphilis,  1886,  pp.  351  et  seq. 

"^  "  Hemorrhagies  et  Syphilis,"  Annales  de  Derm,  et  de  Syph.,  1886,  pp.  1  et  seq. 
^  "  Emoglobinuria  e  Sifilide,"  Bevista  din.  di  Bologna,  fascic.  4  and  5,  1885. 


GENERAL  CONSIDERATIONS  ON  SYPHILIDES.  595 

meats,  caused  the  paroxysms  to  cease.  Later  on  the  man  died  of  severe 
visceral  lesions. 

Schumacher^  also  concludes  that  hsemoglobinuria  is  not  simply  an 
intercurrent  affection,  but  that  it  really  is  caused  in  some  unknown 
manner  by  the  syphilitic  infection. 

Goetze^  reports  a  case  of  paroxysmal  hsemoglobinuria  which  occurred 
in  an  hereditarily  syphilitic  subject.  A  girl  nine  years  old  showed  marked 
evidence  of  inherited  infection  in  deformities  of  the  teeth,  double  kerato- 
iritis,  and  hyperostosis  of  the  tibia.  The  attacks  of  hsemoglobinuria  were 
ushered  in  by  shooting  pains  in  the  limbs  and  region  of  the  liver,  by 
yawning  and  a  sensation  of  cold,  which  were  followed  by  a  short  period 
of  sweating,  after  which  urine  of  the  color  of  ink  was  passed.  Half  an 
hour  later  the  urine  looked  normal.  Quinine  failed  to  cure,  but  relief 
followed  the  use  of  the  mixed  treatment. 


CHAPTER    LX. 


GENERAL  CONSIDERATIONS  ON  THE  AFFECTIONS  OF  THE  SKIN, 

OR  SYPHILIDES. 

Lesions  of  the  skin  may  appear  at  any  period  in  the  course  of 
syphilis,  being  among  its  earliest  symptoms  and  not  infrequently 
among    its    latest. 

Syphilitic  eruptions  are  caused  by  two  distinct  morbid  processes, 
hypergemia  and  cell-infiltration,  each  of  Avhich  is  extremely  chronic 
in  its  nature.  The  hypergemic  or  erythematous  syphilides  present  sev- 
eral varieties,  and  are  peculiar  to  the  early  stages  of  syphilis,  being 
very  rarely  seen  later  than  two  years  after  infection.  While  hj^per^emia 
is  the  essential  morbid  process,  we  not  infrequently  find  associated  with 
it  a  certain  degree  of  cell-increase,  sometimes  so  slight  as  to  be  inappre- 
ciable to  the  naked  ej^e,  and  again  so  marked  as  to  form  well-defined 
patches  or  nodules.  The  infiltrating  cells  of  the  syphilitic  dermal 
lesions  are  round,  granular,  nucleated  bodies,  averaging  g-g^-g-  of  an  inch 
in  diameter,  similar  to  the  white  blood-corpusoles  in  general  appearance 
and  analogous  to  the  cells  of  the  initial  lesion  and  of  the  later  gumma- 
tous tumors  of  syphilis.  The  surprisingly  numerous  and  varied  appear- 
ances resulting  from  these  two  simple  processes  are  modified  and  com- 
plicated by  various  subsequent  changes. 

As  a  general  rule,  the  cell-infiltration  is  in  proportion  to  the  age  of 
the  syphilis.  Thus,  in  the  secondary  period  the  superficial  layers  of  the 
.skin  are  involved  and  papules  are  developed,  while  at  a  later  period,  the 

^  "  Beitrag  zum  Zusammenhang  von  Paroxysmalen  Haemoglobinurie  und  Syphilis," 
Verhandl.  d.  Conr/.  filr  Innere  vied.,  Wiesbaden,  1884,  vol.  iii.  pp.  357  et  seq. 

^  "  Beitrag  zur  Lehre  von  der  Paroxysmalen  Ha?moglobinurie  bei  Syphilis,"  Bed.  klin. 
Wochensehr.,  1884,  p.  716. 


596  SYPHILIS. 

infiltration  being  deeper  and  more  extensive,  tubercles  are  formed.  In 
the  former  the  changes  take  place  chiefly  in  the  papillary  and  Malpigh- 
ian  layers ;  in  the  latter  the  derma  and  the  subcutaneous  tissue  are 
involved,  A  tubercle,  therefore,  is  simply  a  papule  of  large  size. 
Evidently  there  can  be  no  distinct  line  of  division  between  the  two 
lesions,  and  Ave  frequently  meet  with  intermediate  grades  of  infiltration, 
to  which  we  may  apply  the  term  papulo-tubercle.  Tubercles  may,  how- 
ever, appear  early  in  the  course  of  syphilis,  but  are  usually  not  seen 
until  after  the  evolution  of  a  general  superficial  eruption,  A  syphilitic 
pustule  may  be  looked  upon  as  a  pus-producing  papule,  the  secretion  of 
pus  generally  being  secondary  to  the  formation  of  the  papule.  In  some 
instances,  however,  the  formation  of  pus  seems  to  precede  or  to  be  coin- 
cident with  the  cell-infiltration. 

The  occurrence  of  a  vesicular  syphilide  is  rare,  and  has  indeed  been 
denied  by  some  authors.  It  is  true  that  vesicles  similar  to  those  of 
herpes  and  eczema  are  not  developed,  but  it  is  not  uncommon  to  find 
minute  collections  of  serum  beneath  the  epidermis  at  the  apices  of 
papules,  especially  those  small  conical  papules  which  have  a  more  acute 
evolution. 

The  existence  of  a  true  bullous  syphilide  in  the  acquired  disease  has 
also  been  doubted,  but  we  are  convinced  that  it  is  occasionally  devel- 
oped at  a  late  period  in  cachectic  subjects.  The  degree  of  cell-infiltra- 
tion at  the  base  of  bullae  is  usually  much  less  than  in  any  other  syphilitic, 
eruption. 

Thus  we  find  in  syphilis  lesions  of  the  integument  which  correspond 
to  those  of  non-specific  origin — erythemata,  papules,  pustules,  vesicles, 
bullae,  and  tubercles — but  the  syphilitic  eruptions  present  certain  pecu- 
liar features  whose  recognition  is  important. 

In  addition  to  the  above-mentioned  lesions  are  the  syphilitic  gwn- 
mata  or  gummatous  tumors.  These  result  from  cell-infiltration  in  the 
subdermal  tissue,  either  limited  to  this  region  or  involving  secondarily 
the  entire  thickness  of  the  skin,  which  may  be  destroyed,  thus  forming 
gummatous  ulcers. 

A  syphilitic  eruption  may  be  composed  exclusively  of  one  or  another 
of  these  lesions,  or  several  may  be  simultaneously  developed. 

Much  confusion  has  followed  the  application  to  syphilitic  skin  lesions 
of  the  classification  of  non-specific  eruptions  instituted  by  Wilan,  who 
placed  lichen  among  the  papular,  impetigo  among  the  pustular,  eczema, 
among  the  vesicular,  and  psoriasis  among  the  scaly  affections.  Such  a. 
nomenclature  in  syphilis  is  far  from  being  as  useful  as  might  be  expected. 
For  instance,  a  papular  syphilide  in  its  early  stage  would  be  called 
lichen,  but  suppose  it  to  be  capped  with  pus,  as  frequently  happens,  and 
the  name  impetigo  must  be  substituted,  or  we  must  designate  it  by  the 
term  pustulating  syphilitic  lichen.  Should  the  lesion  lose  its  pustular 
feature,  and,  becoming  chronic,  assume  a  scaly  character,  no  term  now 
in  use  could  express  the  exact  condition,  and  we  should  be  compelled  to 
add  the  term  psoriasis. 

Another  objectionable  feature  in  the  nomenclature  of  syphilitic  der- 
mal lesions  is  the  use  of  the  word  "lupus  "  in  describing  certain  tuber- 
cular syphilitic  lesions  whose  features  and  course  resemble  those  of  the 
non-specific  affections. 


GENERAL   CONSIDERATIONS  ON  SYPHILIDES.  597 

I  have,  therefore,  thought  best  to  apply  the  qualifying  adjectives 
erythematous,  papular,  pustular,  etc.  to  the  generic  term  "  syphilide," 
using  the  words  ulcerating,  serpiginous,  etc.  in  addition  as  the  peculiar 
features  of  an  eruption,  in  exceptional  cases,  may  require.  We  thus 
avoid  the  erroneous  inference  that  many  of  the  chief  varieties  of  simple 
skin  aifections  are  caused  by  syphilis. 

Although  we  may  use  the  word  "  scaling "  in  describing  certain 
syphilides,  it  must  be  remembered  that  desquamation  does  not  constitute 
the  lesion,  but  that  the  latter  consists  of  infiltrations  into  the  skin  in 
the  form  of  papular  or  tubercular  eruptions,  exfoliation  of  the  epidermis 
being  secondary.  In  some  cases  the  dermal  irritation  is  so  excessive 
that  desquamation  continues  long  after  the  original  lesion  has  failed. 
It  must  then  be  considered  merely  a  sequel  of  the  specific  process. 

Besides  the  classification  of  syphilides  in  accordance  with  their  ele- 
mentary lesions,  we  have  one  based  on  the  recognized  fact  that  each 
symptom  has  a  favorite  period  of  development.  A  strict  chronological 
order  is  not  followed,  for  a  tubercular  rash  may  be  met  with  at  an  early 
date,  or  a  papular  eruption  may  be  developed  very  late  in  the  course  of 
syphilis.  Some  French  authors  call  the  early  eruptions  precocious  syph- 
ilides (syphilides  precoees),  and  limit  them  to  the  first  eight  months  of 
the  disease ;  those  of  later  appearance  they  term  intermediary  (inter- 
mediaires),  which  may  appear  as  late  as  the  second  year ;  while  the  very 
latest  are  called  tardy  (tardives),  which  may  appear  at  any  time  before 
the  tenth  or  the  twentieth  year. 

A  division  which  is  simpler  and  more  practical,  and  which  we  shall 
employ,  is  that  which  places  erythematous,  papular,  pustular,  and  vesicu- 
lar syphilides  among  secondary  lesions,  and  tubercular,  bullous,  ulcerative, 
and  gummatous  among  tertiary  lesions.  Certain  peculiarities  are  pre- 
sented by  these  two  classes  of  lesions. 

The  early  lesions  of  the  secondary  stage  are  distributed  symmetrically 
and  generally  over  the  body,  involving  the  superficial  layers  of  the  skin ; 
the  later  lesions  of  this  stage,  although  extensively  and  symmetrically 
spread,  are  less  copious,  and  show  a  tendency  to  localization,  and,  more- 
over, invade  deeper  portions  of  the  skin.  The  lesions  of  the  tertiary 
stage  are  always  profound  and  are  less  profusely  distributed,  but  they 
involve  more  extensive  portions  of  particular  regions  for  which  they  seem 
to  have  a  predilection,  and  they  are  frequently  unsymmetrical.  The 
course  of  the  tertiary  lesions  is  decidedly  more  prolonged  and  indolent 
than  that  of  the  secondary. 

Much  difficulty  is  experienced  in  the  study  of  specific  skin  affections 
in  consequence  of  numerous  modifications  which  they  are  prone  to  un- 
dergo. Familiarity  with  the  features  of  the  simple  eruptions  is  essential 
to  an  accurate  knowledge  of  syphilitic  eruptions.  Let  us  now  consider 
some  of  the  characteristics  by  which  the  latter  may  be  recognized. 

Their  course,  as  compared  with  that  of  simple  eruptions,  is  marked  by 
chronicity  and  absence  of  inflammatory  features.  They  may  be  accom- 
panied by  a  moderate  degree  of  systemic  reaction.  In  some  erythematous 
and  papular  syphilides  of  the  early  period  of  syphilis  the  intensity  of 
this  reaction  and  the  active  character  of  the  eruption  may  render  the 
diagnosis  from  one  of  the  simple  exanthcms  very  difficult.  The  actual 
nature  of  the  eruption  is  demonstrated  by  its  quickly  assuming  a  sub- 


598  SYPHILIS. 

acute  course.  With  the  progress  of  the  syphilis  the  tendency  of  the 
eruptions  to  present  a  chronic,  apyretic  character  is  more  marked.  Some 
local  exciting  cause  may  usually  be  found  for  the  hypersemia  and  inflam- 
mation sometimes  attending  tubercular,  ulcerative,  and  gummatous  syph- 
ilides. 

The  Microbic  Complications  of  the  Syphilides. 

There  are  many  points  as  to  the  nature  of  certain  syphilides  which 
may  later  on  be  cleared  up  by  pathological  and  bacteriological  studies. 
In  strict  accuracy  the  only  essentially  and  purely  syphilitic  skin  lesions 
are  those  produced  by  erythema  and  cell-changes — namely,  the  ery- 
thematous and  pigmentary,  and  the  papular,  tubercular,  and  gummatous 
syphilides,  in  which,  when  uncomplicated,  there  is  no  suppuration.  These 
dermal  affections  result  directly,  without  complication,  from  essential 
syphilitic  processes.  The  various  pustular  syphilides  of  the  secondary 
stage  and  the  rupial,  ulcerative,  and  serpiginous  syphilides  of  the  later 
stage  are  really  the  results  of  mixed  processes  or  infections.  In  these 
cases,  in  some  occult  manner,  the  hyperaemia  and  hyperplasia  of  syphilis 
become  complicated  by  the  action  of  pyogenic  microbes.  Many  so-called 
syphilitic  lesions — namely,  the  impetigoform  and  the  ecthymatous  syph- 
ilides— very  often  present  an  exceedingly  striking  clinical  picture  of 
microbic  invasion  of  an  integument  which  seems  susceptible  to  their  in- 
fluence, and  in  which  the  resulting  low-grade  pyogenic  process  seems  to 
luxuriate.     (See  Plate  VI.) 

It  is  difiicult  to  understand  the  essential  nature  of  the  variolaform  and 
acneform  syphilides.  We  know  that  syphilis  is  not  a  pus-producing  dis- 
ease, yet  in  its  v/hole  course  in  many  cases  the  pustulation  seems  to  be 
equal  in  intensity,  if  indeed  it  does  not  predominate  over,  the  hj^per- 
plastic  and  infiltrative  process.  Whether  pyogenic  microbes  lodged  in 
the  skin  or  seated  on  its  external  surface  are  the  morbific  complicating 
agents  we  do  not  know. 

In  like  manner,  later  ulcerations,  rupia,  and  the  serpiginous  syphilides 
sometimes  seem  to  begin  in  microbic  infection,  Avhile  at  others  they  com- 
mence as  essential  syphilitic  new  growths  which  become  attacked  by  pus- 
microbes.     Much  study  is  yet  necessary  to  clear  up  these  obscure  points. 

Absence  of  Itching  and  Pain. — Owing  to  their  indolent  nature  syph- 
ilitic eruptions  do  not,  as  a  rule,  cause  any  irritation  of  the  skin. 

Itching  may  be  present  in  connection  with  an  early  eruption  whose 
evolution  is  particularly  acute.  It  is  never  so  intense  as  in  a  simple 
eruption,  and  is  much  more  ephemeral.  It  is  perhaps  more  troublesome 
with  an  eruption  occurring  on  the  scalp  than  elsewhere,  and  when  com- 
plicating an  early  rash  it  is  generally  limited  to  the  extremities,  the  upper 
more  often  than  the  lower. 

Too  much  reliance  must  not  be  placed  on  the  statement  of  a  patient 
that  an  eruption  itches.  We  must  remember  that  the  irritation  may  be 
caused  by  pediculi  or  by  the  wearing  of  flannel,  and  that  some  persons 
have  an  excessively  irritable  skin. 

Pain  is  even  rarer  than  itching  in  syphilitic  dermal  lesions.  A  few 
instances  have  been  recorded  of  its  occurring  in  connection  with  a 
tubercular  or  a  gummatous  syphilide. 

JPohjmorphism. — The  simultaneous    occurrence  of  several  varieties 


GENERAL   CONSIDERATIONS  ON  SYPHILIDES.  599 

of  lesions  in  the  same  eruption  is  an  important  and  common  feature 
of  syphilis.  It  is  due  to  three  causes :  the  chronic  course  of  syphilides, 
their  relapsing  tendency,  and  the  changes  occurring  in  the  lesions.  A 
similar  feature  may  be  observed  in  some  of  the  simple  eruptions,  as 
eczema,  acne,  and  scabies,  but  in  their  case  the  diversity  evidently  con- 
sists of  modifications  of  the  original  lesion,  while  in  specific  eruptions 
it  is  in  part  due  to  the  development  of  new  forms  of  eruption  before 
the  disappearance  of  preceding  ones.  Polymorphism  is  most  fre- 
quently observed  early  in  the  secondary  stage,  since  eruptions  are 
then  more  numerous ;  yet  it  may  exist  even  with  the  late  tubercular 
eruptions. 

Color  and  Pigmentation. — It  is  important  to  distinguish  the  color  of 
the  syphilides  from  the  pigmentation  which  frequently  follows  them. 
Their  usual  tint  is  pinkish-red,  being  much  more  subdued  than  that  of 
simple  eruptions.  Even  in  exceptional  cases  of  acute  invasion,  in  which 
the  color  may  be  unusually  bright,  it  is  less  intense  than  in  the  simple 
exanthemata.  The  hue  soon  fades  to  a  brownish  one,  which  after  invo- 
lution of  the  eruption  changes  to  a  copper-colored,  yellowish-brown 
maculation.  Pressure  dissipates  the  color  during  the  early  stages  of 
an  eruption,  but  finally  the  pigmentation,  which  has  been  compared  to 
"  the  lean  of  ham,"  to  the  color  of  copper,  and  to  a  combination  of 
yellow  and  brown,  becomes  permanent. 

These  pigmentary  changes  are  not  peculiar  to  syphilis,  being  equally 
well  marked  in  lichen  planus  and  in  cases  of  protracted  dermatitis. 
They  are  probably  due  to  deposit  of  coloring  matter  of  the  blood  in  the 
affected  spots. 

In  persons  whose  circulation  is  feeble  the  color  of  the  pigmentation 
may  be  light  yellow,  and  in  cases  where  the  hypertemia  is  slight  and 
of  short  duration  no  pigmentation  at  all  may  be  induced. 

Syphilis  may  also  produce  a  primary  pigmentation  independently  of 
any  preceding  infiltrating  pathological  process.  This  condition  is  called 
the  pigmentary  syphilide. 

Tendency  to  Assume  a  Circular  Form. — The  early  eruptions  are 
generally  distributed  over  the  surface  without  definite  order,  except  in 
some  instances  in  particular  regions,  where  they  may  be  arranged  in  a 
circular  manner.  This  peculiarity  is  more  commonly  seen  in  the  case 
of  small  papular  rashes  and  in  the  erythematous  syphilide.  The  latter 
often  relapses  in  the  shape  of  distinctly  marked  rings,  differing  from  the 
papular  syphilide,  in  which  the  bases  of  the  papules  generally  merge 
together  and  form  simply  wavy  lines  or  segments  of  circles  or  perhaps 
complete  circles.  In  certain  large  papules  and  in  some  papulo-tubercles 
involution  begins  at  their  centres,  leaving  the  periphery  in  a  ringed 
form.  A  similar  process  may  be  observed  in  psoriasis,  but  in  the  latter 
extension  of  the  patch  may  take  place,  which  is  usually  not  the  case  in 
syphilis.  Ulcers  of  the  later  stages  of  syphilis  may  likewise  exhibit 
this  tendency.  Many  other,  though  less  constant,  features  of  syphilitic 
eruptions  Avill  be  considered  when  describing  individual  lesions. 

Influence  of  Mercury. — By  many  mercury  is  considered  so  infallibly 
curative  of  syphilitic  eruptions  that  it  is  termed  the  "touchstone"  in 
their  diagnosis.  Its  influence  is  certainly  wonderful  in  most  cases, 
especially  in  early  lesions  and  in  those  of  an  infiltrative  character ;  but 


600  SYPHILIS. 

certain  ulcerative  and  chronic  forms,  particularly  those  attended  by 
much  scaliness,  are  often  quite  rebellious. 

In  general,  mercury  is  very  efficient  in  uncomplicated  cases,  but  in 
those  complicated  by  other  morbid  changes,  and  especially  in  those 
which  have   had  a  long  existence,  its  eifect  is  much  less  pronounced. 

The  Influence  of  Intercurrent  Diseases  on  the  Course  of  Si/pMlides. — 
The  course  of  syphilitic  eruptions  is  not  infrequently  interrupted,  or 
even  permanently  arrested,  by  some  acute  disease.  Numerous  instances 
have  been  reported  of  the  disappearance  of  an  eruption  at  the  outset  of 
an  inflammatory  affection  of  the  lungs,  of  acute  articular  rheumatism, 
of  various  adynamic  fevers,  and  of  acute  cerebral  disease.  Jullien 
mentions  the  remarkable  case  of  a  young  man  who  was  vainly  treated 
by  Diday  for  lingual  mucous  patches  and  a  scaling  palmar  syphilide, 
who  was  finally  cured  during  a  general  eruption  of  furuncles. 

Variola  and  varioloid  have  been  known  to  have  a  similar  effect.  It 
was  once  claimed  that  syphilis  could  be  cured  by  vaccination,  but  careful 
trial  of  this  means  has  proved  its  uselessness. 

Our  knowledge  of  the  influence  of  erysipelas  on  the  course  of  syphi- 
litic eruptions  is  derived  chiefly  from  the  French.^  Not  only  superficial 
lesions,  such  as  papules,  mucous  patches,  and  condylomata,  but  deep 
and  diffuse  tubercles  and  even  active  ulcerations,  are  affected ;  not  only 
lesions  within  the  actual  range  of  the  erysipelatous  process,  but  even 
those  at  a  distance,  are  influenced  by  it  in  some  obscure  way,  even  after 
the  failure  of  well-directed  treatment.  When,  however,  the  syphilitic 
diathesis  has  a  malignant  character,  erysipelas  is  likely  to  be  a  fatal 
complication. 

This  healing  action  of  erysipelas  on  syphilitic  neoplasms  is  undoubt- 
edly due  to  the  changes  produced  in  the  tissues  by  the  Loefiler  bacillus 
or  its  toxines.  The  remarkable  action  of  this  microbe  upon  sarcomatous 
new  growths  is  perhaps  in  essence  the  same  as  that  which  it  exerts  in 
syphilis.  This  feature  in  bacterial  life  is  very  significant  and  important, 
and  as  time  goes  on  it  may  perhaps  prove  of  much  benefit  in  the  treat- 
ment of  syphilis. 

That  traumatic  as  well  as  idiopathic  erysipelas  may  have  a  curative 
effect  was  proved  in  a  case  reported  by  Mauriac,  in  which  well-marked 
syphilitic  lesions  were  dissipated  by  an  attack  of  the  disease  which  fol- 
loAved  their  excessive  cauterization.  The  practical  value  of  this  fact  is 
limited  by  our  admitted  inability  to  excite  and  control  an  erysipelatous 
inflammation. 

Intercurrent  diseases  have  no  influence  upon  the  syphilitic  diathesis, 
and  therefore  no  power  to  prevent  relapses. 

Unusual  Modes  of  Uvolution. — The  appearance  of  a  general  erup- 
tion is  looked  upon  as  the  indication  of  constitutional  infection,  but  the 
first  eruption  may  be  limited,  and  a  general  rash  may  not  be  developed 
for  several  weeks.  In  some  cases  only  two  or  three  dermal  lesions  can 
be  found  at  the  usual  date  of  invasion.  Should  the  eruption  be  ery- 
thematous, the  spots  soon  become  coppery,  and  remain  in  a  chronic  con- 
dition ;  if  papular,  the  papules  are  sluggish,  and  usually  leave  a  pigmented 

*  The  most  complete  brochure  on  this  subject  is  that  of  Mauriac  ("Etude  clinique  sur 
I'Influence  curative  de  I'Erysipele  dans  la  Syphilis  ") ;  and  an  important  case  has  been 
reported  by  Deahna  {Vrtljschr.  f.  Dermal.,  vol.  iii.,  1876,  p.  57). 


GENERAL   CONSIDERATIONS  ON  SYPHILIDES.  601 

spot.  In  connection  "with  these  scanty  lesions  the  patient  may  suffer 
from  syphilitic  pains  in  the  head,  in  the  bones,  etc.,  and  perhaps  may 
have  erythema  of  the  fauces  and  high  temperature.  Within  two  to  six 
weeks  the  usual  general  eruption  follows. 

The  Localization  of  tlie  Sypldlides. — Syphilitic  eruptions  are  often 
found  in  regions  where  simple  skin  lesions  are  seldom  or  never  developed. 

Secondary  eruptions  appear  on  the  scalp,  and  especially  at  its  margin 
on  the  forehead,  at  the  angles  of  the  mouth,  on  the  alne  of  the  nose,  about 
the  anus  and  upon  the  genitals,  near  the  umbilicus,  in  the  inguinal  fold, 
between  the  toes,  and  upon  the  palms  and  soles.  The  supra-  and  infra- 
clavicular and  sternal  regions,  where  simple  and  parasitic  eruptions  are 
often  found,  are  rarely  the  seat  of  specific  exanthems,  and  on  the  dorsum 
of  the  hands  the  latter  are  not  often  seen.  Regions  rich  in  sebaceous 
and  hair  follicles  are,  as  a  rule,  less  frequently  invaded  by  simple  than 
by  specific  eruptions.  The  annular  forms  of  simple  erythema  may  occur 
on  any  part  of  the  body,  while  these  forms  of  the  erythematous  and  the 
papular  syphilides  are  more  likely  to  be  limited  to  the  neighborhood  of 
joints,  the  anterior  and  inner  surfaces  of  the  extremities,  and  the  gluteal 
regions. 

The  papular  syphilides  are  prone  to  be  developed  on  the  palms  and 
soles. 

Later  eruptions  are  generally  seated  upon  the  nose,  the  lips,  and  the 
scalp  ;  they  are  found  upon  the  scapular,  sternal,  and  gluteal  regions,  and 
more  often  on  the  legs,  near  the  joints,  than  on  the  thighs. 

The  early  eruptions,  especially  the  papular  syphilides,  are  very  likely 
to  form  a  segment  of  a  circle  at  the  border  of  the  scalp,  which  has  been 
called  the  '■'■corona  veneris."  It  is  a  mistake  to  suppose  that  the  papular 
eruption  is  the  only  one  which  may  be  developed  in  this  way,  since  most 
secondary,  and  even  tertiary,  syphilides  seem  prone  to  develop  here. 

Characters  of  the  Scales  and  Crusts  of  the  Syphilides. — The  scales 
of  specific  eruptions  are  thinner,  less  numerous,  and,  as  a  rule,  less 
glistening  than  those  of  simple  eruptions,  and  they  are  very  rarely 
imbricated.  They  may  consist  of  epidermis  only,  when  they  have  a 
dull-white  color,  or  they  may  be  formed  chiefly  of  serum,  when  they  are 
yellowish  or  brownish.  The  scales  are  never  removed  in  large  patches, 
as  in  psoriasis,  since  the  inflammation  is  of  such  a  low  grade  that  exfo- 
liation is  slow  and  scanty. 

The  crusts  of  syphilitic  pustules  and  ulcers  are  also  peculiar.  Those 
of  small  pustules  soon  dry,  and  are  seated  upon  an  indurated  base ; 
those  of  impetigo  and  eczema  are  placed  in  a  slight  depression  of  the 
inflamed  skin.  The  crusts  of  larger  pustules  are  dark-brown  or  green- 
ish-black, differing  from  those  of  ecthyma  and  scabies,  which  are  yellow- 
ish-brown. If  elevated,  the  syphilitic  crust  is  seated  upon  a  deep  ulcer 
with  brownish-red  infiltrated  base  and  margins;  in  a  simple  eruption 
the  ulcer  is  more  superficial,  its  base  is  inflamed,  and  it  has  reddish, 
violaceous  borders. 

The  crusts  of  rupia  have  no  analogue  in  dermatology.  They  are  of 
a  brownish-black  color,  are  conical  and  distinctly  laminated,  and  they 
rest  upon  a  surface  which  is  bathed  in  viscid  pus,  or,  as  Zeissl  puts  it, 
"they  swim  upon  and  are  kept  afloat  by  pus."  Their  shape  and  struc- 
ture are  due  in  a  measure  to  their  slow  formation. 


602  SYPHILIS. 

The  crusts  of  late  syphilitic  ulcers  have  a  brownish-black  color  and 
a  rough,  uneven  surface,  and  resemble  a  dirty  oyster-shell ;  the  crusts 
of  lupus  are  of  a  bluish-brown  mixed  with  yellow. 

Peculiarities  of  Ulcers  and  Cicatrices. — Syphilitic  ulcers  may  be 
round,  oval,  kidney-shaped,  or  of  the  form  of  a  horseshoe.  The  ulcers 
of  lupus  frequently  assume  similar  forms,  but  the  lesions  of  syphilis  are 
generally  more  numerous,  more  extensively  distributed,  and  more  poly- 
morphous than  those  of  lupus.  The  character  of  the  crusts,  the  rapid 
progress  and  regular  margins  of  the  ulcer,  and  its  proximity  to  a  joint, 
the  general  history  of  the  case,  and  its  amenability  to  treatment,  distin- 
guish a  syphilitic  lesion.  The  margins  of  a  lupoid  ulcer  are  everted, 
softer  and  more  violaceous,  and  are  frequently  studded  with  reddish-blue 
tubercles, while  the  surrounding  tissues  are  much  swollen.  The  cicatrices 
of  syphilitic  ulcers,  especially  where  they  have  been  numerous,  are  often 
diagnostic.  They  are  distinctly  rounded  or  oval,  quite  smooth,  and 
seldom  traversed  by  fibrous  bands  except  at  the  joints ;  they  are  fre- 
quently perforated  Avith  minute  holes,  the  sites  of  former  follicles,  when 
they  are  more  or  less  depressed,  and  when  mature  are  quite  pliable. 
Their  brownish-red  color  slowly  fades  from  the  centre  to  the  periphery, 
until  there  remains  a  white  shining  surface  surrounded  by  a  narrow 
areola  of  brown  pigment.  A  lupoid  scar,  on  the  contrary,  is  generally 
irregular  in  outline ;  its  surface,  which  is  not  always  depressed,  but  may 
be  on  a  level  with  the  general  surface,  or  even  elevated  by  the  subjacent 
thickening,  is  very  uneven  and  is  crossed  by  numerous  fibrous  bands ; 
it  has  not  a  shining  appearance  and  its  areola  is  bluish-red.  Finally, 
false  keloid  is  more  frequent  upon  lupoid  than  upon  syphilitic  cicatrices. 

The  cicatrices  which  sometimes  follow  papular  syphilides  are  small, 
more  or  less  aggregated,  and  at  first  pigmented..  They  are  recognized 
by  the  situation  and  grouping  of  the  scars,  the  coexistence  of  other 
lesions  or  their  sequelse,  and  by  the  history  of  the  case. 

The  Odor  of  Certain  Syphilitic  Lesions. — Some  observers  claim  that 
syphilis  always  gives  rise  to  a  distinctive  odor.  There  is  no  doubt  that 
the  discharges  from  certain  lesions  possess  an  oifensive  and  somewhat 
peculiar  smell.  Mucous  tubercles,  when  seated  upon  the  genitals  or  in 
folds  of  integument,  yield  a  secretion,  often  combined  with  that  or 
sebaceous  and  sweat  follicles,  which  has  a  sickening,  penetrating  odor 
certainly  never  perceived  in  other  lesions.  The  odor  in  some  cases  of 
extensive  gummatous  and  tubercular  ulcerations,  where  the  secretion  is 
abundant  and   the   patient  uncleanly,  is  heavy  and  nauseating. 

G-eneral  Hints  in  Diagnosis. — In  the  diagnosis  of  syphilides  the 
foregoing  features  collectively  are  of  the  greatest  value.  In  every  case 
the  whole  eruption  should  be  reviewed ;  its  extent,  copiousness,  con- 
figui'ation,  and  general  appearance  should  be  carefully  noted ;  its  mode  of 
invasion,  its  concomitant  symptoms,  and  its  course  should  be  determined 
by  careful  questioning  and  observation.  With  regard  to  the  eruption 
itself,  we  must  observe  whether  it  is  composed  of  one  variety  or  of  several 
forms  of  lesion,  and,  if  the  latter,  which  predominates.  For  instance,  in 
a  roseolous  eruption  we  judge  of  its  extent,  its  tendency  to  development 
in  certain  localities,  its  configuration,  whether  the  spots  are  isolated  or 
grouped  in  rings  ;  then  we  consider  whether  the  spots  themselves  are 
in  their  early  hypersemic  stage,  or  whether  they  have   become   pigmented 


GENERAL   CONSIDERATIONS  ON  SYPHILIDES.  603 

or  perhaps  slightly  papular  and  scaly.  By  comparing  the  number  of 
erythematous  and  of  pigmented  spots  we  assure  ourselves  of  the  age  of 
the  rash  and  whether  its  course  has  been  rapid  or  chronic.  We  must 
also  learn  the  general  condition  of  the  patient  and  whether  other  tissues 
have  been  affected. 

In  case  papules,  pustules,  and  scaling  patches  are  associated  with  ery- 
thematous spots,  we  must  decide  which  lesion  predominates,  and  whether 
they  are  not  mere  phases  of  development  of  the  same  process.  We 
may  perhaps  learn  that  the  red  spots  become  pigmented  and  slightly 
papular  where  here  and  there  are  papules  which  change  into  pustules, 
vesicles,  ulcers,  or  scaling  spots.  We  observe  whether  the  lesions  have  a 
tendency  to  unite  and  form  patches.  In  this  feature  syphilis  is  peculiar, 
differing  radically  from  most  of  the  simple  eruptions. 

In  case  of  several  varieties  of  lesions  which  may  undergo  various 
changes,  each  one  runs  its  course  quite  distinct  from  the  other.  This  is 
quite  different  from  what  happens  in  simple  polymorphous  eruptions. 
We  may  have  simple  erythematous  patches,  papules,  and  pustules  asso- 
ciated, but  they  are  related  to  each  other  in  the  development  of  one 
inflammatory  process,  and  they  have  a  tendency  to  blend  and  form  a 
homogeneous  eruption,  as  in  eczema  and  scabies.  In  some  cases  of 
acne  papules  and  pustules  are  scattered  together,  yet  a  bond  of  union 
is  always  found  to  exist  between  them  in  their  inflammatory  follicu- 
lar origin,  while  they  have  other  features  which  differ  from  those  known 
to  be  peculiar  to  syphilis. 

Zoster  and  Zosteriform  Eruptions  in  the  Course  of  Syphilis. 

The  exact  relation  of  herpes  zoster  to  syphilitic  infection  is  a  question 
yet  to  be  settled,  though  several  authors  entertain  the  opinion  that  the  der- 
mal nervous  disturbance  may  in  some  cases  be  etiologically  associated  with 
the  general  infectious  process.  Trapeznikoff  ^  reports  the  case  of  a  young 
man  having  a  chancre  and  roseola  who  was  attacked  with  severe  pain  in 
the  left  temporal  and  frontal  regions  and  marked  fever,  which  were  fol- 
lowed by  a  typical  zosterian  eruption  which  was  seated  on  the  left  side  of 
the  neck,  on  the  ear,  the  tongue,  and  the  left  eyelid.  As  a  result  of 
mercurial  treatment  this  nervous  affection  was  much  improved  in  six 
days;  then  on  leaving  off  the  medicine  all  the  severe  symptoms  returned. 
Mixed  treatment  was  then  administered  and  the  eruption  was  cured. 
Trapeznikoff  believes  that  the  syphilitic  infection  was  the  underlying 
cause  of  this  nervous  outbreak. 

Jullien  ^  also  reports  a  very  interesting  case.  It  Avas  that  of  a  young 
syphilitic  v/oman  who  for  five  days  suffered  severe  pain  in  the  left  chest. 
This  Avas  followed  by  a  red  linear,  slightly  elevated  eruption,  without 
vesicles,  which  looked  like  zoster  and  ran  down  the  arm  and  on  the  side 
of  the  chest,  and  ended  in  the  median  line.  Jullien  is  disposed  to  look 
upon  this  eruption  as  an  evidence  of  the  syphilitic  infection.  In  the  dis- 
cussion of  Jullien's  case  Besnier  and  Fournier  make  the  diagnosis  zona 
fruste  chez  un  svjct  si/jyhilitique. 

^  Medicina,  Nos.  21  and  22,  1894. 

*"  Eruption  zosteriforme  dans  le  Cours  de  la  Syphilis,"  Annales  de  Derm,  el  de  Syph., 
1894,  pp.  1254  et  seq. 


604  SYPHILIS. 

A  similar  case  to  Jullien's  is  reported  by  Gaucher  and  BarbeJ  It  was 
that  of  a  young  woman  who  had  a  linear  papular  eruption  following  severe 
neuralgic  symptoms  of  the  last  left  intercostal  nerve.  This  eruption  was 
followed,  under  similar  circumstances,  a  year  later  by  an  eruption  on  the 
right  side  involving  the  nerves  of  the  lumbo-abdominal  plexus.  This 
subject  is  worthy  of  careful  study,  and  until  more  light  has  been  thrown 
upon  it  it  is  not  well  to  indiscriminately  pronounce  all  cases  of  zona  occur- 
ring in  syphilitics  to  be  due  to  specific  infection. 


CHAPTER    LXI. 

THE  EARLY  OR  SECONDARY  SYPHILIDES. 

The   Erythematous   Syphilide. 

Syn. — Syphilitic  roseola.  Macular  syphilide,  Exanthematous  sypn- 
ilide,  Syphilis  cutanea  maculosa. 

The  erythematous  syphilide  is  usually  the  earliest  syphilitic  eruption. 
It  probably  exists  in  all  cases  of  syphilis,  but  may  escape  observation  on 
account  of  the  extreme  faintness  and  delicacy  of  its  pink  spots,  or  its 
scantiness,  or  -  by  reason  of  its  forming  only  a  part  of  an  eruption  which 
is  chiefly  papular  or  pustular. 

The  lesion  consists  of  round  or  oval  spots,  with  distinct  or  irregular 
outlines  of  an  average  diameter  of  about  one-half  of  an  inch.  Their 
color  varies  from  a  delicate  rosy  pink  to  a  decided  red  or  even  a  purple 
hue.  In  some  cases  there  may  be  only  a  mottling  of  the  skin,  or  the 
eruption  may  be  so  faint  as  to  be  invisible  except  on  careful  inspection  or 
in  an  oblique  light.  Exposure  to  cold  brings  the  spots  into  prominence, 
while  they  disappear  in  the  general  hypergemia  of  the  surface  from  in- 
crease of  temperature,  and  show  themselves  more  clearly  in  the  reaction 
which  follows.  At  first  the  spots  may  be  effaced  by  pressure,  but  about 
the  end  of  the  first  month  they  may  assume  a  grayish-brown  or  coppery 
tint  which  is  permanent.  This  tint  appears  earlier  in  exposed  regions 
and  on  the  legs,  perhaps  owing  to  peculiar  conditions  of  the  circulation. 
Sometimes  the  eruption  disappears  without  this  change  of  color.  There 
is  seldom  either  elevation  or  scaling  of  the  surfaces  of  the  spots. 

The  erythematous  syphilide  requires  a  week  or  ten  days  for  its  com- 
plete development,  but  individual  patches  reach  their  full  size  in  a  day  or 
two,  and  show  no  tendency  to  coalesce  or  to  form  circles.  In  rare  cases 
of  great  intensity,  or  from  any  cause  Avhich  stimulates  the  capillary  circu- 
lation, the  whole  body  may  be  invaded  by  the  eruption  in  a  single  day. 

The  spots  may  be  first  seen  in  the  vicinity  of  the  umbilicus,  soon 
extending  to  the  thorax,  sometimes  following  the  line  of  the  ribs,  and 
finally,  in  severe  cases,  being  closely  crowded  together  over  a  large  por- 

^  "  Syphilide  papulosquameuse  zoniforme  du  Thorax,"  Annales  de  Derm,  et  de  Syph., 
1894,  pp.  535  et  seq. 


THE  EARLY  OR  SECONDARY  SYPHILIDES. 


605 


tion  of  the  surface.  In  exceptional  cases  they  appear  first  on  the  face. 
In  mild  eruptions  the  spots  are  most  numerous  on  the  sides  of  the  trunk 
and  on  the  inner  surfaces  of  the  extremities.  On  the  genitals  of  either 
sex  the  macules  are  prone  to  hypertrophy,  and  hence  "\ve  frequently  see 
condylomata  lata  coexisting  with  roseolous  patches  in  these  regions. 
Similar  changes  are  noticed  about  the  anus,  the  umbilicus,  the  nose,  and 
the  mouth,  and  in  the  fold  of  integument  below  the  breasts.  A  limited 
number  of  patches  may  be  found  on  the  palms  and  soles  which  may  be 
diffuse  or  slightly  elevated  and  scaly.  The  dorsal  surfaces  of  the  hands 
and  feet  are  rarely  invaded.  But  it  is  very  common  to  see  a  well- 
marked,  even  intense,  eruption  on  the  palms  of  the  hands  and  the  soles 
of  the  feet.  The  spots  are  of  irregular  roundish  outline  of  deep-red, 
even  purplish,  color,  and  are  also  found  scattered  on  the  fingers.  In 
many  cases  little  masses  of  epithelium,  somewhat  salient  also,  but 
deeply  imbedded  in  the  superficies  of  the  skin,  are  seen  scattered  over 
the  palm  and  the  fingers,  particularly  near  the  natural  furrows.  This 
whole  condition  is  admirably  shown  in  Fig.  197.  A  common  region 
is  the  lower  two-thirds  of  the  forearms  and  the  wrists.  The  neck  is 
frequently  exempt,  or  an  eruption  on  the  trunk  may  extend  by  occa- 
sional spots  along  the  back  of  the  neck  to  the  scalp. 

Fig.  197. 


The  erythematous  syphilide  of  the  palm,  with  epithelial  hyperplusiae. 

When  the  face  is  invaded  the  macules  are  developed  more  freely  about 
the  nose,  mouth,  and  chin,  and  especially  on  the  forehead  at  tlie  border 
of  the  scalp,  where  they  are  often  associated  witli  minute  follicular  eleva- 
tions, Avhich  become  crested  with  sebum  and  may  be  mistaken  for  pustules. 
Many  of  the  so-called  "scabs"  on  the  scalp  have  this  origin.  These 
patches  at  the  margin  of  the  scalp  are  often  very  irregular  and  confluent. 


606  SYPHILIS. 

This  eruption  on  any  part  of  the  face  is  usually  covered  by  fine  adherent 
scales  of  epidermis  or  by  thin  yellowish-white  crusts,  which  give  it  a 
smooth,  shiny  appearance. 

The  pale-rose  or  pinkish  eruption,  which  so  often  escapes  detection,  is 
usually  of  ephemeral  duration.  The  spots  rarely  become  elevated,  and 
more  rarely  the  seat  of  scaling,  and  they  disappear  as  they  appeared,  sud- 
denly and  quickly.  It  is  not  uncommon  to  see  this  eruption  in  its  sub- 
dued form  coexist  with  Avell-defined  erythematous  spots  on  the  face,  fore- 
head, and  the  flexor  surfaces  of  the  arms.  While,  in  general,  the 
concomitant  systemic  disturbance  is  mild,  very  often  it  is  severe  with 
this  rash. 

The  second  or  more  hypersemic  form  of  the  erythematous  syphilide 
usually  appears  by  prompt  and  comparatively  rapid  invasion,  and  is  often 
accompanied  by  marked  elevation  of  temperature,  malaise,  rheumatoid 
pains,  and  neuralgias.  The  eruption  begins  as  pinkish  or  rosy  spots, 
which  quite  rapidly  become  darker  until  a  rather  deep  pinkish  red  is 
observed.  The  irregularly  and  generally  distributed  spots  are  at  first  of  a 
grayish  red,  which  soon  assumes  the  purplish  tint.  Very  often  with  this 
deepening  of  color  punct^e  of  even  deeper  hue  appear  at  the  orifices  of 
follicles.  Again,  at  these  follicular  openings  circumscribed  cell-increase 
occurs,  forming  very  minute  papules,  which  has  given  to  the  eruption  the 
name  roseola  piquette  or  granular  roseola.  In  some  cases,  usually  in  only 
a  certain  number  of  spots,  there  is,  besides  the  hyper?emia,  moderate  cell- 
increase  into  the  papillae,  producing  a  slight  salience  of  the  lesions — a 
condition  called  roseole  jjajmleuse  and  roseola  urticata. 

In  this  variety  there  is  no  elevation  of  surface,  the  spots  are  sharply 
marginated,  and  very  soon  become  covered  with  minute  scales. 

This  form  of  the  erythematous  syphilide  is  peculiar  for  its  chronicity, 
since  the  purplish  spots  remain  unchanged  for  weeks,  and  perhaps  as  long 
as  three  months.  Then  they  gradually  become  grayish  brown,  then  cop- 
pery, and  finally  a  yellowish  buff,  when  they  disappear,  the  process  of 
involution  sometimes  occupying  several  months.  ]More  or  less  desquama- 
tion is  often  observed  in  this  syphilide  from  its  period  of  development  to 
its  decline. 

The  faint  and  dark  forms  of  this  eruption  may  consist  of  numerous 
closely-packed  and  generously-distributed  spots  or  a  more  or  less  sparse 
eruption.  In  some  cases,  particularly  of  the  dark  spots,  coalescence  into 
patches  of  a  number  is  seen,  chiefly  about  the  joints  or  on  parts  subjected 
to  pressure  and  irritation. 

There  is  a  third  form  of  the  erythematous  syphilide,  not  at  all  uncom- 
mon, but  which  has  not  been  clearly  described.  It  consists  of  small  well- 
marked,  subdued-red  spots,  having  a  blotchy  or  irregular  outline,  often- 
times gradually  lost  in  the  surrounding  skin,-  and  averaging  from  two  to 
four  lines  in  diameter.  These  spots,  besides  being  readily  seen,  are  as 
easily  felt  as  very  minute  little  rough  prominences  of  the  skin.  The 
lesion  is,  though  elevated,  not  at  all  papular,  and  close  inspection  shows 
that  its  salience  is  due  to  the  marked  localized  hypera?mia,  particularly 
around  the  follicles.  This  eruption  has  an  individuality  of  its  own,  is 
wholly  diff"erent  from  the  roseole  papuleuse  of  the  French,  comes  out  with 
tolerable  promptness,  and  is  seen  in  its  most  characteristic  form  on  the 
anterior  aspect  of  the  trunk,  less  so  on  the  back,  limbs,  and  face,  where 


PLATE  V. 


ANNULAR    FORM    OF   THE    ROSEOLOUS   SYPHILIDE. 


THE  EARLY  OB  SECONDARY  SYPHILIDES.  607 

its  so-called  elevation  is  less  marked.  It  is  blotchy,  persistent  in  its 
course,  becomes  scaly  quite  early,  and  on  its  decline  subsides  into  small 
pigmented  spots.  While  we  know  nothing  of  its  histology,  its  clinical 
appearances  impress  one  with  the  idea  that  the  focus  of  hypersemia  is  the 
sebaceous  follicles,  and  that  the  circumambient  erythema  results  from 
that. 

In  their  course  these  three  clinical  forms  of  the  erythematous  syphilide 
present  considerable  variation. 

Annular  or  Circinate  Eruption. 

In  relapses  of  the  erythematous  syphilide  during  the  first  year  of 
infection  the  eruption  sometimes  appears  in  the  form  of  perfect  or  broken 
rings.  This  annular  or  circinate  eruption  is  usually  limited  as  to  the 
number  of  the  efflorescences,  and  is  generally  localized  in  certain  regions. 
The  rings  may  be  quite  broad  or  very  thin,  and  they  may  be  merely  ery- 
thematous, or  they  may  be  slightly  elevated  and  moderately  scaly.  Some- 
times several  rings  or  parts  of  rings  are  seen  enclosed  within  a  larger  ring. 
In  some  cases  this  enclosure  of  rings  within  rings  is  strikingly  perfect  in 
appearance.  The  neck,  the  forearm,  the  shoulders,  and  the  chest  and  the 
thighs  are  the  most  constant  sites  of  the  annular  roseolous  syphilide.  There 
may  be  as  many  as  fifty  and  as  few  as  three  or  four  rings.  In  some  cases 
this  eruption  shows  a  marked  tendency  to  relapse,  particularly  within  the 
first  two  years  of  infection.  In  very  exceptional  cases  this  form  of  erup- 
tion appears  as  late  as  the  third,  fourth,  or  fifth  year  of  syphilis.  In 
some  cases  the  rings  look  like  deep-seated,  very  dull-red  mottlings  of  the 
skin,  particularly  where  it  is  thin  and  fine.  In  many  instances  patients 
complain  that  they  have  these  so-called  ringworms  for  months  and  years. 
These  ringed  eruptions,  as  a  rule,  show  no  tendency  to  peripheral  increase. 

Cases  of  syphilis  in  which  this  affection  appears  at  late  dates  are  some- 
times very  rebellious  to  treatment. 

About  the  face,  arms,  palms,  the  soles  of  the  feet,  and  the  inner  aspect 
of  the  forearms  relapses  of  the  erythematous  syphilide  are  developed 
in  the  form  of  round  or  oval  or  gyrate  patches,  which  show  a  tendency  to 
increase  in  size  at  their  margins.  The  patches  are  of  a  deep  pink  or  red, 
and  sometimes  they  have  a  salmon  tint.  At  their  margins  there  is  very 
commonly  a  scaly,  somewhat  elevated  border,  and  from  this  surface  minute 
scales  may  be  shed.  The  annular  form  of  the  erythematous  syphilide  is 
well  shown  in  Plate  V.,  in  which  a  seborrhoeic  feature  may  be  observed. 
With  this  syphilide,  when  it  appears  on  the  head,  there  is  usually  a  con- 
comitant alopecia. 

The  Symbiosis  of  Syphilis  and  the  Seborrhoeic  Process. 

In  some  cases  of  erythematous  syphilide  of  the  face,  neck,  and  upper 
part  of  the  trunk  there  seems  to  be  an  interlocking  or  symbiosis  of  this 
specific  process  with  the  seborrhoeic  process,  which  is  caused  by  some 
micro-organism.  The  syphilitic  eruption  seems  to  follow  the  evolution 
and  development  of  the  seborrhoeic  process.  The  erythematous  spots 
become  slightly  elevated  and  decidedly  scaly,  the  scales  having  the  dirty, 
somewhat  greasy  appearance  of  those  of  the  simpler  process.     The  redness 


608  SYPHILIS. 

is  dull  and  of  the  salmon  tint.  The  clinical  picture  of  the  symbiosis  is 
well  shown  in  Fig.  198,  in  which  scaly  spots  and  patches  are  seen  on  the 
forehead,  ala  nasi,  around  the  mouth,  and  on  the  chin  and  neck.  This 
is  a  good  example  of  what  Unna  terms  the  seborrhoeic  facies.^ 

Fig.  198. 


Erythematous  syphilide  complicated  by  the  seborrhoeic  process. 

In  exceedingly  mild  forms  of  this  syphilide  there  is  probably  no  other 
change  than  temporary  capillary  stasis,  and  occasionally,  in  debilitated 
subjects,  hemorrhagic  effusion.  In  chronic  cases  a  proliferation  of  cells 
occurs,  which  is  described  by  Biesiadecki  as  follows :  "  AVe  find  the  walls 
of  the  capillaries  studded  at  this  point  with  numerous  nuclei,  projecting 
on  their  inner  and  outer  surfaces,  and  surrounded  by  a  row  of  cells  here 

^  The  reader  is  referred  for  further  information  to  Unna's  paper,  "Syphilis  and 
Eczema  Seborrhoicuni,"  British  Journal  of  Dennntolofiy,  Nov.  and  Dec.,  1888,  and  to  one 
by  me,  entitled  "The  Seborrhoeic  Process  and  the  Early  Syphilitic  Eruptions,"  Journal 
of  Cutaneous  and  Gen.-urin.  Diseases,  May,  1890. 


THE  EARLY  OR  SECONDARY  SYPHILWES.  609 

and  there  interrupted.  These  cells  exactly  resemble  in  size  and  structure 
white  blood-corpuscles  or  the  cells  of  dermatitis.  They  are  situated 
around  the  vessels  in  a  clearly  bounded  space.  The  adventitia  of  the 
vessels  in  the  region  of  the  macule  encloses  round  and  spindle-shaped 
cells.  This  exuberance  of  cells  is  most  marked  in  the  adventitia  of 
vessels  running  toward  the  papillae  ;  their  calibre  is  contracted,  while  that 
of  the  capillaries  in  the  papillse  is  somewhat  dilated.  Neither  the  cells 
nor  the  fibres  of  connective  tissue  show  any  appreciable  change ;  only 
here  and  there  granules  of  brownish-yellow  pigment  are  interspersed. 
The  syphilitic  macule  must  therefore  be  regarded  as  a  disease  of  the 
blood-vessels,  as  shown  by  the  increase  of  their  granular  and  cellular 
elements."  Further  microscopic  observations  have  been  made  by  Kaposi, 
who  confirmed  the  occurrence  of  cell-changes  in  the  capillary  walls,  and 
also  observed  cell-infiltration  of  the  papillae.  It  is  quite  probable  that 
these  combined  changes  occur  in  erythematous  spots,  which  are  more  or 
less  papular. 

In  very  chronic  eruptions  several  minute  specks  of  darker  tint  appear 
on  the  surface  of  some  of  the  roseolous  patches,  indicating  a  more  intense 
hypersemia  at  follicular  openings.  They  are  usually  a  little  above  the 
level  of  the  patch,  and  are  frequently  traversed  by  a  hair,  and  their  pig- 
mentation is  generally  more  persistent  than  that  of  the  surrounding  patch. 

The  course  of  the  erythematous  syphilide  is  slow,  and  except  in  cases 
of  active  invasion  it  is  not  attended  by  special  irritation  or  heat  of  the 
skin. 

Its  duration  depends  on  the  degree  of  the  hyperaemia  and  on  treatment. 
A  faint  rash  often  disappears  spontaneously,  even  within  a  week,  under 
the  use  of  mercury.  After  pigmentation  has  taken  place  internal  treat- 
ment needs  to  be  supplemented  by  the  external  use  of  mercury  in  oint- 
ment, lotion,  or,  still  better,  the  vapor  bath. 

A  relapse  of  this  syphilide  may  occur  during  the  first  year  of  conta- 
gion, and  is  generally  less  copious  than  the  primary  eruption.  The  macules 
are  more  localized,  and  are  likely  to  assume  the  circular  form,  which  is 
never  seen  in  the  initial  eruption,  and  they  are  attended  by  less  febrile 
reaction.  In  certain  cases  as  many  as  three  and  four  recurrences  have 
been  observed,  the  forearms  and  gluteal  regions  being  the  parts  most  often 
afi"ected. 

Coexisting  Lesions  and  Symptoms. — On  account  of  its  early  appear- 
ance the  erythematous  syphilide  is  often  associated  with  many  other  lesions, 
one  of  which  is  the  fully-developed  initial  lesion.  Indurated  ganglia  may 
also  be  found,  and  hyperaemia  or  mucous  patches  of  the  fauces.  Where 
two  surfaces  of  integument  are  in  contact,  the  confluence  of  erythematous 
spots  may  form  large  inflamed  patches,  sometimes  mistaken  for  intertrigo. 

They  have  sharply  circumscribed  margins  and  superficially  ulcerated 
surfaces,  which  secrete  a  viscid  off'ensive  fluid.  They  are  often  accom- 
panied by  papules  about  the  hair-follicles,  or  even  by  pustules  and  condy- 
lomata lata.  Alopecia  and  aff'ections  of  the  nails  sometimes  occur  at  this 
period.  Slight  periostitis  and,  in  bad  cases,  osseous  affections  may  be  pres- 
ent. Superficial  scaling  of  the  palms  or  even  of  the  soles  may  be  observed. 
Iritis  is  rarer  than  in  a  general  papular  eruption.  In  a  person  with  a 
long  prepuce  and  of  uncleanly  habits  patches  of  erythema  on  the  mucous 
membrane  of  the  glans  may  result  in  quite  destructive  ulceration. 

39 


610  SYPHILIS. 

Diagnosis. — The  diagnosis  of  the  erythematous  syphilide  is  to  be  made 
in  its  form  of  hypersemic  patches,  in  its  pigmented  condition,  and  in  its 
ringed  form. 

In  its  hypersemic  stage  it  may  be  mistaken  for  rubeola,  scarlatina,  or 
the  erythema  following  the  ingestion  of  balsams  or  the  use  of  mercury. 

The  mode  of  invasion,  the  absence  of  severe  general  symptoms,  and 
the  circumscribed  and  indolent  character  of  the  rash  will  usually  enable 
us  to  distinguish  it  from  rubeola  and  scarlatina ;  moreover,  the  presence 
of  catarrhal  and  conjunctival  symptoms  in  the  former,  and  of  gastric  and 
throat  symptoms  in  the  latter,  will  be  of  assistance. 

The  rash  caused  by  cubebs,  copaiba,  tar,  etc.  is  always  attended  by 
high  fever  and  serious  gastric  disturbance,  and  the  patches  are  many  of 
them  very  large  and  oedematous  or  like  the  wheals  of  urticaria.  It  soon 
fades  on  cessation  of  the  exciting  cause. 

An  eruption  may  be  caused  by  either  the  internal  or  external  use  of 
mercury.  It  appears  suddenly  in  the  form  of  very  large  hypersemic 
patches  of  a  bright-red  color,  which  soon  become  dull  and  quickly  fade, 
leaving  no  trace.    It  is  not  infrequently  mistaken  for  a  relapsing  eruption. 

One  of  the  most  frequent  errors  in  the  diagnosis  of  syphilitic  eruptions 
is  that  of  confounding  the  pigmentary  stains  of  the  erythematous  syph- 
ilide with  tinea  versicolor.  They  somewhat  resemble  each  other  in  color, 
but  that  of  tinea  is  more  yellow,  and  many  of  its  patches  are  very  large, 
and  they  are  always  accompanied  by  some  extremely  small  ones.  Tinea 
is,  moreover,  slightly  pruritic,  and  its  scales  contain  the  mierosporon  fur- 
fur. The  patches  of  tinea  are  always  found  over  the  sternum,  where 
syphilitic  eruptions  are  rare,  and  they  are  much  less  scattered  than  those 
of  the  syphilide. 

In  rare  instances  of  slight  elevation  and  scaliness  the  rings  of  the 
erythematous  syphilide  may  be  mistaken  for  tinea  circinata,  particularly 
when  this  eruption  is  of  a  pink  or  red  color.  The  scales  of  tinea  circinata 
always  contain  the  parasite  tricophyton  tonsurans. 

Pityriasis  maculata  and  circinata  are  sometimes  mistaken  for  the  ery- 
thematous syphilide.  In  the  simple  eruption  the  patches  are  of  a  de- 
cidedly more  inflammatory  nature.  There  is  no  history  of  syphilis ;  the 
ganglia  are  unaffected,  and  there  are  not  present  on  the  skin,  mucous 
membrane,  or  scalp,  as  there  commonly  is  with  the  erythematous  syph- 
ilide, concomitant  lesions  whose  nature  is  readily  perceptible.  I  have 
seen  cases  of  the  simple  eruption  which  required  much  study  to  deter- 
mine the  fact  that  it  was  not  due  to  syphilis.  The  syphilitic  rings  are 
much  more  numerous,  do  not,  as  a  rule,  increase  in  size,  and  the  area  of 
enclosed  skin  is  usually  unaltered. 

The  Papular  Syphilides. 

These  most  important  dermal  lesions  of  syphilis  are  composed  of  cir- 
cumscribed infiltrations  into  the  superficial  layers  of  the  skin,  and  present 
two  varieties — the  conical  ov  miliary  and  the  lenticular  or  flat. 

They  may  constitute  the  first  symptom  of  the  secondary  stage,  or  they 
may  be  combined  with  the  erythematous  syphilide.  In  relapses  they  fre- 
quently occur  alone,  or  are  by  far  the  larger  proportion  of  a  recurring 
eruption.     They  may  be  seen  even  in  the  tertiary  stage,  and  they  merge 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  611 

into  the  tubercular  syphilide  by  intermediate  grades  of  papulo-tubercles. 
Some  of  these  intermediary  papules  are  attended  by  an  epidermal  prolif- 
eration, and  have  therefore  sometimes  been  erroneously  called  "  squam- 
ous syphilides."  The  various  changes  of  form  and  distribution  which  the 
papules  undergo  sometimes  give  them  a  strong  resemblance  to  simple  skin 
lesions. 

The  Miliary  Papular  Syphilide. — The  miliary  papular  syphilide 
has  two  distinct  varieties,  one  composed  of  large  and  the  other  of  small 
papules. 

Some  of  the  small  papules  are  about  the  size  of  a  pin's  head,  while 
others  are  two  or  three  times  as  large.  They  consist  of  distinctly  limited, 
conical  or  rounded  elevations  of  the  skin,  sometimes  umbilicated,  and  in 
their  early  stages  they  have  a  deep  pinkish-red  color.  When  forming 
the  first  eruption  of  the  secondary  period  or  an  early  relapse  they  are  dis- 
tributed over  the  whole  body,  sometimes  closely  packed  together,  and 
particularly  copious  on  the  forehead,  about  the  nose  and  chin,  on  the 

Fig. 199. 


The  small  miliary  papular  syphilide  of  the  face. 

back  of  the  neck,  on  the  outer  surfaces  of  the  extremities,  and  upon  the 
scapular  and  gluteal  regions.  The  papules  may  be  arranged  in  groups 
in  the  form  of  circles  or  segments  of  circles,  or  like  the  letter  S  or  the 
figure  8.  Sometimes  the  papules,  composing  rings  which  may  have  a 
diameter  of  half  an  inch  or  two  inches,  fuse  together  and  lose  their  indi- 
vidual shape.  The  circular  form  is  assumed  only  in  the  regions  referred 
to,  while  elsewhere  papules  may  be  seated  without  definite  order. 


612  SYPHILIS. 

In  a  general  eruption  papules  may  be  seen  on  the  backs  of  the  hands 
and  upon  the  scrotum  and  penis,  where  they  usually  become  excoriated 
and  are  transformed  into  condylomata.  Unlike  the  flat  papules,  these 
are  rarely  accompanied  by  condylomata  about  the  anus  in  the  male  and 
the  vulva  in  the  female.  After  frequent  relapses  the  papules  are  gen- 
erally less  numerous  and  less  confined  to  particular  regions,  while  the 
ring-form  becomes  a  more  prominent  feature.  When  the  eruption  occurs 
late  in  the  secondary  period  it  may  be  seen  in  but  one  region,  and  may 
even  be  unsymmetrical. 

This  eruption  usually  begins  about  the  face  and  neck,  and  is  fully 
developed  at  the  end  of  two  weeks.  In  some  instances  its  evolution  is  so 
rapid  that  it  has  been  called  the  "  acute  papular  syphilide."  In  late 
relapses  the  papules  appear  as  slowly  as  any  other  syphilitic  eruption. 
Many  of  the  papules  are  seen  to  be  at  the  openings  of  follicles — a  feature 
which  is  more  noticeable  in  this  than  in  any  other  form  of  syphilitic  papule. 

After  their  complete  development  the  papules  remain  unchanged  for 
a  time.  In  some  cases  new  papules,  and  exceptionally  pustules,  appear 
among  the  old  ones.  Soon  their  color  changes  to  a  sombre  brown,  and 
finally  to  a  coppery  hue.  Small  scales  of  epidermis,  frequently  in  the 
form  of  rings,  which  correspond  to  the  margins  of  papules,  are  detached 
by  the  infiltrative  process  beneath.  This  feature  was  regarded  by  Biett, 
who  first  described  it,  as  of  considerable  diagnostic  importance.  A  marked 
tendency  to  further  desquamation  is  observed  only  in  chronic  cases  and 
in  regions  where  the  epidermis  is  thick  ;  it  is  sometimes  so  decided  as  to 
resemble  the  early  stage  of  psoriasis. 

Frequently  a  few  of  the  papules  are  converted  into  vesicles  or  pustules 
by  the  accumulation  at  their  apices  of  a  minute  quantity  of  serum  or 
pus.  They  may  remain  in  this  condition  for  a  long  time.  Generally  the 
fluid  dries  and  forms  a  minute  crust  which  may  fall  off  spontaneously, 
leaving  the  papules  apparently  in  their  elementary  state.  In  some  cases 
pustules  form,  which  may  dry  or  become  ulcers. 

The  occurrence  of  distinct  groups  of  papules  which  have  undergone 
these  changes,  generally  on  the  face,  about  the  mouth,  and  on  the  fore- 
arms and  backs  of  the  hands,  has  perhaps  led  some  authors  to  admit  the 
existence  of  a  vesicular  syphilide. 

In  some  instances  papules  about  the  nose  and  mouth  have  a  yellow 
crust  composed  of  sebaceous  matter  from  the  follicles  around  which  they 
are  developed.  On  account  of  the  appearance  of  the  crust  and  the 
superficial  infiltration  of  the  papules  the  case  might  be  mistaken  for  one 
of  seborrhoea. 

When  uninfluenced  by  treatment  the  course  of  the  eruption  is  chronic. 
In  its  early  stage  it  yields  slowly  to  treatment,  but  after  long  persist- 
ence it  becomes  very  obstinate,  and  requires  local  as  well  as  general 
treatment.  Its  rapid  and  early  disappearance  is  desirable,  since  perma- 
nent atrophic  spots  like  those  of  variola  remain  after  a  lesion  which  has 
had  a  long  existence.  These  spots  are  pigmented,  and  they  become 
white  only  after  several  months.  Pigment  may  also  be  deposited  when 
atrophy  has  not  occurred. 

The  diagnosis  is  generally  easy,  at  least  in  the  early  stage.  The 
eruption  may  be  mistaken  for  the  punctate  form  of  psoriasis  or  for  cer- 
tain cases  of  lichen  pilaris  and  lichen  planus. 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  613 

In  psoriasis  the  papules  tend  to  form  patches  of  an  inch  or  more  in 
diameter,  and  the  scales  are  copious,  silvery,  and  iifibricated. 

Lichen  pilaris  is  an  inflammatory  affection,  chiefly  of  hairy  regions, 
and  is  accompanied  by  intense  pruritus,  and  the  papules  often  form 
patches  of  thickened  skin. 

In  lichen  planus  the  papules  are  flatter,  less  uniform,  more  commonly 
umbilicated,  are  always  pruritic,  and  are  more  likely  to  lose  their  original 
character  by  confluence. 

Moreover,  with  the  syphilide  we  have  the  specific  history  and  possibly 
the  coexistence  of  other  and  distinctive  lesions. 

In  addition  to  the  small  conical  papules,  there  are  others  as  large  as 
peas,  markedly  conical,  and  having  an  elevation  of  about  a  line.  They 
rarely  appear  in  large  numbers  or  constitute  an  early  general  eruption, 
but  are  found  at  the  time  of  a  relapse  mingled  with  the  smaller  papules, 
with  pustules,  or  with  an  erythematous  syphilide.  They  are  more  profuse 
on  the  back  and  buttocks  than  elsewhere.  Their  evolution  is  slow. 
Their  bright-red  color  soon  fades,  and  they  are  quite  apt  to  pustulate  and 
form  ulcers.  They  have  no  orderly  arrangement  either  in  groups  or  in 
circles.  They  yield  more  readily  to  treatment  than  the  small  papules, 
and  seldom  leave  atrophic  and  coppery  spots. 

This  form  of  papular  syphilide  may  be  mistaken  for  acne,  especially  on 
account  of  its  appearance  on  the  back.  In  acne  the  lesions  are  most 
abundant  about  the  face  and  shoulders  ;  they  vary  greatly  in  size,  and 
are  accompanied  by  more  hypersemia.  Acne  usually  begins  about  pu- 
berty and  has  a  history  of  many  recurrences. 

The  Lenticular  Papular  Syphilide. — There  are  two  varieties  of 
flat  papules  caused  by  syphilis — the  small  and  the  la7'ge.  The  small 
]japules  frequently  occur  in  the  form  of  a  general  eruption ;  this  is 
rarely  true  of  the  large  papules,  which  are  usually  seen  concurrently 
with  a  small  papular  eruption,  an  erythematous  or  perhaps  a  pustular 
syphilide.     These  two  forms  of  papules  present  striking  differences. 

The  Small  Flat  Papular  Syphilide. — The  small  2yajmles  begin 
as  minute  red  spots,  which  rapidly  increase  until  they  reach  a  diameter 
of  one-eighth  to  one-fourth  of  an  inch  and  an  elevation  of  one-third  to 
one-half  a  line.  They  are  either  round  or  oval,  have  flat  surfaces,  and 
rounded  and  distinctly  limited  margins.  A  few  papules  may  be  slightly 
depressed  at  the  centre,  but  we  do  not  find  them  surrounding  follicular 
openings  or  pierced  with  hairs.  In  the  early  and  general  eruptions  the 
papules  are  scattered  and  show  no  tendency  to  fuse  together.  In  relapses 
they  are  less  numerous,  and  are  more  likely  to  be  grouped  and  arranged 
in  a  circular  form. 

Mode  of  Distribution. — The  papules  are  first  seen  about  the  shoulders, 
or  at  the  back  of  the  neck,  or  on  the  sides  of  the  thorax,  and  are  soon 
followed  by  others  on  the  forehead  at  the  margin  of  the  hairy  scalp,  with 
perhaps  a  few  on  the  face,  chiefly  about  the  nose,  mouth,  and  chin,  and 
on  the  anterior  surface  of  the  neck,  rarely  on  the  ears.  At  the  same 
time  or  soon  after  the  trunk  is  invaded,  particularly  the  back,  and  the 
papules  may  follow  the  line  of  the  ribs.  As  a  rule,  the  supra-  and 
infraclavicular  regions  are  wholly  spared.  The  papules  are  copious  in 
the  hypogastric  region  ;  but  few  are  seen  over  the  sternum ;  they  are 
numerous  over  the  anterior  surface  of  the  shoulders,  but  comparatively 


614 


SYPHILIS. 


sparse  on  the  outer  surface  of  the  arms,  while  they  are  more  numer- 
ous on  the  inner  or  flexor  surfaces,  especially  near  the  joints.  Few  are 
seen  on  the  dorsum  of  the  hands,  while  the  palms  are  more  freely  sup- 
plied. They  are  unusually  numerous  on  the  gluteal  regions,  and  are  not 
infrequently  found  upon  the  penis,  the  mons  Veneris,  and  in  the  inguinal 


Fig.  200. 


SmaU  flat  papular  syphilide  of  the  face. 


regions.  They  are  more  plentiful  on  the  inner  than  the  outer  aspects  of 
the  thio-hs,  and  they  either  do  not  extend  below  the  knees  or  are  sparsely 
distributed  upon  the  inner  surfaces  of  the  legs  and  sometimes  upon  the 
soles.  The  face  is  spared  by  this  syphilide  more  frequently  than  by  the 
small  miliary  variety.  It  sometimes  assumes  the  form  of  the  so-called 
"  corona  Veneris,"  and  occupies  the  forehead  where  the  hat  presses  ;  it  is 
seen  upon  the  alge  nasi  and  about  the  mouth,  and  shows  a  marked  tend- 
ency to  development  near  the  junction  of  the  skin  with  mucous  mem- 
branes. In  rare  cases  the  papules  are  very  copious  and  hypertrophic, 
and  really  constitute  papulo-tubercles  upon   the  face,  where  they  cause  a 


THE  EARLY  OR  SECONDARY  SYPHILIDES. 


615 


peculiar  expression,  similar  to  that  sometimes  seen  in  true  leprosy,  which 
is  called  by  some  authors  "  syphilitic  leontiasis."     (See  Fig.  201.) 

The  color  of  the  small  flat  papules  varies  in  different  regions  of  the 
body  and  in  different  persons.  In  their  early  stage  it  is  a  pinkish-red, 
which  soon  becomes  brownish  or  coppery ;  this  change  occurs  first  on  the 
face,  especially  the  forehead,  then  on  the  legs.     In  persons  with  delicate 

Fig.  201. 


Papulo-tubercular  syphilide. 

skin  or  feeble  circulation  the  color  is  at  first  very  light  red,  which  changes 
to  a  light  yellow  tinged  with  brown.  On  the  legs  the  papules  sometimes 
become  of  a  purple  color,  owing  to  bloo<l-stasis  or  effusion.  This  condi- 
tion may  be  general  in  broken-down  or  scorbutic  subjects.  In  rare  cases 
some  of  the  papules  on  the  face  are  of  the  color  of  the  normal  skin  ;  they 
are  always  accompanied  by  others  which  are  colored.     On  parts  freely 


616  SYPHILIS. 

supplied  with  sebaceous  follicles  some  of  the  papules  are  covered  by  a 
thin  yellowish  crust,  which,  being  easily  removed,  exposes  a  shining  sur- 
face with  no  evidence  of  ulceration.  This  crust,  formed  of  epithelium 
and  sebaceous  matter,  is  generally  coextensive  with  the  papule. 

There  is  a  marked  difference  in  the  amount  of  scaling  of  the  papules 
in  different  persons  and  in  different  parts  of  the  body.  The  epithelium 
at  the  border  of  fully-developed  papules  may  be  detached  and  form  a 
fringe  around  them,  as  in  the  case  of  miliary  papules.  The  scales  on 
the  surface  of  the  papules  are  generally  small,  adherent,  and  not  of  the 
silvery-white  color  of  those  of  psoriasis.  On  surfaces  where  the  epi- 
dermis is  thick  the  papules  are  not  infrequently  lost  in  a  desquamating 
patch  ;  this  is  apt  to  be  the  case  with  late  papular  syphilides  of  the 
palms  and  soles,  which  have  received  the  name  "  syphilitic  psoriasis." 

These  papules  are  of  softer  consistence  than  the  small  miliary  pap- 
ules, and  do  not  give  to  the  finger  the  rough,  firm  sensation  of  the 
latter. 

In  exceptional  cases  a  peculiar  necrotic  change  takes  place  upon  the 
surface  of  many  of  the  papules.  Their  epidermis  is  thrown  off  either  by 
scaling  or  by  molecular  decay,  and  is  replaced  b}^  a  dirty-brownish  mem- 
brane of  a  fibrous  nature,  which  is  removed  in  fragments  or  in  mass  and 
exposes  a  granular  ulcerated  surface.  This  seems  to  be  a  diphtheritic 
deposit.  AVe  have  seen  but  few  instances  of  this  complication,  and  only 
in  cachectic  subjects. 

Like  all  other  syphilitic  papules,  these  disappear  by  absorption  of 
their  cell-elements.  Under  the  use  of  mercury  the  process  is  rapid ; 
otherwise  the  papules  slowly  flatten,  and  are  gradually  replaced  by 
copper-colored  spots  of  pigment,  which,  though  quite  persistent,  are  not 
so  obstinate  as  those  left  by  the  small  miliary  papule.  Although  inter- 
nal treatment  causes  the  absorption  of  the  papules,  it  is  almost  powerless 
against  the  pigmentation  left  by  them. 

The  Large  Flat  Papular  Syphilide. — The  large  flat  syphilitic 
papules  are  either  round  or  oval,  and  have  a  diameter  of  three-eighths  to 
one-half  of  an  inch,  and  exceptionally  of  fully  one  inch.  They  begin  as 
minute  spots,  which,  as  a  rule,  rapidly  increase.  Their  surface  is  flat,  but 
occasionally  there  is  a  well-marked  sloping  depression  at  the  centre.  They 
are  distinctly  elevated,  with  rounded,  sharply-defined  edges.  A  few  small 
adherent  scales  lie  upon  the  surface,  and  at  the  margins  of  the  papules 
an  epidermal  fringe  or  rim  may  be  seen.  They  generally  have  a  decidedly 
red  color,  which  soon  becomes  coppery.  In  rare  cases  they  are  bright 
crimson  red,  and  exceptionally  they  have  a  deep  purplish-red  tint.  They 
run  a  chronic  course,  and  cause  neither  pain  nor  itching.  The  surfaces  of 
the  papules  in  rare  instances  undergo  superficial  necrosis  and  become  cov- 
ered with  a  thin,  dirty-looking  diphtheroid  membrane.  Such  an  occur- 
rence is  always  indicative  of  a  depressed  condition  of  the  system  and  of 
a  severe  form  of  the  disease. 

This  eruption  occurs  under  a  variety  of  circumstances.  In  some 
instances  a  few  papules  may  be  found  Avith  an  erythematous  syphilide 
or  an  eruption  of  small  flat  papules  on  the  forehead,  the  neck,  and  about 
the  genitals.  In  rare  cases  this  syphilide  is  the  first  eruption,  and  it  then 
resembles  the  small  flat  variety  in  its  mode  of  appearance  and  its  course. 
It  occurs  upon  the  palms  and  soles  with  about  the  same  frequency  as  the 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  617 

latter,  and  in  these  regions  it  may  develop  the  so-called  palmar  and  plantar 
psoriasis.  When  occurring  as  a  first  general  rash  this  syphilide  shows  no 
tendency  to  a  circular  arrangement,  and,  although  the  papules  may  be 
more  closely  aggregated  on  such  parts  as  the  face,  neck,  shoulders,  ingui- 
nal and  gluteal  regions,  and  near  joints,  they  do  not  coalesce  except  in 
parts  continuously  irritated.  Owing  to  irritation  their  area  sometimes 
becomes  greatly  increased. 

In  general  this  syphilide  belongs  to  the  middle  and  late  periods  of  the 
secondary  stage,  and  is  with  good  reason  classed  by  some  French  authors 
as  an  intermediary  syphilide.  While,  therefore,  it  is  rarely  observed  as 
the  first  rash,  it  is  often  met  with  as  late  as  the  second  and  even  the 
third  year  of  syphilis.  As  a  rule,  the  earlier  its  appearance  the  more 
copious  is  the  eruption.  Appearing  on  the  subsidence  of  a  first  general 
rash,  it  may  consist  of  quite  a  large  number  of  papules  scattered  irregu- 
larW  over  the  body ;  such  a  rash  may  be  composed  of  less  than  two  hun- 
dred papules  or  even  one-third  that  number.  Provided  treatment  is  fol- 
lowed, relapses  are  composed  of  even  a  more  limited  number  of  papules, 
which  then  show  a  tendency  to  appear  on  the  palms  and  soles,  on  the  face, 
abdomen,  and  near  joints — seldom,  however,  in  an  annular  form.  About 
the  beginning  of  the  second  year,  sometimes  later,  the  distribution  of  this 
syphilide  is  even  more  limited.  A  few  papules  appear  on  the  arms  or 
palms,  run  a  chronic  course,  and  are  followed  by  a  few  on  the  abdomen, 
thighs,  or  forehead.  In  late  eruptions,  where  the  papules  are  so  few, 
they  are  often  much  larger  than  those  of  earlier  stages,  though  they 
rarely  exceed  a  diameter  of  one  inch.  In  these  cases  the  term  "  papulo- 
tubercle  "  is  perhaps  more  strictly  expressive  of  the  character  of  the 
lesion. 

When  seated  on  the  face  and  on  parts  freely  supplied  with  sebaceous 
follicles,  as  in  the  case  of  the  small  flat  papules,  thin,  yellowish,  non- 
adherent crusts  are  sometimes  observed  on  the  surfaces  of  these  papules. 
Not  infrequently  the  margins  of  some  of  them  become  elevated  into  dis- 
tinct rims.  Again,  an  annular  crust  of  a  dirty-yellow  color  may  occupy 
the  periphery  of  a  papule.  Sometimes  this  rim  is  so  yellow  as  to  give 
the  impression  that  it  is  composed  of  pus,  but  its  removal  shows  no  ulcera- 
tion beneath,  and  no  pus-cells  can  be  found  in  it.  In  these  cases  there  is 
usually  a  concomitant  symbiotic  seborrhoeic  process.  Exceptionally  super- 
ficial ulceration  may  occur  on  some  of  the  papules,  which  in  broken-down 
subjects  are  sometimes  entirely  converted  into  ulcers.  Sometimes,  on 
freely  movable  parts,  superficial  or  deep  fissures  may  form. 

A  rare  metamorphosis  of  this  syphilide  is  sometimes  seen.  The 
papules  become  somewhat  larger  and  more  elevated.  At  first  their 
surface  is  slightly  granulated,  the  appearance  suggesting  an  extraordinary 
swelling  of  the  papillce  cutis.  The  surface  soon  looks  watery  and  resem- 
bles a  raspberry.  The  prominences  are  smooth  and  red,  and  vary  greatly 
in  size,  and  between  them  there  may  be  slight  ulcerations,  from  which 
escapes  a  secretion  which  dries  and  forms  a  crust.  Sometimes,  when 
copious,  the  secretion  has  a  sickening  odor.  When  thus  hypertrophied 
these  papules  may  be  elevated  to  the  extent  of  two  or  three  lines  or  more  ; 
their  surface  may  be  level  or  markedly  rounded.  This  condition  is  most 
prone  to  occur  upon  the  face,  on  the  scalp,  about  the  shoulders,  and  near 
the  genitals.     When  thus  changed  this  syphilide  has  received  the  names 


618  SYPHILIS. 

" framboesoid,"  "vegetating,"  and  "verrucous."  The  extent  of  the 
process  varies,  in  some  cases  being  limited  to  a  few  papules.  This  same 
condition  is  sometimes  observed  with  the  tubercular  syphilide.  ( Vide 
infra.) 

A  similar  feature  is  sometimes  observed  on  the  surface  of  flat  condy- 
lomata, and  in  a  more  hypertrophic  form  on  some  syphilitic  tubercles. 

Upon  surfaces  that  are  in  coaptation  or  covered  Avith  moisture,  as 
between  the  toes,  around  the  navel,  at  the  margin  of  the  nostril,  and  on 
the  perineum,  these  papules  may  become  superficially  excoriated  or  trans- 
formed into  condylomata  lata.  This  is  well  seen  in  some  cases  of  papules 
on  the  thighs  of  women.  Those  on  the  lower  part  are  simply  scaly,  those 
near  the  genitals  are  superficially  eroded  and  emit  an  offensive  secretion, 
while  those  on  the  vulva  are  truly  condylomatous. 

Under  mercurial  treatment  the  papules  composing  this  syphilide  are, 
as  a  rule,  slowly  absorbed,  a  more  or  less  deeply  pigmented  spot  being 
left.  The  earlier  treatment  is  begun,  the  less  in  degree  will  be  the  result- 
ing pigmentation.  The  later  and  more  scattered  eruptions  are  often  more 
rebellious.  They  remain  indolent,  causing  more  or  less  desquamation ; 
in  which  feature,  as  well  as  in  their  color,  they  sometimes  resemble 
psoriasis. 

Not  uncommonly  in  the  retrogressive  stage  of  these  papules,  particu- 
larly in  late  eruptions,  absorption  of  the  centre  of  the  lesion  occurs, 
leaving  a  ring  which  may  be  scaly,  and  which  is  itself  finally  absorbed 
without  showing  any  tendency  to  centrifugal  increase. 

When  occurring  as  the  first  general  eruption,  this  syphilide  coexists 
with  the  numerous  symptoms  peculiar  to  the  early  period.  When  of  later 
occurrence  it  is  not  infrequently  accompanied  by  pustular  eruptions  on 
hairy  parts,  iritis,  alopecia,  onychia  or  perionychia,  condylomata,  and 
often  by  cachexia.  When  of  very  late  appearance  it  may  be  the  only 
manifestation  of  the  disease,  and  it  often  recurs  in  a  limited  degree,  to  be 
finally  replaced  by  lesions  of  the  tertiary  period. 

Prognosis. — The  early  appearance  of  this  syphilide  indicates  an  active 
and  severe  form  of  syphilis,  and  calls  for  prompt  and  careful  treatment, 
otherwise  the  supervention  of  cachexia  and  of  tertiary  lesions  may  be 
expected.  A  relapse  of  the  eruption  indicates  continued  activity  of  the 
disease.  As  to  the  eruption  itself,  its  disappearance  is  merely  a  question 
of  time  and  of  treatment. 

Diagnosis. — A  general  eruption  of  this  syphilide  presents  such  dis- 
tinctive features  that  errors  in  diagnosis  are  scarcely  possible.  Where  it 
occurs  in  limited  numbers  and  runs  a  chronic  coui-se,  particularly  when 
there  are  several  outbursts  of  papules  at  short  intervals,  no  other  lesions 
being  visible,  it  may  be  mistaken  for  psoriasis.  The  question  may  be 
still  further  complicated  by  the  appearance  of  papules  upon  the  elbows 
and  knees.  A  distinction  can,  however,  generally  be  made  by  attention 
to  certain  points.  In  syphilis  the  papules  have  a  uniform  size  not  seen 
in  psoriasis ;  in  psoriasis  the  spots  are  likely  to  blend  and  form  gyrate 
patches ;  while  in  syphilis  they  gradually  pass  away  after  reaching  ma- 
turity. The  color  of  the  psoriatic  patches  is  pinkish  or  deep  crimson ; 
that  of  the  syphilitic  papules  is  deep  brown  or  dull  crimson.  It  must  be 
confessed,  however,  that  a  diagnosis  must,  in  some  cases,  be  established 
by  other  features.     The  scales  of  the  syphilitic  papules  are  not  as  copious 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  619 

and  usually  not  as  silvery  as  those  of  psoriasis ;  they  are  simply  more  or 
less  adherent  flakes  of  epidermis.  By  scraping  a  patch  of  psoriasis  much 
epidermal  debris  is  collected,  and  there  is  exposed  either  a  shiny,  thin 
pellicle  covering  the  patch  or  a  granular  bleeding  surface.  Similar  treat- 
ment of  a  syphilitic  papule  gives  much  less  epidermal  debris  and  shows 
that  we  are  tearing  a  solid  tissue.  In  the  ringed  form,  from  absorption 
of  the  centre  of  the  papules  the  resemblance  to  psoriasis  is  sometimes 
striking,  but  the  scantiness  of  the  scaling,  the  uniformity  in  size  of  the 
rings,  and  their  stationary  condition  are  in  contrast  with  the  abundant 
scaling,  the  varying  size  of  the  rings,  and  the  tendency  to  centrifugal 
growth  and  fusion  seen  in  psoriasis.  The  sharply-defined  border  of  syph- 
ilitic papules  is  seldom  observed  in  psoriasis.  Moreover,  in  syphilis  there 
is  a  history  of  some  other  symptom  or  lesion,  or  there  may  be  other  spe- 
cific lesions  on  the  body  at  the  time.  There  may  also  be  cachexia  in 
syphilis,  while  patients  with  psoriasis  are  generally  remarkably  healthy. 
The  age  of  the  patient  is  sometimes  a  point  of  importance.  As  a  rule, 
psoriasis  begins  in  early  life  and  only  exceptionally  after  puberty.  The 
syphilide  is  more  common  after  puberty,  on  account  of  the  more  frequent 
occurrence  of  syphilis  after  that  period.  Finally,  mercurial  treatment 
has  no  efi'ect  upon  psoriasis,  while  it  is  especially  beneficial  in  this  form 
of  syphilide. 

Scaling  Papular  Syphilide  of  the  Palms  and  Soles  (Syphilitic 
Psoriasis  of  the  Palms  and  Soles). — Papular  syphilides  of  the  palms 
and  soles  are  often  peculiar  and  difficult  of  diagnosis.  They  may  occur 
at  any  time  in  the  secondary  period  or  may  coexist  with  tertiary  lesions  ; 
they  run  a  chronic  course,  unaccompanied  by  pain  and  itching,  and  are 
generally  rebellious  to  internal  treatment. 

The  erythematous  syphilide  is  often  developed  on  the  palms  in  scat- 
tered spots  which  have  a  deep-red  color,  are  slightly  elevated,  and  covered 
by  a  layer  of  epidermis.  In  favorable  cases,  subjected  to  treatment, 
scaling  soon  occurs,  leaving  a  smooth,  rosy,  slightly-depressed  surface, 
surrounded  by  an  undermined  rim  of  epidermis.  The  mode  of  develop- 
ment of  these  spots,  when  not  treated,  will  be  described  later. 

In  a  general  eruption  of  flat  papules  a  few  sometimes  occur  in  the 
hollow  of  the  palms  and  soles.  They  are  small,  decidedly  elevated,  and 
have  a  deep-red  or  purple  color,  Avhich  soon  becomes  obscured  by  the 
great  increase  of  epithelial  scales.  This  is  well  shown  in  Fig.  202.  Ex- 
ceptionally they  are  very  numerous  in  the  above  regions.  They  dis- 
appear under  treatment,  but  if  left  to  themselves  they  become  chronic. 

In  some  cases,  usually  early  in  the  secondary  period  and  coexisting 
with  dermal  or  other  manifestations,  or  perhaps  being  the  only  evidence 
of  syphilis,  a  varying  number  of  small,  firm,  hard,  colorless  elevations  or 
miniature  corns  appear  on  the  palms.  Usually  there  are  about  a  dozen 
on  each  hand ;  there  may  be  only  two  or  three  or  they  may  be  much  more 
plentiful.  They  cause  neither  itching  nor  pain,  but  are  in  some  instances 
tender  under  pressure.  They  run  an  indolent  course  and  disappear 
chiefly  by  scaling.  They  are  composed  of  dense  masses  of  epidermal 
scales  which  can  be  dug  out  with  a  knife.  Usually  they  are  of  little 
importance,  but  exceptionally  they  are  very  persistent,  even  if  active 
treatment  is  adopted. 

The  well-marked  scaling  syphilides  of  these  parts  may  appear  as  early 


620  SYPHILIS. 

as  the  third  month  of  syphilis,  at  the  time  of  a  relapsing  eruption,  or  even 
at  a  much  later  period.  They  usually  begin  during  or  at  the  decline  of 
an  eruption  of  the  flat  papular  syphilide,  but  they  may  be  developed 
independently.  In  the  hollow  of  the  palm  or  sole  a  few  flat  papules  of  a 
diameter  of  one  or  two  lines  appear.  At  first  the  elementary  lesion  can 
be  distinctly  recognized,  being  elevated,  sharply  outlined,  and  of  a  deep- 

FiG.  202. 


Circumscribed  scaling  papular  syphilide  of  the  palm. 

red  color.  If  treatment  is  neglected,  they  soon  become  flattened  and 
lose  their  color  and  well-defined  margins.  Meanwhile,  other  papules  may 
be  formed  on  the  borders  of  the  palms,  which  likewise  soon  lose  their 
characteristics.  They  all  increase  in  size,  and  may  form  irregular  patches 
by  fusion.  In  severe  cases  the  entire  palm  and  the  fingers  may  be  in- 
vaded, when  we  find  either  a  number  of  small  patches  or  a  large  one  in 
the  hollow  of  the  hand,  with  smaller  ones  around  it. 

These  patches  constitute  the  true  scaling  syphilide  of  these  parts,  and 
are  called  by  most  authors  "  syphilitic  psoriasis  of  the  palms  and  soles  " 
(Fig.  203).  By  careful  examination  we  find  general  thickening  of  the 
epidermal  layer,  with  much  scaling  and  redness  of  the  surface.  The 
papules  are  frequently  seated  in  the  furrows  of  the  hand,  which  in  severe 
cases  may  be  converted  into  superficial  fissures  or  "rhagades."  When 
thus  developed  this  syphilide  may  persist  for  months  or  years,  causing 
annoyance  by  the  desquamation  and  the  feeling  of  stiffness  produced,  and 
giving  rise  to  pain  when  fissures  are  formed. 

In  some  cases  the  disease  creeps  slowly  up  the  fingers  until  it  reaches 
the  nails,  which  then  become  thickened  and  brittle.  In  some  instances 
one  or  more  well-marked  rings  of  papules  occur  on  these  localities.     If, 


THE  EABLY  OR  SECONDARY  SYPHILIDES. 


621 


not  cured,  these  soon  coalesce  and  form  a  patch  which  runs  the  usual 
course. 

As  a  rule,  the  affection  spreads  by  the  formation  of  new  distinct  pap- 
ules at  the  border  of  the  original  patch.  Exceptionally,  when  a  large 
patch  has  formed  in  the  hollow  of  the  hand,  the  disease  extends  by  a 
crescentic  margin  a  line  or  more  in  width,  which  is  distinctly  elevated, 
and,  as  it  invades  healthy  tissues,  the  parts  left  are  scaly  and  subacutely 
inflamed.  In  this  way  the  whole  palm  or  sole,  with  the  corresponding 
surfaces  of  the  fingers  or  toes,  may  be  involved.  Sometimes  the  lesion 
progresses  in  this  crescentic  manner  up  the  inner  side  of  the  foot  toward 
the  ankle  and  around  the  radial  or  ulnar  borders  of  the  hand,  generally 

Fig.  203. 


The  diflfiise  scaling  syphilide  of  the  palm. 


not  invading  the  dorsum  and  not  passing  the  line  of  the  wrist.  The 
lateral  surfaces  of  the  fingers  may  likewise  be  afiected. 

Several  years  are  occupied  by  this  process,  and  as  a  result  we  some- 
times find  general  cornification  of  the  dense  parts  of  the  epidermis,  with 
thickening  of  the  thinner  parts.  The  dense,  hard  stratum  of  epidermis 
covering  the  sole,  and  rather  less  frequently  the  palm,  often  becomes 
perforated  Avith  minute  holes,  while  from  it  may  be  dug  hard  masses  of 
epidermis  having  a  chalky  appearance.  This  affection  is  called  by  some 
'■^syphilis  cutanea  corjiea.'"  All  of  these  forms  of  epidermal  thickening 
are  very  often  wholly  uninfluenced  by  internal  treatment,  and  always 
require  vigorous  local  measures. 

Chronic  syphilis  sometimes  causes  the  development  of  corns  or  horns 
on  the  palms  and  the  soles.  Lewin  has  published  an  interesting  case  of 
horns  of  the  hand  which  were  fully  half  an  inch  high.^ 

To  the  question  whether  syphilis  produces  genuine  scaling  eruptions 
we  must  answer  that,  while  they  may  be  scaly  and  no  infiltration  of  gran- 

^"Cornua  Cutanea  Syphilitica,"  International  Atlas  of  Rare  Skin  Diseases,  Part  7, 
1892. 


622  SYPHILIS. 

ulation-cells  can  be  found  in  their  later  stages,  all  syphilitic  scaling  erup- 
tions begin  as  a  true  papular  syphilide.  Owing  to  the  fact  that  the 
integument  of  the  palms  and  soles  is  so  firmly  bound  down  and  is  subject 
to  such  constant  compression  and  attrition,  and  also  to  the  fact  that  the 
cell-infiltration  in  these  regions  is  not  limited  to  the  vicinity  of  foHicles, 
the  lesion  becomes  spread  out  into  extensive  patches.  Probably  the 
specific  feature  of  the  process  is  the  deposit  of  cells  which  are  subsequently 
absorbed  ;  resulting  from  this  is  a  low  grade  of  inflammation  and  a  chronic 
epidermal  cell-increase.  Therefore,  while  the  papular  lesion  is  character- 
istic of  syphilis,  the  scaling  which  follows  is  in  all  essentials  similar  to 
that  of  psoriasis.  The  application  of  the  term  "psoriasis"  is,  however, 
objectionable.  Moreover,  the  result  of  treatment  shows  that  the  papular 
aff'ection  is  influenced  by  mercury,  while  the  scaling  condition  is  unaff"ected. 

The  diagnosis  of  the  early  papular  syphilides  of  the  palms  and  soles 
is  generally  easy,  since  neither  eczema  nor  psoriasis  produces  similar 
appearances.  In  their  early  stage  the  color  and  situation  of  the  patches 
indicate  their  nature,  while  the  history  of  the  case  and  the  coexistence  of 
other  syphilitic  lesions  furnish  additional  evidence.  When  the  patches 
are  diffuse  their  resemblance  to  psoriasis  is  almost  perfect.  The  latter, 
however,  is  often  more  scaly,  is  usually  more  scattered,  and  is  scaly  from 
the  first,  or  begins  as  rosy-red  patches  and  scaling  spots.  In  many  cases 
of  the  syphilitic  eruption,  particularly  when  it  is  quite  chronic,  only  one 
hand  will  be  found  to  be  attacked,  and  that  one  will  be  that  most  com- 
monly used  and  subjected  to  friction. 

It  is  always  important  to  get  the  patient's  idea  of  the  manner  in  which 
the  affection  began.  In  cases  of  psoriasis  similar  conditions  have  been 
observed  elsewhere  on  the  body.  Psoriasis  usually  begins  in  early  life ; 
the  syphilitic  affection  generally  occurs  after  puberty.  It  is  very  rare 
indeed  for  psoriasis  to  appear  exclusively  in  these  localities ;  when  seen 
here  it  may  usually  be  found  elsewhere,  especially  on  the  elbows  and 
knees.  Some  authors  mention,  as  a  point  of  distinction,  that  the  scales 
of  psoriasis  are  silvery,  while  those  of  the  papular  syphilide  are  dull  and 
dry.  I  have  seen  the  scales  of  the  specific  affection  silvery,  resembling 
asbestos.  In  many  old  chronic  cases  the  diagnosis  cannot  be  made  from 
the  study  of  the  eruption  itself,  but  only  after  a  careful  consideration  of 
its  history  and  of  the  case  in  general.  Certain  chronic  palmar  eczemas 
resemble  the  scaling  syphilide.  Usually  there  is  more  thickening  in  the 
former,  and  there  is  always  much  itching.  It  is  more  diffuse  than  the 
syphilitic  affection,  and  has  a  tendency  to  invade  contiguous  parts. 

As  a  rule,  atrophy  of  the  skin  does  not  follow  the  absorption  of  the 
small  flat  papules,  although  in  very  chronic  cases  minute  depressed 
cicatrices  result  from  absorption  of  some  of  the  cells  of  the  skin  itself  as 
well  as  those  of  the  papules.  This  occurrence  is  more  common  on  the 
face  than  elsewhere. 

The  invasion  of  this  syphilide  is  usually  subacute,  but  it  may  be 
hastened  by  excessive  heat,  hot  baths,  alcoholic  drinks,  or  similar  influ- 
ences. It  rarely  appears  as  rapidly  as  the  small  miliary  papular  erup- 
tion, and  is  never  accompanied  by  itching,  A  period  of  a  week  or  ten 
days  usually  elapses  before  the  eruption  is  complete.  The  number  of 
papules  varies  :  when  this  syphilide  is  the  first  manifestation  upon  the 
skin,  as  it  is  in  about   12  per  cent,  of  the  cases,  the  papules  are  very 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  623 

numerous,  so  that  the  tip  of  the  finger  can  scarcely  be  laid  upon  the  skin 
without  touching  one  or  more  of  them.  This  may  be  true  also  in  a  first 
relapse  following  an  erythematous  syphilide. 

Although  the  eruption  may  be  less  copious,  it  is  usually  Avidely  dis- 
tributed. Relapses  are  quite  amenable  to  treatment.  Uninfluenced  by 
mercurials,  this  syphilide  is  very  indolent ;  while  some  papules  are  under- 
going resolution,  new  ones  appear,  so  that  all  stages  of  development  may 
be  represented  in  a  single  case.  Treatment  quickly  dispels  the  eruption 
and  diminishes  the  copiousness  of  succeeding  lesions.  This  fact  is  par- 
ticularly noticeable  in  private  practice,  where  patients  seek  advice  early  ; 
with  careless  persons,  on  the  contrary,  a  relapse  may  be  extensive  and 
profuse. 

A  relapse  of  this  syphilide  may  be  expected  at  any  time  within  two 
years  after  infection.  In  one  occurring  after  the  sixth  month  the 
papules  are  limited  in  number  and  extent,  and  their  color  is  generally 
darker  than  that  of  an  early  rash.  A  few  papules  may  appear  oVer  the 
trunk,  upon  the  face,  and  on  the  inner  aspect  of  the  limbs  near  the 
joints,  either  scattered  or  in  a  ringed  form.  In  relapses  of  this  syphilide 
the  papules  tend  to  appear  on  the  elbows  and  knees,  sometimes  in  the 
form  of  circles  or  segments  of  circles,  and  perhaps  accompanied  by 
papules,  either  scattered  or  grouped  in  rings  about  the  shoulders  and 
trunk.  Psoriasis  presents  certain  similar  features,  and  is  particularly 
prone  to  appear  in  these  regions.  The  syphilide  may  be  found  upon  the 
elbows  alone  ;  it  is  rather  unusual  to  see  it  upon  the  knees  and  not  upon 
the  elbows.     Generally  a  few  papules  are  scattered  over  the  body. 

Careful  examination  of  the  patches  shows  that  the  rings  are  formed 
either  by  fusion  of  the  papules  or  by  their  interrupted  distribution.  With 
care  it  is  seen  that  the  basis  of  the  eruption  is  papular,  and  that  there  is 
no  morbid  change  in  the  encircled  area  of  skin.  This  is  quite  diff"erent 
from  the  condition  in  psoriasis,  in  which  a  papule  increases  centrifugally 
until  it  reaches  a  diameter  of  an  inch  or  more,  when  evolution  takes 
place  at  the  centre  of  the  lesion,  the  periphery  remaining  unchanged. 

Coexisting  Symptoms  and  Lesio7is. — When  this  eruption  is  the  first 
dermal  manifestation,  it  is  usually  accompanied  by  several  others,  such  as 
buccal  and  pharyngeal  lesions,  swelling  of  ganglia,  alopecia,  pains  of 
various  kinds,  and  perhaps  iritis.  The  latter  affection  occurs  more  fre- 
quently with  this  than  with  any  other  form  of  papular  sypbilides. 
Having  a  marked  tendency  to  relapse  at  any  time  during  the  secondary 
period,  this  syphilide  may  coexist  with  any  of  the  manifestations  peculiar 
to  that  period. 

Diagnosis. — General  eruptions  of  this  syphilide  are  so  peculiar  in  the 
distribution,  shape,  and  appearance  of  the  papules,  and  are  so  often  ac- 
companied by  other  syphilitic  symptoms  that  the  diagnosis  is  usually 
clear.  In  some  sparse  eruptions  which  are  especially  chronic,  and  in 
which  papules  are  extraordinarily  scaly,  there  may  be  some  doubt  be- 
tween syphilis  and  psoriasis  in  its  guttate  stage.  The  latter  disease  is 
essentially  scaly,  and  the  patches  are  not  uniform  in  size;  it  generally 
begins  in  early  life  and  recurs  in  subjects  apparently  healthy  ;  its  scales 
are  silvery,  imbricated,  and  plentiful,  while  those  of  syphilis  are  of  a 
more  sombre  hue,  are  not  imbricated,  and  usually  not  very  copious.  In 
psoriasis  there  is  a  history  of  numerous  similar  eruptions ;    in  syphilis 


624  SYPHILIS. 

there  may  be  relapses  of  similar  papules,  but  they  are  likely  to  be  less 
copious  and  more  localized  with  each  succeeding  outburst.  In  syphilis 
there  is  the  history  of  the  initial  or  other  lesion  and  perhaps  the  coexist- 
ence of  other  symptoms,  and  usually  a  condition  of  ill-health.  Arsenic 
cures  psoriasis,  but  not  syphilis  ;  syphilis  is  curable  by  mercury,  an  agent 
which  is  powerless  in  psoriasis.  There  is  one  diagnostic  point  between 
syphilis  and  psoriasis  which  is  very  constant.  In  psoriasis  we  never 
find  ulceration  of  the  patches,  whereas  in  many  cases  of  syphilis  there 
will  be  found  ulcerated  cracks  or  excoriations  in  one  or  more  of  the  lesions, 
particularly  on  parts  of  the  skin  subjected  to  pressure  or  friction. 

In  those  cases  in  which  the  papules  are  developed  in  a  ringed  form 
upon  the  elbows  and  knees  the  general  distinctions  just  given  apply. 
On  examination  of  the  rings  or  segments  of  rings  they  are  found  to  be 
formed  by  the  fusion  of  individual  papules.  They  are  less  scaly,  more 
copper-colored,  and  more  sharply  defined  than  the  rings  of  psoriasis, 
which  are  formed  by  absorption  of  the  centre  of  a  circular  patch,  and 
which  continue  to  increase  in  diameter. 


The  Pustular  Syphilides. 

These  syphilides  constitute  an  important  group  of  eruptions,  which, 
though  less  common  than  the  erythematous  and  papular  forms,  may 
appear  at  the  earliest  stage  of  syphilis,  at  any  time  in  its  secondary 
period,  or  even  late  in  its  tertiary  period.  They  vary  in  severity  from 
a  mild  and  ephemeral  eruption  to  one  of  the  gravest  character.  The  size 
of  the  pustules  varies  from  that  of  a  pin's  head  to  that  of  a  ten-cent-piece ; 
they  may  be  acuminate,  globular,  or  flat ;  they  are  generally  round,  but 
sometimes  oval ;  and  they  are  surrounded  by  a  dull,  coppery-red  areola. 
Some  have  a  well-marked  papular  base,  the  pustule  being  a  minor  part 
of  the  lesion  ;  beneath  all  of  them  there  is  more  or  less  infiltration.  They 
may  begin  as  papules  or  as  distinct  pustules.  They  vary  greatly  in  num- 
ber, sometimes  covering  the  entire  body  or,  on  the  contrary,  being  limited 
to  special  regions.  They  show  a  marked  tendency  to  appear  on  localities 
rich  in  hair-  and  sebaceous  follicles,  while  certain  ones  are  prone  to  be 
developed  in  particular  regions.  The  pustules  may  be  either  scattered  or 
in  groups,  and  are  almost  always  symmetrically  placed.  Relapses  of  this 
syphilide  are  common  ;  the  earlier  the  eruption  the  more  rapid  is  its  inva- 
sion and  the  more  numerous  are  its  lesions,  while  later  eruptions  appear 
slowly,  in  limited  numbers,  and  Avith  a  marked  tendency  to  localization. 

Some  pustules  become  encrusted  more  quickly  than  others ;  as  a  rule, 
the  secretion  of  the  large  ones  dries  sooner  than  that  of  the  small.  In 
all  cases  the  size  and  form  of  the  crust  correspond  to  those  of  the  pustule. 
The  crust  of  the  small  pustules  have  a  greenish-brown  color — those  of 
larger  and  later  ones  a  greenish-black  color,  similar  to  that  of  an  oyster- 
shell.  They  are  usually  of  firm  consistence  and  somewhat  adherent. 
Their  surface  is  rough  and  sometimes  distinctly  laminated,  and  may  be 
flat  or  conical.  Their  shape  may  be  round,  oval,  or  like  a  horseshoe. 
Under  small  crusts  there  is  usually  little,  if  any,  ulceration,  and  their 
removal  exposes  a  well-marked  papule ;  under  larger  ones  is  an  ulcerating 
surface,  more  or  less  deep,  of  a  grayish-red  color,  covered  with  a  quantity 
of  thick  brownish-yellow  pus. 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  625 

The  earlier  eruptions,  being  papulo-pustular,  usually  cause  no  destruc- 
tion of  the  skin,  while  the  late  ones,  being  extensive,  deep,  and  localized, 
leave  cicatrices,  which  remain  pigmented  for  a  long  time,  but  finally 
become  shining  white. 

Though  the  visible  changes  are  pustulo-crustaceous,  the  base  of  all  of 
these  lesions  consists  of  an  infiltration  of  small  round  granulation-cells 
similar  to  that  of  papules.  In  the  early  history  of  these  lesions  molecular 
decay  and  pus-formation  seem  to  be  in  proportion  to  the  cell-infiltration, 
the  destruction  of  tissue  very  often  being  limited  to  the  death  of  the  new 
cells,  since  perceptible  change  in  the  skin  itself  seldom  exists.  In  other 
cases  the  derma  melts  away  with  the  infiltration,  leaving  nothing  of  the 
original  framework. 

The  Acneform  Syphilide. — This  syphilide  is  thus  called  because, 
like  acne  vulgaris,  it  attacks  the  hair-  and  sebaceous  follicles,  and  because 
it  is  a  papulo-pustular  lesion.  It  consists  of  conical  or  slightly-rounded 
pustules,  varying  in  diameter  and  elevation  from  one-third  of  a  line  to  a 
line.  Sometimes  the  pustules  are  as  small  as  a  pinhead.  The  pustules 
may  form  the  whole  eruption,  or  they  may  be  mingled  with  miliary  papules 
or  the  erythematous  syphilide. 

When  appearing  at  the  beginning  of  the  secondary  stage  as  a  general 
eruption,  they  are  usually  accompanied  by  fever,  which  sometimes  reaches 
the  highest  point  observed  in  syphilis,  and  by  other  symptoms  peculiar  to 
that  stage.  The  mode  of  invasion  may  be  rapid  or  subacute.  In  the 
former  case  the  small  red  spots  rapidly  become  papular  and  then  pustular, 
the  lesion  reaching  its  full  development  within  twenty-four  or  forty-eight 
hours.  In  such  cases  the  pustules  are  generally  numerous  and  scattered 
over  the  whole  body.  In  the  subacute  form  they  appear  slowly,  and  for 
several  days  may  look  like  papules,  on  the  apices  of  which  a  small  quantity 
of  pus  slowly  forms.  The  lesions  are  less  numerous,  more  localized,  and 
more  likely  to  be  grouped  than  in  the  acute  form.  The  fever  in  the  latter 
mode  of  invasion  often  arises  abruptly,  and  continues  at  a  high  grade  for 
several  days,  when  it  may  fall  abruptly  or  slowly  to  a  point  between  99° 
and  101°  F.  In  the  subacute  form  it  usually  rises  slowly  to  100°  or  101°, 
and  may  remain  at  or  about  that  elevation  for  several  weeks. 

The  color  of  the  base  of  the  pustules  is  at  first  bright  red,  but,  as  in 
the  case  of  miliary  papules,  it  soon  becomes  dull  brownish-red.  This 
change  first  occurs  on  the  legs  and  face,  and  upon  the  former  the  pustules 
are  sometimes  accompanied  by  hemorrhagic  eff"usion.  The  apex  of  the 
pustules  is  at  first  yellow,  but  is  soon  transformed  into  a  greenish-brown, 
slightly  adherent  crust.  In  many  cases,  particularly  of  small  pustules, 
the  purulent  apex  is  thrown  oif,  leaving  a  papule,  which  may  be  surrounded 
by  the  detached  rim  or  collarette  already  described  as  a  feature  of  the 
papular  syphilides.  Subse(|uently  the  papule  is  absorbed,  leaving  a  small 
pigmented  spot.  In  cases  not  treated,  and  especially  in  badly-nourished 
subjects,  the  pustules  become  small  ulcers.  Their  base  extends,  being 
very  hyper^emic,  and  the  crust  enlarges  with  the  extending  ulceration. 
It  may  thus  happen  that  some  of  the  pustules  run  together,  although  there 
is  no  general  tendency  to  fusion,  and  tliey  may  be  distributed  in  the  form 
of  complete  or  partial  rings. 

This  eruption  generally  begins  about  the  face,  scalp,  back  of  the  neck, 
and  shoulders,  and  may  thence  invade  the  trunk  and  extremities,  being 

40 


626  SYPHILIS. 

more  copious  on  the  scapular,  sternal,  and  gluteal  regions  and  on  the  outer 
aspects  of  the  limbs.  We  frequently  find  syphilitic  papules  or  erythema- 
tous patches  on  the  inner  surface  of  the  arms  and  legs  and  on  the  anterior 
aspect  of  the  trunk.  When  the  pustules  are  scattered  over  the  entire 
body,  they  may  be  closely  crowded  together  or  separated  by  marked 
intervals.  The  first  eruptions  are  always  more  copious  than  relapses,  in 
which  the  pustules  appear  possibly  grouped  in  patches  or  in  a  ringed  form 
about  the  face,  scalp,  or  shoulders,  usually  having  been  preceded  by  an 
erythematous  or  papular  syphilide. 

This  eruption,  which  generally  appears  from  the  third  to  the  sixth 
month  of  the  secondary  period,  may  run  a  chronic  course,  occupying 
several  months  in  the  development  and  complete  disappearance  of  the 
lesions.  Having  run  its  course,  it  usually  does  not  recur  in  its  original 
form,  but  in  the  form  of  larger  and  deeper  pustules  or  tubercles. 

Commonly  the  skin  is  not  destroyed,  the  pustules  merely  leaving  small 
brown  spots,  which  disappear  in  a  few  months.  The  hair  of  the  scalp 
falls  from  the  affected  follicles,  but  is  usually  replaced;  exceptionally  the 
follicle  is  destroyed  and  a  minute  cicatrix  results. 

The  prognosis  of  this  syphilide  is  not  so  good  as  that  of  other  earlier 
forms.  The  eruption  itself  is  troublesome,  and  the  general  health  is  rather 
more  frequently  impaired  after  this  rash  than  after  others. 

The  concomitant  symptoms  vary  with  the  date  at  which  the  eruption 
appears.  If  it  is  the  first  rash,  it  is  of  course  accompanied  by  symptoms 
and  lesions  peculiar  to  the  period  of  invasion  ;  at  a  later  period  it  may 
coexist  with  alopecia,  onychia,  mucous  patches,  iritis,  neuralgia,  nervous 
symptoms,  and  perhaps  lesions  of  the  bones  and  testes. 

Diagnosis. — The  history  of  the  case,  the  usual  presence  of  other  lesions, 
and  the  appearance  of  a  generally  distributed  pustular  syphilide  preclude 
the  possibility  of  mistake.  Acne  vulgaris  resembles  it  in  certain  particu- 
lars. Acne,  however,  generally  begins  about  puberty,  and  is  confined  to 
the  face  and  back,  and  rarely  attacks  the  hair  of  the  scalp.  It  is  never 
attended  by  systemic  reaction.  Moreover,  it  presents  papules,  pustules, 
and  comedones,  which  have  no  uniformity  of  size;  some  are  indeed  mini- 
ature furuncles,  and  all  have  at  some  time  a  more  or  less  hypen-emic 
areola.  The  pustules  retain  their  character  indefinitely,  and  on  pressure 
pus  exudes  from  a  cavity,  whereas  in  the  syphilitic  lesion  the  pus  sur- 
jnpunts  a  papular  base.  Acne  attacks  exclusively  the  upper  parts  of  the 
body ;  syphilis  may  be  general. 

In  its  papular  stage  the  pustular  syphilide,  when  grouped,  may  resemble 
lichen,  the  distinguishing  points  of  Avhich  have  been  given  in  describing 
the  miliary  papules. 

Some  French  writers  have  called  this  eruption  a  "  vesicular  syphilide," 
since  the  purulent  contents  of  the  pustules  are  occasionally  so  thin  as  to 
resemble  serum.-  About  the  face,  and  especially  the  chin,  a  few  Avell- 
marked  vesicles  may,  in  rare  cases,  be  seen.  They  are  very  minute,  may 
be  grouped  in  a  ringed  form,  and  they  either  become  pustular  or  they 
flatten,  scale,  and  become  pigment-spots.  Usuallv  pus  is  present  from  the 
first. 

In  exceptional  cases  pustules  are  found  on  the  sides  of  the  thorax 
along  the  line  of  the  ribs,  presenting  some  resemblance  to  herpes  zoster. 
Theyare  always  symmetrical,  whereas  herpes  is  rarely  so.     The  syphilitic 


THE  EARLY  OR  SECONDARY  SYPEILIDES. 


627 


lesions  are  not  preceded  or  follo'wed  by  pain,  as  is  the  case  in  herpes.  In 
the  latter  affection,  moreover,  the  lesions  are  generally  limited  to  the  inter- 
costal spaces,  and,  if  found  elsewhere,  follow  the  course  of  some  nerve, 
whereas  in  syphilis  the  localities  are  quite  definite  and  other  specific  lesions 
may  coexist. 

The  Variolaform  Syphilide — This  eruption  is  much  less  common 
than  the  acneform  variety,  and  is  interesting  chiefly  in  its  resemblance  to 
varicella  and  variola.  It  is  rarely  the  first  eruption  of  syphilis,  but 
appears  after  any  of  the  early  rashes. 

It  consists  of  round  superficial  pustules,  the  epidermis  covering  the 
pus  being  rather  thin.  It  begins  in  the  form  of  red  spots,  which  within 
a  day  or  two  become  pustules  with  a  diameter  and  an  elevation  of  one  or 
two  lines.     (See  Fig.  204.)     These  pustules  are  surrounded  by  a  limited, 

Fig.  204. 


The  variolaform  syphilide. 


deep-red  areola,  and  there  is  evidently  not  very  much  thickening  at  their 
bases.  When  fully  developed  they  flatten  slightly  at  the  centre,  some 
presenting  marked  umbilication.  Jhe  epithelial  cover  of  the  pustules 
slowly  shrinks,  becomes  darker,  and  finally,  in  a  fcAv  weeks  or  sooner, 
deep  greenish-broAvn  crusts,  about  half  a  line  in  thickness,  are  formed, 
which  adhere  somewhat  closely  to  a  slightly  exulcerated  base.    In  general 


628  SYPHILIS. 

the  pustules  run  an  indolent  course  and  do  not  increase  much  in  size,  but 
in  aggravated  cases  they  become  very  large  and  may  run  together.  They 
may  be  disseminated  over  the  body  or  grouped  in  particular  regions,  and 
they  sometimes  form  circles  and  parts  of  circles. 

These  pustules  have  no  tendency  to  a  follicular  origin,  but  are  found  on 
parts  where  the  skin  is  soft  and  delicate,  frequently,  like  other  syphilides, 
upon  the  forehead  and  at  the  line  of  junction  of  skin  with  mucous  mem- 
brane. They  are  generally  sparse  on  the  outer  aspect  of  the  extremities, 
more  numerous  on  the  anterior  of  the  trunk,  and  often  abundant  near  the 
genitals  and  in  the  inguinal  region.  In  rare  cases  they  are  found  on  the 
palms,  and  still  more  seldom  on  the  soles ;  I  have  seen  but  one  instance 
of  the  latter,  and  very  few  cases  have  been  reported. 

On  account  of  the  large  size  of  the  pustules  this  syphilide  has  been 
called  by  some  French  writers  '•^pemphigus  syphiliticus,"  and,  owing  to 
its  occasional  development  upon  the  palms,  it  has  been  claimed  that  pem- 
phigus may  occur  here  in  acquired  as  well  as  in  hereditary  syphilis.  The 
large  pustules  which  may  form  in  these  regions  in  acquired  syphilis  are 
not,  however,  pemphigoid  bullae.  The  thickness  and  firm  attachment  of 
the  skin  of  these  parts  prevent  elevation  of  the  epidermis  to  a  great  degree ; 
hence  the  pustules  spread  out  and  run  together,  thus  coming  to  resemble 
bullee.  While  admitting  the  rare  occurrence  of  pemphigus  in  acquired 
syphilis,  I  do  not  believe  that  it  is  developed  upon  the  palms  and  soles. 

The  mode  of  invasion  of  this  eruption  is  generally  rather  slow,  and  is 
seldom  accompanied  by  very  pronounced  febrile  movement.  It  begins 
about  the  face,  and  thence  spreads  slowly  over  the  body  in  the  course  of 
one  or  two  weeks.  The  crusts,  which  form  when  the  pustules  reach  their 
height,  fall  off,  leaving  pigmented  spots.  Sometimes  new  crops  rapidly 
succeed  old  ones,  so  that  an  eruption  may  last  several  months.  The  erup- 
tion is  greatly  influenced  by  treatment ;  although  its  full  arrest  is  difficult, 
future  outbursts  may  be  prevented. 

Where  untreated  and  in  poorly-nourished,  weakly  subjects  this  syphi- 
lide ulcerates  deeply  and  induces  a  condition  of  marasmus.  Under  such 
circumstances,  when  the  eruption  seems  to  assume  a  malignant  type  and 
is  accompanied  by  cachexia,  we  have  an  illustration  of  a  somewhat  rare 
form  of  syphilis  called  by  the  French  ^'■precocious  malignant  syp)hilis" 
{syphilis  maligne  precoce)  or  '■'■galloping  syphilis"  {syphilis  gallopante). 
Any  form  of  pustular  syphilide  may  assume  these  characters. 

A  very  limited  eruption  of  this  syphilide  sometimes  occurs  on  the 
face  or  body  or  symmetrically  on  the  arms.  Such  a  rash  runs  a  slow 
course,  usually  without  much  fever,  and  generally  occurs  in  cases  where 
treatment  has  been  stopped  too  early. 

This  eruption  rarely  appears  earlier  than  the  third  month,  and  may 
be  seen  as  late  as  the  second  year,  of  syphilis.  With  it  may  be  found 
lesions  peculiar  to  this  period,  and  frequently  a  sparse  papular  eruption, 
mucous  patches,  or  condylomata  lata. 

The  diagnosis  of  this  syphilide  is  generally  easy.  Prodromal  symp- 
toms observed  in  small-pox  and  varicella,  such  as  backache  and  eruptive 
fever,  are  noticeably  absent,  and  there  is  much  less  general  disturbance. 
In  the  acute  eruptions  there  are  great  heat  and  tension  of  the  skin,  and  at 
the  outset  small  shot-like  papules  may  be  felt,  which  rapidly  pustulate. 
More  or  less  diffuse  patches  of  hyperasmia,  accompanied  by  sensations  of 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  629 

itching  and  burning  of  the  skin,  are  sometimes  present.  Variola  pro- 
gresses so  rapidly  that  its  character  is  perfectly  clear  after  the  second 
day.  The  slow  development  of  the  syphilitic  eruption  and  the  absence 
of  subjective  symptoms  are  distinctive  points  in  the  diagnosis. 

The  Impetigoform  Syphilide. — This  syphilide,  like  the  preceding, 
is  a  pustulo-crustaceous  eruption,  and  attacks  the  more  superficial  layers 
of  the  skin,  differing  from  it,  however,  in  the  fact  that  the  lesions  are 
not  so  distinctly  circumscribed,  but  have  a  tendency  to  involve  a  much 
greater  surface  and  often  to  assume  a  serpiginous  character. 

The  resemblance  of  this  eruption  to  simple  impetigo  is  in  the  group- 
ing of  the  pustules,  in  their  fusion,  and  chiefly  in  the  somewhat  similar 
appearance  of  the  crusts.  The  pustules  of  the  specific  eruption  are  usu- 
ally much  larger  and  flatter  than  those  of  the  simple  form,  and  their 
resemblance  is  hardly  so  close  as  to  Avarrant  the  term  '*  impetigoform  " 
applied  to  them.  They  dry  so  quickly  into  crusts  that  the  pustular  stage 
is  soon  lost. 

This  syphilide  almost  never  occurs  as  the  first  exanthem,  but  rather 
during  a  late  relapse,  its  earliest  appearance  being  at  the  decline  of  the 
initial  rash,  and  its  usual  time  of  evolution  being  about  the  middle  or 
latter  part  of  the  first  year  of  syphilis.  In  cases  not  treated  it  may 
occur  during  the  second  or  even  the  third  year.  Most  of  the  pustules 
have  a  perifollicular  origin,  and  are  found  on  hairy  parts,  rarely  on  the 
hands  and  feet.  When  this  syphilide  occurs  early  the  pustules  are  rather 
discretely  distributed  over  the  whole  body  ;  when  it  appears  later  they 
are  distinctly  localized  and  grouped. 

The  pustules  begin  as  circumscribed  red  spots  which  rapidly  become 
elevated  by  yellow  pus  seated  beneath  the  epidermis.  These  spots,  few 
of  which  are  papular,  are  sometimes  small  and  round,  and  again  are  very 
large  and  irregularly  oval.  After  the  eff"usion  of  pus  each  patch  becomes 
covered  by  a  dark-brown  adherent  crust.  The  crusts  of  several  pustules 
may  run  together,  their  mode  of  formation  being  indicated  by  incomplete 
lines  of  separation.  Their  surfaces  are  usually  flat,  their  edges  rounded 
and  in  relation  with  the  margin  of  the  ulcer,  and  they  are  surrounded  by 
a  narrow,  dull-red  areola. 

Upon  the  face,  at  the  margin  of  the  hairy  scalp,  in  the  scalp  itself, 
about  the  alas  nasi  and  commissures  of  the  lips,  upon  the  chin,  and  in  the 
beard  these  crustaceous  pustules  run  together  and  form  patches,  usually 
not  more  than  two  inches  in  diameter.  In  the  hairy  parts  the  outline  of 
the  incrustation  is  generally  not  at  all  regular.  Only  in  late  eruptions 
do  the  pustules  unite  and  form  large  patches.  On  the  trunk  a  few  may 
be  seen  over  the  sternum  and  in  the  hypogastric,  inguinal,  and  gluteal 
regions.  On  the  anterior  aspect  of  the  forearms,  and  more  rarely  of  the 
thighs,  some  may  also  be  found,  and  here  they  arc  likely  to  be  grouped 
and  to  increase  rapidly  in  size,  a  pustule  sometimes  reaching  a  diameter 
of  an  inch  or  more  within  two  weeks.  The  pustules  usually  retain  their 
circular  form  as  they  increase  in  size,  but  sometimes  they  become  kidney- 
shaped  :  this  peculiarity  is  noticed  rarely  on  the  face,  but  more  commonly 
on  the  forearm. 

In  some  untreated  and  broken-down  cases  these  pustido-crustaccous 
lesions  take  a  serpiginous  course,  invading  the  superficial  layers  of  the 
derma,  generally  of  the  upper  extremities.     They  progress  by  a  ring  of 


630  SYPHILIS. 

ulceration,  covered  by  a  crust  and  enclosing  an  area  of  skin  already 
healed.  This  ring  of  ulceration  is  prone  to  extend  in  a  circular  form  on 
the  face  and  in  an  oval  form  on  the  arms.  When  the  patch  is  a  few 
inches  in  diameter  the  aspect  of  the  original  lesion  is  wholly  lost.  We 
then  find  a  distinctly  raised  ring,  one  to  three  lines  in  breadth,  of  a  yel- 
lowish-brown or  black  color,  which  encloses  a  round  spot  of  slightly 
hyperaemic  skin.  The  ring  gradually  extends  until  the  whole  forearm 
and  part  of  the  arm,  the  greater  part  of  the  face,  or  the  entire  sternal 
region  may  be  invaded.  Even  in  the  worst  cases  surprisingly  little  alter- 
ation of  the  skin  follows  this  process,  and  in  many  no  change  whatever 
is  apparent. 

Besides  this  superficial  form  of  the  serpiginous  syphilide,  there  is  a 
similar  lesion  which  attacks  the  tissues  more  deeply  and  induces  destruc- 
tion and  cicatrization  of  the  skin.  This  latter  eruption  I  shall  call  the 
seiyiginous  tubercular  syphiUcle.  The  supe7[fic{al  serpiginous  syphilide 
may  also  begin  as  a  variolaform  pustule,  and  may  persist  many  months 
or  even  years.  While  it  usually  attacks  large  areas  superficially,  it  may 
also  attack  deeper  portions  of  the  skin.  In  the  latter  case  the  areolae  of 
the  pustular  ulcers  become  thickened  and  more  red,  and  the  crust  be- 
comes more  elevated  and  uneven.  Underneath  the  crust  ulceration  pro- 
gresses, and,  instead  of  the  superficial  grayish-red  ulcer  usually  found, 
there  is  a  deep  and  sharply  cut  excavation,  with  a  red,  uneven  surface 
freely  covered  with  secretion. 

The  ulcerations  vary  in  size  :  in  neglected  cases  we  have  seen  them 
large  and  deep  on  the  scalp  and  in  the  beard,  and  more  superficial  upon 
the  forehead.  In  some  cases  the  alge  of  the  nose  may  be  lost.  The  de- 
struction of  tissue  is  generally  greater  about  the  face  and  head  than  else- 
where. Severe  cachexia  may  occur  coincidently  with  this  eruption,  and 
other  serious  lesions  may  follow,  until  we  have  an  instance  of  malignant 
precocious  syphilis  which  is  attended  by  much  suffering  and  may  even 
imperil  the  patient's  life.  Usually,  however,  now  that  syphilis  receives 
early  and  careful  treatment,  this  eruption  does  not  assume  these  destructive 
features ;  healing  takes  place  under  the  crusts,  which  are  then  thrown 
off,  leaving  a  smooth,  deep-red  surface,  which  may  be  slightly  scaly  and 
deeply  pigmented  for  several  months.  On  raising  the  crust  from  a  fully- 
developed  patch  on  the  arm  we  usually  find  a  smooth,  reddish-gray  ulcer 
without  undermined  edges  ;  on  the  face,  however,  the  surface  is  likely  to 
be  uneven  and  frequently  covered  by  little  papillomatous  elevations,  over 
which  the  crusts  are  accurately  fitte^.  This  warty  appearance,  which  is 
often  seen  on  hairy  parts,  is  the  result  of  an  increased  cell-infiltration 
into  the  papillae  cutis  around  follicular  openings.  These  uneven  surfaces 
gradually  become  flat  and  lose  their  color. 

The  course  of  this  eruption  is  usually  very  chronic.  On  its  invasion 
the  pustules  may  be  very  numerous,  or  a  few  only  may  first  appear  on 
the  head.  Thus  for  long  periods  new  pustules  may  appear  as  old  ones 
fade.  In  other  cases  a  general,  extensive  rash  may  run  its  full  course  in 
a  comparatively  short  time. 

Coexisting  lesions  are  those  peculiar  to  the  period  at  which  the  erup- 
tion appears.  Rarely  being  an  early  eruption,  Ave  seldom  find  it  coincide 
with  the  erythematous  syphilide,  except  during  a  relapse  of  that  lesion. 
It  is  not  uncommonly  found  in  a  sparse  and  limited  form  with,  or  at  the 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  631 

decline  of,  one  of  the  papular  syphilides.  Condylomata  lata  are  fre- 
quently present  on  regions  which  this  eruption  attacks,  and  very  often  it 
is  continuous  at  the  angle  of  the  mouth  with  a  mucous  patch  of  the  lip  or 
cheek.  Since  it  may  occur  at  any  time  in  the  secondary  or  tertiary 
period  of  syphilis,  any  of  the  intermediary  and  many  of  the  late  mani- 
festations of  this  disease  may  be  present  with  it. 

This  syphilide  most  commonly  attacks  persons  in  a  debilitated  con- 
dition, those  who  have  some  organic  disease  or  who  have  neglected  early 
treatment.  The  prognosis  must,  therefore,  be  based  upon  the  patient's 
general  condition  as  well  as  upon  the  eruption  itself.  The  presence  of 
the  eruption,  however  slight,  is  an  indication  for  careful  and  continued 
treatment  and  for  attention  to  the  patient's  nutrition  and  hygiene. 

This  eruption  may  be  mistaken  for  small-pox,  but  its  invasion  is  less 
severe  and  rapid,  and  the  development  of  the  pustules  is  much  slower. 

This  syphilide  may  be  mistaken  for  impetigo  in  its  disseminated  and 
in  its  confluent  form.  The  lesions  of  impetigo  retain  their  pustular 
character  much  longer  than  do  those  of  syphilis.  They  are  attended  by 
heat  and  itching  of  the  skin,  and  have  an  inflammatory  areola ;  they  are 
much  more  uniform  in  size  than  are  the  pustules  of  syphilis,  and  their 
crusts  are  of  a  greenish-yellow  color  instead  of  the  greenish-black  of 
syphilis.  The  acuteness  of  invasion  in  the  case  of  large  patches  of  the 
simple  eruption  is  in  striking  contrast  with  the  slow,  painless,  and  indo- 
lent character  of  the  syphilide.  These  features,  considered  in  connection 
with  the  history  of  the  case,  make  the  diagnosis  clear. 

The  Ecthymaform  Syphilide. — There  are  two  varieties  of  this 
syphilide,  superficial  and  deep.  The  superficial  is  the  earlier  eruption, 
appearing  at  any  time  during  the  first  year  of  syphilis,  and  is  usually 
composed  of  a  greater  number  of  pustules.  The  latter  resembles  those 
of  non-specific  ecthyma  in  having  a  solid,  elevated  base  surrounded  by  a 
crust,  and  in  their  tendency  to  ulcerate.  The  deep  form  may  be  an 
intermediary  lesion,  or  even  a  rather  late  one.  The  pustules  of  the 
superficial  form  vary  in  diameter  from  one  to  three  lines.  They  begin  as 
slight  red  elevations  of  the  skin,  which  in  a  day  or  two  become  small, 
conical  pustules.  The  pustules  gradually  increase  in  size,  and  crusts  are 
formed  by  desiccation  of  the  pus.  The  crusts  grow  in  proportion  to  the 
bases  of  the  pustules,  and  their  yellow  color  soon  becomes  brown,  which 
is  rendered  still  darker  by  particles  of  dirt  and  sometimes  by  admixture 
of  a  little  blood.  When  fully  formed  their  color  is  yellowish-brown  and 
their  shape  round  or  conical.  As  the  pustules  increase  in  size  the  crusts 
become  flattened  and  even  depressed  at  the  centre.  The  base  is  at  first 
of  a  bright-red  color,  which  soon  becomes  a  dull  reddish-brown,  and  it  is 
surrounded  by  an  abruptly  limited  areola.  Beneath  the  crust,  which  is 
seldom  firmly  adherent,  is  an  ulceration,  involving  the  superficial  layers 
of  the  derma,  and  having  a  smooth  floor  covered  by  a  grayisli-red  film  of 
molecular  detritus  bathed  in  thick  pus.  After  commencing  treatment 
and  with  improvement  in  the  general  health  the  base  becomes  less  dark 
and  contracts ;  the  areola  fades  ;  the  crust  becomes  hard,  dry,  and  very 
adherent,  and,  if  removed,  a  smooth  red  surface  is  seen,  sometimes 
slightly  papillated.  This  surface  may  be  again  covered  by  a  thin  crust 
made  up  chiefly  of  epidermis,  which  in  turn  falls  off",  leaving  a  smooth, 
reddish-brown   patch  or  a  slightly  elevated,  papular,  and  scaly  surface. 


632  SYPHILIS. 

Under  unfavorable  circumstances  the  areola  and  the  base  are  redder  and 
more  extended,  pus  is  secreted  in  greater  quantity,  the  ulcer  increases  in 
depth  and  extent,  in  extreme  cases  reaching  a  diameter  of  one  or  two 
inches,  and  perhaps  several  ulcers  may  unite.  In  such  cases  the  syphilis 
assumes  a  malignant  form,  and  there  is  much  systemic  prostration. 

The  course  of  such  an  ulcer  is  similar  to  that  of  the  impetigoform 
syphilide  when  the  latter  becomes  serpiginous. 

The  superficial  ecthymaform  syphilide  begins  by  the  development  of 
pustules  either  in  a  disseminated  or  an  aggravated  form,  about  the  scalp, 
particularly  at  its  junction  with  the  face  and  neck.  They  may  appear 
gradually  and  without  much  febrile  movement,  or  in  a  manner  quite  the 
reverse.  Soon  after  other  portions  of  the  body,  such  as  the  anterior  sur- 
faces of  the  legs  and  forearms,  the  trunk,  particularly  on  the  posterior 
surface,  and  the  inguinal  and  gluteal  regions,  may  be  invaded.  (See 
Plate  VI.)  In  some  cases  this  is  accomplished  in  a  week  or  ten  days  ;  in 
others  small  crops  of  pustules  succeed  each  other  at  short  intervals,  and 
fully  a  month  may  be  occupied  in  the  complete  development  of  the  erup- 
tion. When  this  eruption  occurs  early,  especially  in  cases  inefiiciently 
treated,  the  lesions  are  apt  to  be  extensive  and  copious  ;  occurring  later, 
it  may  be  limited  to  one  region,  and  may  even  be  unsymmetrical.  The 
pustules  may  be  isolated  or  grouped  in  patches  or  in  the  form  of  circles 
or  parts  of  circles.     They  may  or  may  not  leave  cicatrices. 

The  deep  variety  of  the  ecthymaform  syphilide  is  usually  a  rather 
late  lesion,  but  it  is  sometimes  precocious.  In  the  latter  case  it  may 
be  very  malignant,  and  it  is  then  the  expression  of  profound  syphilitic 
cachexia,  thus  constituting  another  instance  of  the  "  galloping  syphilis  " 
of  the  French.  This  syphilide  begins  as  a  papulo-tubercle.  A  round 
or  oval  elevation  appears,  upon  which  a  quantity  of  yellow  pus  soon 
forms,  and  this  becomes  thicker  and  dries  into  a  crust  of  a  brownish- 
black  color,  owing  to  the  effusion  of  a  little  blood.  When  fully  formed 
we  find  an  incrusted  papulo-tubercle,  with  a  diameter  of  one-quarter  to 
one-half  of  an  inch.  The  firm,  deeply-seated  base  has  a  dark,  coppery- 
red  color  and  is  surrounded  by  an  areola  of  a  similar  hue.  The  crust 
is  generally  rounded  or  conical,  but  may  flatten  out  as  it  extends.  (See 
Fig.  205.)  A  deep,  punched-out  ulcer,  with  sharply-cut  edges  and  a 
smooth,  grayish-red  surface,  covered  with  a  foul,  rust-colored  pus,  under- 
lies the  crust,  which  can  be  removed  with  little  force.  In  some  cases 
the  crust  fully  covers  the  ulcer ;  in  others  it  is  smaller  and  is  surrounded 
by  a  ring  of  ulceration.  If  untreated,  the  ulcer  continues  to  increase, 
and  may  become  serpiginous,  invading  extensive  surfaces.  Several 
ulcers  may  merge  together.  Influenced  by  treatment,  the  areola  fades, 
the  base  contracts  and  becomes  slightly  wrinkled,  and  a  granulating 
surface  is  found  beneath  the  crust,  which  becomes  hard  and  adherent. 
In  some  cases,  as  a  result  of  stimulation,  a  layer  of  epidermis  soon 
covers  the  surface  of  the  ulcer,  but  often  profuse  granulations  spring 
up,  and  may  even  rise  above  the  level  of  the  surrounding  skin.  After 
healing  of  the  ulcer  there  remains  a  coppery-red  spot,  which  gradually 
fades,  and  finally  leaves  a  shining  white  cicatrix,  Avhich  is  for  a  long 
time  fringed  by  a  narrow  copper-colored  areola. 

This  eruption  is  generally  most  abundant  on  the  antero-exterior  sur- 
faces of  the  legs ;  often  these  pustules  may  form  on  the  corresponding 


PLATE  VI. 


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THE   SUPERFICIAL    ECTHYMA-FORM    SYPHILIDE. 


THE  EARLY  OR  SECONDARY  SYPHILIDES. 


633 


surfaces  of  the  arms  or  about  the  face  and  on  the  lower  portions  of  the 
trunk.  It  is  usually  developed  slowly,  appearing  in  crops  of  from  two 
to  twelve  at  intervals  of  one  or  several  weeks.  It  may  be  accompanied 
by  cachexia,  and  not  infrequently  by  fever  of  a  remittent  type.  The 
course  of  the  eruption  is  very  slow  and  insidious,  often  extending  over 
many  months  or  even  more  than  a  year.  In  many  cases  there  is  no 
true  cachexia,  but  simply  extreme  prostration.  In  such  cases  the  ulcers 
are  not  numerous,  and  show  only  a  slight  tendency  to  spread. 


Fig.  205. 


J 


The  deep  ecthymaform  syphilide. 

The  prognosis  of  this  syphilide  is  variable.  In  the  superficial  form 
the  eruption  often  gives  much  annoyance,  yet  it  may  disappear  without 
leaving  scars.  The  condition  of  the  system  is  always  below  par,  and 
the  prognosis  should  be  governed  in  great  measure  by  the  degree  of  im- 
provement under  treatment.  In  most  cases  a  favorable  result  may  be 
expected  in  the  course  of  a  few  months,  but  in  rare  cases  prolonged 
cachexia  follows. 

The  prognosis  of  mild  and  limited  cases  of  the  deep  variety  is  usu- 
ally good.  In  more  extensive  and  relapsing  cases  the  outlook  is  less 
favorable ;  the  presence  of  the  eruption  indicates  a  depraved  condition 
of  health,  which  is  greatly  aggravated  by  the  irritation  and  drain  of  the 
deep  ulcerations.  A  few  months  of  proper  treatment  will,  however, 
generally  effect  a  cure. 

The  diagnosis  of  tliis  syphilide  is  almost  always  quite  easy,  although 
it  may  be  mistaken  for  ecthyma.  The  superficial  form  is  to  be  distin- 
guished from  a  similar  ecthyma  by  the  peculiar  course,  situation,  and 
appearance  of  the  syphilitic  pustules  as  compared  with  the  more  inflam- 
matory, pruritic  pustules  of  ecthyma,  which  are  more  uniform  in  size, 


634  SYPHILIS. 

have  yellowish-brown  crusts,  and  much  less  tendency  to  ulceration. 
Moreover,  ecthyma  usually  occurs  on  the  legs  of  broken-down  subjects, 
and  is  an  eruption  of  papules  and  pustules,  the  latter  forming  only 
superficial  ulcers.  In  some  cases  of  phtheiriasis  in  uncleanly  and  un- 
healthy persons  pustulo-crustaceous  ulcers,  somewhat  resembling  those 
of  syphilis,  are  seen,  but  with  care  a  diagnosis  can  always  be  made. 
The  discovery  of  the  pediculus  vestimentorum,  the  presence  of  minute 
blood-crusts  caused  by  the  bite  of  the  insect,  and  very  often  scratch- 
marks,  and  a  general  papular  and  pruritic  condition,  establish  the  diag- 
nosis of  phtheiriasis. 

The  deep  ecthymaform  syphilide  might  perhaps  be  mistaken  for 
ecthyma  cachectica  livida,  since  the  latter  occurs  in  much  debilitated 
subjects.  The  histories  of  the  cases  and  a  comparison  of  the  lesions 
render  the  distinction  clear.  The  lesions  of  syphilis  are  less  inflamma- 
tory than  those  of  the  non-specific  eruption ;  they  involve  much  less  of 
the  surface,  but  extend  much  deeper  and  they  secrete  much  less  pus. 
Moreover,  the  areola  of  the  simple  lesion  is  either  bright  red  or  deep 
purple,  and  is  much  more  extensive  than  that  of  the  syphilitic  pustule. 

Malignant  Precocious  Syphilides. 

Under  this  title  French  authors  have  described  certain  syphilitic 
eruptions  which  have  a  malignant  ulcerative  character,  appear  early  in 
syphilis,  and  are  accompanied  by  general  cachexia.  These  eruptions 
vary  greatly  in  extent  and  duration.  In  some  cases  the  malignant  tend- 
ency is  exhibited  from  the  first,  while  in  others  it  attacks  a  previously 
mild  eruption.  It  has  already  been  stated  that  certain  pustular  erup- 
tions, particularly  the  impetigoform  and  the  ecthymaform  syphilides, 
and  much  less  frequently  the  papular  rashes,  develop  this  character. 
In  some  instances  this  peculiar  feature  of  the  eruption  is  due  merely  to 
the  excessively  debilitating  influence  of  the  syphilitic  poison  or  to  a 
lowered  condition  of  nutrition.  Dr.  Ory,  who  has  studied  the  etiology 
of  the  malignant  syphilides,  concludes  that  alcoholism  is  a  very  potent 
cause,  but  that  any  adynamic  influence  may  have  the  same  effect. 

These  syphilides  are  divided  into  three  classes :  the  syphilide  puro- 
crustacee  ulcSreuse,  the  syphilide  tuberculo-erustaeee  uleereuse,  and  the 
syphilide  tuherculo-uleerante  gangreneuse. 

The  syphilide  puro-erustacee  ulc^reuse  is  a  pustular  rash  attended 
with  extensive  ulceration  and  formation  of  scabs.  It  begins  as  rounded 
pustules,  grouped  or  irregularly  scattered,  which  soon  ulcerate  and 
form  flat  or  conical  greenish-black  crusts  which  may  blend  together. 
The  ulcers  are  deep,  with  sharply-cut,  undermined  edges  and  a  foul 
base  secreting  a  fetid  pus.  Such  an  eruption  appears  first  upon  the  face 
or  scalp,  where  the  lesions  are  often  in  groups ;  then  it  invades  the 
arms,  and  may  even  extend  over  the  entire  body,  successive  crops  of 
pustules  being  developed  in  bad  cases.  There  is  rarely  a  tendency  to 
ringed  distribution,  but  sometimes  one  group  of  pustules  is  increased  by 
the  formation  at  its  periphery  of  new  pustules. 

The  syphilide  tuberculo-erustaci.e  ulc^reuse  begins  as  a  small  red 
tubercle  of  the  size  of  a  pea,  which  is  rapidly  converted  into  an  ulcer 
with  a  thick  crust.     The  subsequent  course  is  similar  to  that  of  the 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  635 

previous  variety,  except  that  the  destruction  of  tissue  is  often  much 
greater.  This  eruption  is  prone  to  appear  first  on  the  head  and  upper 
extremities.  In  some  cases  these  regions  only  are  attacked ;  in  others 
the  whole  body  is  invaded.  Upon  the  face  the  ulcers  are  often  confluent ; 
upon  the  arms  they  are  usually  scattered,  but  later  on  groups  may  be 
formed  by  the  continual  accession  of  new  tubercles.  The  invasion  of 
this  eruption,  like  that  of  the  preceding  one,  may  be  rapid  or  slow.  Its 
course  is  chronic,  sometimes  occupying  six  or  eight  months  or  even  a 
year.  During  ulceration  the  lesions  sometimes  cause  a  dull  pain,  and 
are  at  all  times  a  source  of  much  discomfort. 

The  syphilide  tub erculo-ulcer ante  gangreneuse,  one  of  the  most  for- 
midable manifestations  of  syphilis,  is  happily  rare.  It  is  always  accom- 
panied by  cachexia,  and  if  not  fatal  always  leaves  a  condition  of  perma- 
nent ill-health.  It  begins  as  round  tubercles  of  a  dark-red  color,  slightly 
elevated  and  deeply  seated  in  the  skin,  which  attain  a  diameter  of  an 
inch  or  more.  A  small  blackish  slough  forms  in  the  centre  of  each 
tubercle,  and  is  at  first  firmly  adherent;  it  extends  rapidly,  and,  soon 
becoming  loosened  by  the  secretions,  is  cast  off  as  a  fetid,  cup-shaped 
mass,  looking  something  like  an  inverted  rupia  crust.  The  ulcer  thus 
exposed  is  very  deep,  has  a  foul,  dark-brown  surface  with  hard,  everted 
edges,  and  secretes  a  fetid  ichor.  To  the  touch  it  gives  the  impression 
of  being  deeply  seated  and  indurated  like  a  typical  initial  lesion  or 
chancre.  Surrounding  each  tubercle  is  a  broad,  deep-red  areola.  Phage- 
dena may  occur  and  run  a  course  similar  to  that  of  phagedenic  gummous 
ulcers.  From  time  to  time  brownish-green  crusts  form  and  are  thrown 
off.  In  favorable  cases  the  surface  of  the  ulcer  gradually  assumes  a 
more  healthy  appearance,  the  edges  become  softer,  and  the  areola  fades. 
Grranulations  appear,  and  true  pus  replaces  the  ichorous  discharge.  The 
healing  process  is  finally  completed,  leaving  a  depressed  cicatrix  of  a 
coppery-red  color,  which  gradually  fades  from  the  centre  toward  the 
periphery  of  the  cicatrix.  When  fully  formed  the  cicatrix  is  of  a  dead- 
Avhite  color,  flexible,  and  thin  like  parchment. 

The  invasion  of  this  syphilide  is  generally  rapid,  but  its  subsequent 
course  is  slow.  Usually  tubercles  are  developed  in  region  after  region, 
followed  perhaps  by  additional  crops.  They  are  irregularly  scattered, 
with  no  tendency  to  a  ringed  form.  The  face,  the  extremities,  the 
shoulders,  and  buttocks  are  its  favorite  seats.  The  eruption  may  persist 
for  several  months,  or  even  years,  although  in  the  most  malignant  cases 
it  runs  a  course  called  by  French  authors  '"''  galloping."  In  such  cases 
the  invasion  is  very  rapid  and  the  result  is  generally  fatal. 

At  or  shortly  before  the  appearance  of  these  precocious  syphilides 
the  patients  complain  of  weakness,  and  appear  pale  and  sallow.  They 
often  suffer  from  fugitive  pains  and  neuralgias  and  from  a  general  sense 
of  discomfort.  They  have  no  appetite  and  become  emaciated.  At  the 
same  time  some  febrile  reaction  may  be  noticed.  If  not  checked,  this 
adynamic  condition  increases  pari  passu  with  the  eruption  ;  the  patient 
falls  into  a  typhoid  state  and  dies.  Possibly  some  intercurrent  visceral 
lesion  of  the  lungs  or  of  the  nervous  system  hastens  the  fatal  result.  In 
some  cases  no  definite  visceral  affection  can  be  detected,  and  the  patient 
dies  of  marasmus.  Very  often  lesions  peculiar  to  a  later  period,  such 
as  nodes,  necroses,  sarcocele,  etc.,  appear  with  this  malign  eruption. 


636  SYPHILIS. 

In  other  cases,  although  the  syphilide  is  essentially  malignant,  health 
gradually  returns  after  a  prolonged  period  of  impaired  nutrition  and 
extreme  debility. 

The  prognosis  of  these  syphilides  is  always  grave,  since  they  indicate 
a  most  intense  and  active  form  of  syphilis.  The  health  of  the  patient 
previous  to  infection,  his  habits,  the  extent  and  character  of  the  eruption, 
and  the  deg-ree  of  cachexia  must  all  be  considered.  The  course  of  the 
lesions  and  the  influence  of  treatment  must  be  watched.  Death  almost 
always  results  from  the  intercurrence  of  some  pulmonary  or  nervous 
affection. 

As  regards  treatment,  every  e^ort  should  be  made  to  improve  nutri- 
tion. Much  can  be  done  toward  checking  the  course  of  the  eruption 
by  the  employment  of  local  measures.  Careful  dressing  of  the  ulcers, 
their  thorough  disinfection,  and  the  early  removal  of  secretions  not  only 
add  to  the  comfort  of  the  patient,  but  promote  healing.  In  spite  of  every 
precaution ;  indelible  cicatrices  are  generally  left.  Internal  treatment  must 
also  be  employed.  The  guarded  use  of  mercury,  preferably  by  inunction, 
with  iodide  of  potassium,  sodium,  or  ammonium  internally,  is  indicated. 
Opium  is  often  found  particularly  useful  in  these  cases  by  calming  the 
restlessness  of  the  patient  and  quieting  the  pain  of  the  ulcers.  In  a  recent 
case  of  my  own,  in  which  the  malignant  syphilide  was  accompanied  by 
profound  cachexia,  by  severe  and  persistent  rheumatoidal  pains,  and  by 
double  iritis,  this  deplorable  condition  was  in  less  than  a  week  markedly 
improved  by  the  addition  of  a  little  opium  to  the  mixed  treatment,  com- 
bined Avith  tonics.  We  may  sometimes  resort  to  mercurial  vapor  baths 
with  iodide  of  potassium  or  sodium,  combined  with  bitter  tonics,  internally, 
beginning  with  ten-  to  fifteen-grain  doses  three  or  four  times  a  day,  and 
gradually  increased  by  two  or  three  grains  daily.  Mercury  given  in  this 
way  is  supposed  to  have  a  beneficial  local  as  well  as  general  efi"ect.  The 
condition  of  the  stomach  demands  that  the  most  digestible  and  nutritious 
food  be  taken,  if  possible,  in  small  quantity  and  at  frequent  intervals. 
Stimulants,  preferably  good  port  wine  or  brandy,  must  be  given  regularly. 
Such  treatment  as  the  above  is  suitable  when  the  patient  is  still  able  to 
move  about.  In  a  typhoid  condition  treatment  applicable  to  the  adynamic 
fever  is  called  for,  together  with  the  careful  use  of  the  iodides.  The 
crusts  of  the  ulcers  should  be  removed  after  softening  them  with  simple 
ointment  or  cosmoline  to  which  a  few  drops  of  carbolic  acid  have  been 
added.  When  they  cover  the  whole  body  an  alkaline  bath  may  be 
required  for  this  purpose.  The  exposed  surface  of  the  ulcers  should  be 
touched  with  carbolic  acid,  applied  with  cotton-wool  or  a  brush.  Its 
action  is  twofold :  it  allays  pain  and  destroys  the  diseased  tissue.  The 
formation  of  scabs  may  be  prevented  by  the  application  of  an  ointment 
or  the  water  dressing.  An  ointment  composed  of  one  part  of  mercurial 
ointment,  one  part  of  balsam  of  Peru,  and  six  parts  of  vaseline,  applied 
on  lint  and  frequently  renewed,  is  of  great  service.  Simple  lead-water 
or  a  solution  of  the  bichloride  of  mercury,  1  :  2000  or  even  weaker,  is  to 
be  preferred  when  there  is  much  hyperemia.  The  latter  has  a  special 
detergent  and  stimulating  effect.  As  the  case  progresses  such  a  super- 
ficially destructive  stimulant  as  nitrate  of  silver  in  strong  solution  or  fluid 
carbolic  acid  may  be  indicated.  The  ulceration  is  sometimes  arrested  and 
repair  hastened  by  prolonged  immersion  of  the  body  in  hot  water.     These 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  637 

hot  baths  may  be  rendered  more  efficacious  by  the  addition  of  two  or  three 
drachms  of  corrosive  sublimate  to  each  thirty  gallons  of  water.  Care  must 
be  exercised  as  regards  their  frequency  and  duration.  The  mercurial 
vapor  bath  is  often  of  benefit  after  removal  of  all  the  crusts,  but  its  effect 
must  be  carefully  watched. 

By  way  of  prophylaxis,  when  the  eruption  shows  a  tendency  to  extend 
all  possible  sources  of  irritation  of  the  skin  must  be  removed. 

The  Pigmentary  Syphilide. 

The  history  of  the  pigmentary  syphilide  is  a  most  peculiar  one  and 
worthy  of  consideration.  It  is  an  affection  which  at  first  was  clearly  and 
sharply  described,  but  which  in  the  course  of  time  has  been  rendered  so 
obscure  that  to-day  very  few  have  clear  and  precise  ideas  as  to  its  course 
and  its  nature.  In  the  whole  range  of  syphilography  there  is  not  a  like 
instance  in  which  the  knowledge  of  a  manifestation  of  syphilis  has  be- 
come so  progressively  obscure,  and  in  which  so  much  confusion  has  been 
interjected  by  reason  of  the  successive  additions  to  its  literature  by  many 
writers.  In  the  sixties  we  knew  what  the  pigmentary  syphilide  was  as  a 
result  of  the  writings  of  Hardy,  Fournier,  Pillon,  and  Tanturri.  To-day 
this  well-marked  and  peculiarly  characteristic  affection  is  so  little  under- 
stood that  it  is  confounded  with  the  pigmentations  and  the  leucoderma- 
tous  conditions  left  as  a  result  of  previous  syphilitic  processes.  The  writ- 
ings of  a  number  of  Continental  authors  have  had  much  to  do  with  the 
obscuration  of  this  question,  for  these  authors  regard  any  pigmentation 
or  leucodermatous  condition  primary  or  secondary  to  a  previous  syphilitic 
process  as  examples  of  the  pigmentary  syphilide. 

We  cannot  too  strongly  insist  upon  the  necessity  of  holding  fast  to  the 
postulate  that  the  pigmentary  syphilide  is  a  unique,  well-marked  affec- 
tion, having  a  sharply  defined  pathological  basis  and  a  course  attended 
by  well-demonstrated  morphological  changes.  As  a  corollary  of  this,  I 
may  add  that  secondary  pigmentations  and  leucodermatous  conditions 
occurring  in  the  course  of  syphilis,  as  relics  or  sequehie  of  lesions  chiefly 
secondary,  are  in  no  sense  examples  of  the  pigmentary  syphilide  ;  they 
are  simply  dischromatous  accidents  and  not  sharply-defined  essential  af- 
fections. 

The  reasons  why  this  confusion  has  been  produced  are  many,  and  the 
chief  ones  are  the  following  : 

1.  Many  of  the  writers  have  had  little  experience  in  the  study  of 
syphilis,  and  have  written  in  a  dogmatic  manner  from  the  observation 
(and  that  usually  very  limited  as  to  time)  of  one  or  perhaps  two  cases. 

2.  Conclusions  have  been  drawn  from  clinical  appearances  presented 
at  various  stages  in  the  progress  of  the  affection,  which,  being  of  long 
duration  and  pi'esenting  at  different  periods  varying  pictures,  cannot  be 
well  understood  by  any  one  unless  he  has  had  his  case  or  cases  under  his 
observation  during  the  whole  period  of  development,  evolution,  and  in- 
volution of  the  affection. 

3.  With  one  exception  (Maieff )  authors  have  studied  the  question  from 
a  histo-pathological  basis  in  a  haphazard  way,  but  have  been  none  the 
less  dogmatic  in  their  conclusions.  Thus  no  observer  until  Maieff 's  time 
studied  the  disease  microscopically,  step  by  step,  in  accordance  with  its 


638  SYPHILIS. 

natural  evolution.  On  the  contrary,  sections  of  skin  were  made  indis- 
criminately in  cases  of  secondary  pigmentations  and  leucodermatous  con- 
ditions, and  perhaps  in  cases  of  the  true  pigmentary  syphilide.  In  no 
instance  is  any  distinction  observed.  In  this  way  discrepancies  have 
been  produced  and  flat  contradictions  and  anomalies  have  resulted. 

4.  Every  pigmentation  in  a  syphilitic,  recent  or  old,  is  called  the 
pigmentary  syphilide,  and  the  latter  is  thus  deprived  of  its  essential 
character. 

The  primordial  pigmentary  anomalies  due  to  syphilis  consist  essentially 
in  a  superpigmentation,  which  may  in  whole  or  in  part  be  replaced  by  a 
corresponding  loss  of  color  or  leucodermatous  condition.  This  primordial 
hyperpigmentation  is  the  essential  pigmentary  syphilide ;  all  other  dis- 
colorations  are  secondary  processes  and  in  no  manner  entitled  to  be  classed 
as  pigmentary  syphilide. 

The  pigmentary  syphilide  is  seen  in  three  well-marked  and  quite  dis- 
tinct conditions  : 

1.  In  the  form  of  spots  or  patches  of  various  sizes. 

2.  As  a  diffuse  pigmentation  of  greater  or  less  intensity,  which  sooner 
or  later  becomes  the  seat  of  leucodermatous  changes  in  the  shape  of  small 
spots  which  gradually  increase  in  size.  This  is  the  retiform  pigmentary 
syphilide — the  syphilide  pigmentaii-e  a  dentelles  of  Fournier. 

3.  In  an  abnormal  distribution  of  the  pigment  of  the  skin,  in  which, 
owing  to  the  lack  of  or  crowding  out  of  the  pigment  in  places,  they  become 
whiter,  while  the  parts  involved  in  the  abnormal  distribution  become 
darker ;  in  this  way  a  dappled  appearance  is  presented.  In  this  form 
there  is  probably  no  excess  of  pigment ;  it  is  seemingly  unequally  dis- 
tributed throughout  the  tissue-expanse.  This  form  has  been  termed  the 
marmoraceous,  from  its  resemblance  to  some  forrhs  of  marble  in  which 
there  is  an  intimate  interblendino;  of  light  and  darker  colors.  This  mar- 
moraceous  pigmentary  syphilide  is  not  common,  and  it  is  peculiarly  liable, 
by  reason  of  its  delicacy  of  tone  and  tint,  to  pass  unobserved. 

All  forms  of  the  pigmentary  syphilide  appear  both  early  and  late  in 
the  secondary  period,  and  they  may  be  the  only  evidence  of  the  diathesis 
or  they  may  coexist  with  other  manifestations.  The  evolution  of  this 
syphilide  may  occur  as  early  as  the  second  or  third  month,  but  it  usually 
appears  about  the  sixth  month  or  toward  the  close  of  the  first  year,  or  it 
may  develop  during  the  second  or  third  year  of  infection.  It  occurs 
most  commonly  in  females,  particularly  blondes,  up  to  the  age  of  thirty 
or  thirty-five  years.     It  is  rarely  found  in  the  male  sex. 

The  parts  of  predilection  of  the  syphilide  are  the  lateral  surfaces  of 
the  neck,  less  frequently  the  face,  and  then  more  commonly  the  forehead. 
It  may  be  seen  on  the  trunk,  arms,  and  legs,  and  may,  very  exceptionally, 
slowly  invade  the  whole  body.  It  is  unattended  by  any  subjective  symp- 
toms whatever.  The  pigmentary  syphilide  is  peculiar  in  the  fact  that  it 
is  wholly  uninfluenced  by  internal  treatment,  and  external  applications 
have  little  if  any  effect  upon  it. 

The  pigmentary  syphilide  in  the  form  of  spots  or  patches  consists  of 
round,  oval,  or  irregular  plaques,  which  may  have  sharply  defined  borders 
or  their  margins  may  be  dentated  or  jagged.  Their  color  varies  from  a 
light-brown  caf^-au-lait  to  even  a  quite  deep-brown  tint.  They  are 
unaffected  by  pressure  and  the  condition  of  the  circulation.     In  persons 


PLATE  VII 


X 


■#?'■' 


Retiform   Pign-^entarLj   Syphilide. 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  639 

of  light  and  delicate  skin  they  may  be  very  faint  in  tint  and  perhaps  only 
perceptible  in  oblique  light. 

In  this  form  of  pigmentary  syphilide  it  is  common  to  see  the  uneven 
distribution  of  the  pigmentation ;  sometimes  the  color  is  deeper  at  the 
margin.  Commonly  there  is  no  involvement  of  the  intervening  skin, 
though  sometimes  the  hyperchromatous  condition  produces  the  illusion 
that  the  unaffected  skin  is  whiter  than  normal.  These  pigmented  spots 
may  remain  unchanged  and  indolent  for  months,  particularly  in  cold 
■weather.  In  the  course  of  time  they  show  evidence  of  fading,  and  they 
slowly  disappear.  The  process  of  involution  may  begin  at  the  margin 
and  extend  centripetally,  or  it  may  take  place  in  the  whole  morbid  area. 
In  some  cases  colorless  patches  are  left  after  the  disappearance  of  the  pig- 
mentation ;  there  is  then  produced  a  secondary  or  pseudo-leucoderma. 
Now,  if  a  case  is  seen  only  in  this  stage,  I  can  well  understand  an  observer 
reaching  the  conclusion  that  the  process  was  an  atrophic  one ;  conse- 
quently, it  is  easy  to  see  why  so  much  is  written  upon  syphilitic  leuco- 
derma  and  syphilitic  vitiligo.  These  expressions  clearly  show  the  want 
of  a  full  knowledge  of  the  disease,  and  that  the  observer  has  only 
acquainted  himself  with  its  stage  of  decline.  In  most  cases  the  skin 
retains  its  normal  appearance  after  the  full  involution  of  this  syphilide. 

The  second  form  of  pigmentary  syphilide  (see  Plate  VII.) — the  lace  or 
retiform  variety — is  far  more  common  than  the  previous  form.  More  or 
less  slowly,  and  even  rapidly,  the  sides  of  the  neck  become  discolored,  the 
tint  being  that  of  cafe-au-lait,  or  even  of  decided  yellowish- brown.  The 
most  common  site  of  this  eruption  is  on  the  sides  of  the  neck  and  perhaps 
on  the  back  of  the  neck.  The  patients  usually  say  that  they  noticed  or 
Avere  told  that  their  necks  were  getting  or  had  got  dirty.  Intelligent  and 
observant  patients  will  very  often  distinctly  state  that  their  trouble  began 
with  a  browning  of  the  skin,  and  they  will  state  positively  that  there  Avas 
no  intermingling  of  white  spots.  From  the  neck  this  eruption  may  extend 
more  or  less  extensively  over  the  trunk,  mostly  anteriorly  or  doAvn  the 
arms.  I  have  never  seen  it  go  up  on  the  face.  In  many  cases  this  erup- 
tion passes  unnoticed,  and  may  be  attributed  to  the  action  of  the  sun,  to 
irritation,  or  even  to  uncleanliness.  When  the  pigmented  patch  has  in- 
volved more  or  less  of  the  sides  of  the  neck,  a  peculiar  change  will  be 
observed  in  it — namely,  the  development  of  whitish  spots  which  may  be 
taken  for  leucoderma.  Scattered  irregularly  over  the  pigmented  surface 
close  observation  will  show  a  few  or  many  minute  Avhite  specks,  Avhich  in 
a  short  time,  particularly  in  hot  weather,  will  be  large  enough  to  present 
definite  shapes,  which  may  be  round,  oval,  linear,  or  irregular.  These 
white  spots  gradually  grow,  and  in  many  instances  the  neck  is  largely 
covered  with  them  before  the  patient  knows  of  any  change  having  taken 
place.  They  then  say  or  are  told  that  their  necks  are  groAving  Avhite. 
Undoubtedly,  many  a  doctor,  upon  this  information  being  given  him,  has 
concluded  that  he  has  a  case  of  leucoderma  before  him.  Sometimes  the 
Avhite  patches  are  distinctly  lighter  than  the  normal  skin ;  in  other 
instances  the  contrast  betAveen  dark  and  light  is  illusory,  and  there  is 
really  no  difference  in  color  between  the  so-called  leucodermatous  patches 
and  the  unaffected  skin.  The  Avhite  spots  may  or  may  not  be  sharply 
marginated,  in  some  cases  the  line  of  margination  being  clear  and  sharp 
and  in  others  indistinct.     I  have  never  seen  the  thin,  filmy,  superpig- 


640  SYPHILIS. 

mented  area  around  white  patches  of  true  pigmentary  syphilide  which  we 
see  so  clearly  and  so  commonly  at  the  circumference  of  patches  of  leuco- 
derma  or  vitiligo,  as  it  is  called.  This  point,  in  my  judgment,  is  of  diag- 
nostic import,  and  is  explained  by  the  pathology  of  the  disease,  to  be 
considered  farther  on.  The  tendency  of  the  white  spots  to  extend  neces- 
sarily means  the  diminution  of  the  brown  background.  In  this  way  we 
have  various  pictures  presented,  and  a  dappled  appearance  is  produced, 
which  warrants  the  name  for  this  eruption  at  this  time  of  the  dappled 
syphilide.  Toward  the  final  stage  of  the  disease  the  preponderance  of 
the  white  spots  leaves  only  round,  oval,  or  wavy  lines  or  strands  of  brown 
pigment,  which  give  the  appearance  of  lace  with  large  meshes,  the  inter- 
stices being  formed  by  the  white  spots,  which  are  round,  oval,  gyrate, 
linear,  or  irregular.  In  this  way  the  skin  in  the  course  of  months,  and 
in  some  cases  of  a  year  or  more,  gradually  seemingly  returns  to  its  normal 
condition.  In  the  study  of  these  cases  I  have  sometimes  seen  during 
the  activity  of  the  process  a  mild  and  ephemeral  hyperaemia  which 
might  easily  have  escaped  observation,  and  the  question  suggests  itself 
to  my  mind  whether  or  not  a  mild  form  of  congestion  may  precede  the 
hyperpigmentation. 

The  third  or  marmoraceous  form  of  pigmentary  syphilide  is  by  far  the 
least  common.  Its  mode  of  invasion  is  slow  and  aphlegmasic,  and  there 
is  little  or  no  hyperpigmentation.  The  natural  color  of  the  skin,  in  spots 
of  irregular  size  and  shape,  becomes  white,  while  the  margins,  which  are 
hazy  and  indefinite,  become  browner  than  normal.  It  seems  to  be  a  dis- 
placement of  pigment  resembling  strikingly  some  delicate  varieties 
of  marble  in  which  there  are  imperceptibly  blended  shades  of  white  and 
very  light  black.  In  my  experience,  this  form  is  always  seen  on  the 
sides  of  the  neck,  and  it  does  not  show  a  tendency  to  extend.  It  can 
only  be  found  upon  persons  of  delicate  skin,  and  very  often  only  by 
close  observation.  It  slowly  disappears  and  the  skin  is  left  in  its  normal 
color. 

I  attach  little  if  any  importance  to  the  mass  of  literature  relating  to 
the  pathological  anatomy  of  the  pigmentary  syphilides,  since  the  investi- 
gations were  made  in  general  at  haphazard  upon  any  pigmented  or  achro- 
matous  skin  without  any  consideration  for  the  stage  of  the  process  or  for 
the  clearness  of  the  diagnosis. 

Maieflf's  ^  observations,  made  under  the  direction  of  Professor  Tarnow- 
sky,  are  worthy  of  unqualified  acceptance,  for  the  sections  of  skin  were 
taken  only  from  patients  suffering  with  the  primary  pigmentary  syphilide, 
and  the  morbid  process  was  studied  upon  very  many  sections  made  in  tis- 
sues in  all  the  progressive  stages  from  its  evolution  to  involution.  Further, 
these  microscopic  studies  were  supplemented  by  prolonged  and  accurate 
clinical  observation.  Maieff  thinks  the  pigmentary  spyhilide  is  due  to 
a  chronic  specific  inflammation  of  the  minute  blood-vessels  of  the  skin, 
which  may  be  due  to  nutritional  changes  incident  to  the  early  and  active 
period  of  syphilis.  At  its  inception  the  morbid  process  consists  in  endo- 
thelial inflammation  with  cellular  infiltration  into  the  adventitia  of  the 
vessels,  which  are  thereby  diminished  in  calibre  and  even  occluded.  As 
a  result  of  the  circulatory  disturbance  the  red  blood-cells  lose  their  pig- 

'  "Contribution  a  I'Etnde  de  la  Syphilide  pigmentaire,"  Compies  rendus  du  Congres 
international  de  Dermatolocjie  el  de  Syphiligraphie,  I'aris,  1890,  pp.  677  et  seq. 


THE  EARLY  OB  SECONDARY  SYPHILIDES.  641 

ment,  which  escapes  and  infiltrates  the  adventitia  of  the  vessels,  the  con- 
nective-tissue cells,  those  of  the  derma  and  of  the  Malpighian  layer,  and 
even  works  its  way  into  the  lymphatics.  During  the  evolution  of  the 
process  most  of  the  altered  vessels  become  completely  obliterated ;  the 
papillae  become  stunted  and  undergo  atrophy.  Then  the  pigmentation 
begins  to  be  gradually  absorbed,  the  color  of  the  skin  grows  less  intense, 
and  gradually  and  slowly  the  discoloration  disappears,  leaving  in  its  wake 
a  whitish  surface. 

These  microscopic  demonstrations,  it  will  be  seen,  agree  perfectly  with 
the  clinical  history  of  the  pigmentary  syphilide,  and  show  beyond  a  doubt 
that  this  eruption  has  a  definite  and  orderly  mode  of  evolution  and  of 
involution. 

In  the  light  of  its  clinical  history  and  of  its  pathological  anatomy  it 
is,  I  think,  now  clearly  proved  that  this  syphilide  begins  as  a  true 
specific  superpigmentation,  which  is  the  essential  feature  of  the  morbid 
process,  and  that  the  subsequent  leucodermatous  changes  are  those  of  a 
degenerative  nature,  consequently  dependent  upon  and  secondary  to  the 
initial  dischromia.  It  can  therefore  be  seen  how  illogical  and  incorrect 
it  is  to  call  this  affection  syphilitic  leucoderma  or  syphilitic  vitiligo. 

This  view  has  further  the  support  of  Dr.  Fiveisky,^  who  studied  the 
subject  exhaustively  under  the  direction  of  Profesor  Tarnowsky.  Fiveisky 
agrees  with  my  contention,  that  the  syphilide  constitutes  one  of  the  most 
characteristic  and  most  reliable  diagnostic  signs  of  secondary  syphilis. 

Diagnosis. — In  the  stage  of  superpigmentation  the  case  may  be  mis- 
taken for  chloasma  if  the  history  is  not  clearly  brought  out.  When  the 
white  spots  have  become  plainly  visible,  a  diagnosis  of  leucoderma  may 
be  made.  But  usually  the  situation  of  the  eruption,  chiefly  on  the  sides 
of  the  neck,  will  point  to  its  specific  nature.  Then,  again,  in  leucoderma 
the  white  patches  have  a  distinctly  brown  though  narrow  margin,  which 
is  never  seen  in  the  pigmentary  syphilide.  The  diagnosis  of  the  syphilide 
from  tinea  versicolor  is  readily  made.  This  eruption  rarely  exists  on  the 
sides  of  the  neck  alone,  and  if  present  there  is  continuous  with  large 
patches  on  the  trunk.  It  is  usually  darker  in  color,  slightly  elevated,  and 
scaly,  and  may  be  attended  with  mild  pruritus.  If  a  few  scales  are 
removed  and  microscopically  examined,  the  microsporon  furfur  will  be 
readily  seen  among  the  epithelial  cells.  The  pigmentary  syphilide  is  not 
a  scaling  affection,  and  if  any  scales  are  scraped  from  the  surface  no 
micro-organism  will  be  found. 

Addison's  Disease  and  Syphilis. 

In  connection  with  the  pigmentary  syphilide  the  description  of 
Sacaze's  ^  case,  in  which  Addison's  disease  developed  in  a  syphilitic  sub- 
ject, is  interesting.  The  patient  was  a  man  twenty  years  old.  Six 
months  after  infection  he  was  attacked  by  a  generalized  pigmentation  of 
face,  neck,  hands,  genital  organs,  and  inner  surface  of  thighs.  Besides 
this  dischromatous  change  there  were  loss  of  strength  and  appetite,  lumbar 
pains,  hebetude,  and  gastralgia.  Mercurials,  tonics,  and  liydrotherapy 
produced  only   temporary   benefit.     In  a  short  time  profound   asthenia 

^  Meditzinaknie  Ohozrenie,  No.  2,  1891,  p.  167. 

^  "Syphilis  avec  Syndrome  Addisonienne,"  Gaz.  des  Hopil.,  No.  7,  p.  58,  1895. 

41 


642  SYPHILIS. 

and  vomiting  supervened.  The  patient  died  of  marasmus  in  the  fifteenth 
month  of  infection  and  nine  months  after  the  onset  of  Addison's  disease. 
Sacaze  suggests  that  in  cases  of  this  disease,  other  causes  being  absent, 
it  is  well  to  ascertain  Avhether  the  patient  has  had  syphilis. 

Precocious  Gummata. 

Since  it  is  not  at  all  uncommon  to  observe  the  precocious  evolution  of 
gummata  even  as  early  as  the  second  or  third  month  of  the  infection,  it  is 
necessary  to  describe  these  lesions  in  this  place. 

There  are  three  distinct  varieties  of  early  or  precocious  gummata — a 
generalized,  a  localized,  and  a  neurotic  variety. 

The  generalized  form  appears  as  early  as  the  eighth  week  of  infection, 
and  at  any  time  during  the  first  and  early  parts  of  the  second  year,  the 
rule  being  that  the  earlier  the  date  of  appearance  the  more  extensive  is 
the  eruption  and  the  more  numerous  the  lesions.  It  begins  in  the  form 
of  small  circumscribed  swellings  under  the  skin,  usually  unattended  with 
pain  and  only  perceptible  to  the  touch.  In  a  short  time  these  become 
adherent  to  the  skin,  and  then  they  appear  like  bright-red  spots,  which 
are  frequently  looked  upon  as  blind  boils.  Thus  early  they  are  found  to 
be  round  or  oval  tumors  of  the  size  of  a  bean  deeply  set  in  the  skin. 
They  grow  quite  rapidly,  and  within  ten  days  may  attain  an  area  of  an 
inch  or  inch  and  a  half.  A  slower  growth  is  also  seen.  As  they  increase 
in  size  their  red  color  becomes  more  sombre,  and  perhaps  coppery.  When 
fully  developed  they  present  a  quite  firm  structure,  and  may  be  said  to 
be  in  the  stage  of  condensation.  Their  course  is  usually  quite  constant 
and  without  much  variation.  As  they  grow  older  their  red  color  becomes 
more  coppery,  and  they  gradually  grow  softer  in  structure,  as  if  they  were 
permeated  with  fluid.  This  may  be  called  the  stage  of  softening,  which 
varies  in  degree  in  different  cases.  In  some  tumors  there  is  simply  a  soft, 
yielding  condition  of  the  tissues ;  in  others,  what  appears  to  be  true  fluc- 
tuation may  be  felt.  To  the  inexperienced  these  tumors  in  the  latter  case 
may  give  the  impression  of  abscesses  and  suggest  the  use  of  the  knife, 
which,  however,  should  not  be  used,  since  absorption  may  occur  even  in 
this  stage  of  liquefaction  of  the  gummy  infiltration.  Under  favorable 
circumstances  these  lesions  do  not  go  on  to  ulceration,  and  they  are  then 
said  to  belong  to  the  resolutive  variety  of  this  early  form  of  gummata. 
Then  the  tumors  gradually  lose  the  slight  convex  elevation  Avhich  they 
had  attained,  and  slowly  flatten  out,  while  they  gradually  melt  away  from 
their  outer  edge,  their  color  fading  pari  passu  until  a  pigment-spot  is 
left  which  is  most  persistent  upon  the  legs.  Slight  or  severe  cicatrices 
may  also  be  left.  The  period  of  development  of  these  tumors  usually 
occupies  from  ten  days  to  two  weeks,  but  after  that  their  duration  is 
variable.  Under  careful  treatment  they  may  promptly  retrogress, 
and  may  without  it  remain  in  an  indolent  condition  in  the  second  stage 
indefinitely. 

This  eruption  is  prone  to  appear  symmetrically  over  the  body,  at  first 
in  a  crop  of  goodly  number,  which  may  be  increased  by  successive  smaller 
ones  at  shorter  or  longer  intervals.  Sometimes,  even  when  the  general 
eruption  is  copious,  medication  is  very  efficient  in  the  control  of  this 
syphilide,  and  new  crops  may  be  prevented  if  treatment  is  instituted 


THE  EARLY  OR  SECONDARY  SYPHILIDES.  643 

promptly.  The  arms,  forearms,  the  scapular  regions,  perhaps  the  back, 
the  anterior  surface  of  the  trunk,  the  gluteal  regions,  thighs,  and  legs, 
mostly  on  the  anterior  and  outer  aspects,  are  the  parts  usually  invaded. 
On  the  legs  these  tumors  frequently  take  on  inflammatory  action  when 
complicated  with  varicose  veins,  with  oedema,  chronic  eczema,  dermatitis, 
erysipelas,  and  pediculosis. 

In  some  cases  the  resolutive  tendency  in  this  eruption  is  not  observed, 
but  a  necrobiotic  action  soon  appears.  The  stage  of  condensation  is  then 
quite  short  and  softening  begins  early.  The  centre  of  the  tumors  assumes 
a  dark-red  color  in  one  or  in  several  spots,  and  distinct  fluctuation  is  soon 
made  out.  Then  slight  ulceration  begins,  usually  in  several  places,  cor- 
responding to  the  follicular  openings,  and  very  soon  the  epidermal  roof 
of  the  tumor  melts  away,  and  an  unhealthy  ulcer  with  a  slightly  fungat- 
ing  greenish-red  floor,  covered  with  a  sanious  pus  and  surrounded  by  a 
thickened,  deep-red,  undermined,  and  more  or  less  everted  edge,  is  seen. 
As  a  rule,  however,  these  precocious  gummatous  ulcers  are  more  super- 
ficial than  the  tertiary  ones  ;  their  floor  is  less  deep,  their  edges  less  under- 
mined and  everted,  and  their  whole  appearance  indicates  that  the  destruc- 
tion is  less  profound.  The  further  course  of  these  ulcers  is  largely  de- 
pendent upon  local  and  internal  medication,  without  which  it  may  be 
indefinite. 

The  concomitant  symptoms  of  this  generalized  early  gummatous  erup- 
tion are  those  of  the  secondary  period  of  syphilis.  It  frequently  follows, 
and  even  coexists 'with,  the  generalized  secondary  rashes.  There  is  usually 
much  accompanying  systemic  reaction,  cachexia,  malaise,  and  disturbance 
of  the  nervous  system. 

The  localized  form  of  early  gummata  appears  somewhat  later  than  the 
preceding  one ;  that  is,  at  about  the  fifth  month  and  within  the  first  year 
of  infection,  and  perhaps  later.  The  diff"erence  between  the  tAvo  is  mainly 
that  of  degree  and  extent  of  developm'ent  of  the  lesions.  Like  the  first 
variety,  the  evolution  of  the  tumors  is  aphlegmasic,  but  a  little  more  indo- 
lent and  insidious;  in  short,  partaking  to  a  certain  extent  of  the  charac- 
teristics of  both  the  very  early  secondary  and  tertiary  gummata.  The 
tumors  present  the  same  appearance,  except  that  they  are  larger  and  per- 
haps not  quite  as  salient  as  those  of  the  first  variety.  The  regions  of  the 
head  and  face,  pharyngeal  walls  and  mouth,  the  forearms  and  legs,  are 
the  ones  upon  which  the  eruption  usually  appears,  though  it  is  sometimes 
seen  upon  the  trunk,  arms,  and  thighs.  The  stages  of  condensation  and 
softening  are  observed  in  the  course  of  these  tumors,  which  may  become 
absorbed  or  may  break  down  into  ulcers  which  are  larger  and  more  pro- 
nounced in  their  features  than  the  earlier  ones. 

The  eruption  is  usually  symmetrical  in  the  early  months  of  syphilis, 
and  it  shows  a  progressive  tendency  to  unsymmetrical  development  as  it 
appears  later  in  the  disease. 

These  two  forms  of  gummata  are  found  in  aged  persons,  in  those  given 
to  alcoholic  excesses,  in  subjects  of  strumous  tendency,  and  those  debili- 
tated by  any  exhausting  cause  or  adynamic  influence,  such  as  visceral 
diseases,  fevers,  pneumonia,  diphtheria,  chronic  malaria,  want  and  squalor, 
and  in  persons  of  poor  fibres. 

The  neurotic  form  of  the  early  gummata  has  a  marked  individuality 
of  its  own,  and  presents  points  of  resemblance  to  erythema  nodosum.     In 


644  SYPHILIS. 

the  very  early  months  of  syphilis,  either  in  the  stationary  period  of  an 
early  syphilide  or  at  its  decline,  generally  preceded  or  accompanied  by 
severe  neuralgic  symptoms  involving  the  facial  or  cranial,  intercostal, 
anterior  crural,  or  any  cutaneous  nerve,  by  cephalalgia  continuous  or  noc- 
turnal, by  rheumatoid  pains  in  the  muscles  or  joints,  and  by  malaise  and 
debility,  this  eruption  makes  its  appearance  with  more  or  less  promptitude 
and  develops  quite  rapidly.  In  some  instances  so  acute  is  the  invasion 
that  in  a  week  we  may  find  fully-developed  tumors  an  inch  or  two  long, 
but  in  general  their  evolution  is  rather  less  rapid.  In  addition  to  the 
neuralgic  phenomena,  local  pains  on  the  sites  of  the  lesions  or  on  the 
whole  territory  or  limb  on  which  they  are  developed  are  complained  of. 
These  pains  may  be  continuous  or  intermittent,  and  in  some  instances  are 
as  excruciating  as  in  severe  herpes  zoster.  They  are  described  as  flash- 
ing, burning,  lancinating,  and  are  sometimes  said  to  resemble  those  of  an 
abscess.  In  some  instances  the  patient's  sufferings  are  less  after  the  evo- 
lution of  the  syphilide,  but  in  most  cases  the  tumors  are  so  painful  that 
patients  shrink  in  terror  from  their  palpation.  There  is  also  a  moderate 
febrile  movement,  an  evening  temperature  of  100°  or  101°  Fahr.,  and  in 
very  severe  cases  as  high  as  104°  ;  emaciation,  want  of  appetite,  and  all 
their  concomitant  symptoms.  The  seats  of  predilection  are  the  forearms 
and  legs,  but  the  tumors  may  appear  on  the  shoulders,  arms,  thighs,  chest, 
and  trunk.  As  a  result  of  the  pain  and  swelling  in  the  arms  and  legs 
there  are  more  or  less  discomfort,  stiffness,  impairment  of  motion,  even  to 
the  extent  of  pseudo-paralysis. 

The  eruption  consists  of  two  orders  of  lesions :  first,  oval  or  round 
tumors,  or  irregular  plaques  from  fusion  of  tumors ;  second,  tumors  or 
nodosities  seated  in  the  subcutaneous  tissues,  and  at  first  freely  movable 
under  the  skin  and  fasciae,  and  later  on  adherent  by  both  their  upper  and 
lower  surfaces. 

The  cutaneous  tumors  begin  by  infiltration  in  the  deeper  portions  of 
the  skin  and  its  contiguous  connective  tissue.  When  first  seen  they  are 
in  bright-red  and  rather  sharply  circumscribed  spots,  which  soon  form 
round  or  oval  swellings,  slightly  raised  and  convex.  In  some  cases  the 
bright-red  color  rapidly  becomes  darkened  until  a  blackish-red  or  de- 
cidedly ecchymotic  appearance  is  seen,  while  in  others  it  is  of  a  deep 
bright-red  similar -to  that  of  erythema  nodosum,^     In  some   cases,  again, 

'  The  coincidence  of  erythema  multiforme  with  syphilis  has  been  observed  by  Dan- 
ielsen  [Norsk  Magaz.  f.  Laegervidsk,  iv.  6),  Lipp  [Archiv  fixr  Dermatologie  und  Syphilis, 
1871,  vol.  iv.  p.  221),  and  Finger  ("  Ueber  den  Zusammenhang  der  multiformen  Erytheme 
mit  dem  Syphilis-Process,"  Prager  med.  Wochenschrift,  1882,  p.  262),  and  has  been  the 
subject  of  a  recent  paper  by  Bronson  ('•  Erythanthema  Syphiliticum,"  Medical  Record, 
Sept.  4,  1886),  but  beyond  the  fact  that  in  such  cases  syphilis  runs  a  severe  course,  as 
I  myself  have  observed,  little  which  is  definite  or  practical  has  been  evolved.  The  con- 
sensus of  opinion  concerning  this  coincidence  seems  to  be  that  these  symptoms  are  the 
result  of  angio-neuritic  disturbances,  and,  though  due  to  some  occult  infinence  of  the 
syphilitic  diathesis,  are  not  pathognomonic  of  the  disease.  Eronson  goes  still  further  in 
holding  that,  though  they  may  begin  as  simple  eruptions,  they  may  later  on  assume  a 
true  syphilitic  nature. 

I  am  firmly  of  the  opinion  that  the  precocious  neurotic  gnmmata  are  purely  of  syph- 
ilitic origin  and  nature,  and  not  in  any  sense  intercurrent  simple  eruptions.  As  in  the 
palate,  throat,  iris,  and  periosteum  there  is  often  precocious  gummatous  infiltration,  so  in 
the  subcutaneous  connective  tissue  of  the  skin,  which  is  essentially  the  one  upon  which 
the  activity  of  syphilis  is  spent,  may  this  precocious  development  take  place.  In  syphilis, 
as  in  sarcoma  and  leprosy,  while  in  general  its  new  growths  are  slow,  aphlegmasic,  local- 
ized, and  chronic,  in  exceptional  cases  they  be  precocious,  generalized,  and  very  active. 


AFFECTIONS  OF  THE   VARIOUS  MUCOUS  MEMBRANES.       645 

the  red  centre  pales  and  becomes  the  color  of  white  wax  or  of  a  billiard 
ball,  while  the  deep  red  border  or  areola  remains  in  various  stages  of 
intensity,  consisting  of  a  commingling  or  play  of  colors,  such  as  we  see 
following  a  bruise  or  erythema  nodosum.  In  many  cases  resolution  takes 
place ;  in  others  the  stage  of  softening  may  end  in  ulceration.  The 
resulting  ulcers  present  all  the  characters  of  the  late  gummata,  except 
that  they  are  rather  more  superficial.  Their  subsequent  course  is  usually 
chronic  and  aphlegmasic.  In  some  cases  general  inflammation  and  swell- 
ing attacks  a  limb  or  the  seat  of  these  lesions,  and  the  patient's  suffering 
is  thereby  much  increased.  Commonly,  these  tumors  or  ulcers  remain 
separate,  but  sometimes  they  increase  and  coalesce.  They  are,  as  a  rule, 
symmetrically  placed.  The  resulting  cicatrices  are  usually  slight  and 
superficial. 


CHAPTER    LXII. 

AFFECTIONS  OF  THE  VARIOUS  MUCOUS  MEMBRANES. 

Erythema,  Mucous  Patches,  and  Condylomata  Lata. 

The  mucous  membranes  continuous  with,  and  rather  remote  from,  the 
muco-cutaneous  junctions  are  frequently  afiected  in  the  secondary  stage 
by  hypergemic  and  hyperplastic  processes. 

Erythema  of  the  mucous  membranes  is  usually  identical,  in  the  time 
of  its  appearance  and  in  its  general  character,  with  the  same  eruption 
upon  the  skin.  Like  the  latter,  it  ordinarily  appears  six  or  eight  weeks 
after  infection,  and  may  affect  any  of  the  outlets  of  mucous  canals,  although 
it  is  most  frequently  seen  upon  the  fauces,  pituitary  membrane,  and  gen- 
ital organs,  and  in  many  instances  doubtless  fails  to  attract  attention.  It 
is  most  frequently  seen  upon  the  fauces  in  persons  exposed  to  sudden 
changes  of  temperature,  in  smokers,  and  in  those  who  are  subject  to  fre- 
quent attacks  of  catarrh  ;  upon  the  vulva  in  Avomen  who  have  frequent 
sexual  intercourse  ;  and  upon  the  glans  penis  in  men  with  a  long  pre- 
puce. It  may  be  the  only  general  lesion  present,  or  more  frequently  it  is 
accompanied  by  other  early  manifestations.  It  may  occur  in  patches  like 
the  erythematous  syphilide  upon  the  skin,  as  in  a  case  described  and 
figured  by  Ricord  of  erythema  of  the  glans  penis  coexisting  with  roseola 
upon  the  trunk,  in  which  the  former  eruption  was  arranged  in  circles  of  a 
bright-red  color,  enclosing  sound  portions  of  the  mucous  membrane  and 
closely  resembling  the  roseola  upon  the  body.  As  a  general  rule,  hoAv- 
ever,  especially  upon  the  fauces  and  vulva,  the  eruption  is  diffused  and 
its  outline  well  defined. 

Syphilitic  erythema  of  the  mucous  membranes  may  exhibit  more  red- 
ness of  the  surface,  without  structural  changes  in  the  tissues.  In  some 
cases,  however,  the  epithelium  has  a  milky  hue,  and  becomes  detached 
in  spots,  giving  rise  to  erosions.      The  surface  is  sometimes  dry,  and  at 


646  SYPHILIS. 

other  times  smeared  with  an  abundant  secretion.  There  is  usually  but 
little  swelling,  except  when  the  vulva,  the  tonsils,  and  the  pituitary  mem- 
brane or  the  labia  minora  are  affected.  In  the  case  of  the  nose  the 
swollen  folds  of  mucous  membrane  may  interfere  with  breathing  or  the 
passage  of  the  tears  through  the  lachrymal  ducts,  and  also  obstruct  the 
Eustachian  tubes.  Aside  from  these  mechanical  annoyances,  it  is  at- 
tended with  but  little  pain  or  inconvenience. 

This  eruption  often  disappears  quite  suddenly,  but  is  very  prone  to 
return. 

The  name  "  mucous  patch  "  is  applied  to  a  lesion  peculiar  to  syphilis, 
consisting  of  elevations  of  a  more  or  less  decided  rose-color,  frequently 
rounded  in  form,  the  surface  resembling  a  mucous  membrane,  and  situ- 
ated in  the  neighborhood  of  the  outlet  of  mucous  canals,  especially 
around  the  genital  organs  and  anus,  upon  the  mucous  membrane  of  the 
mouth,  and  sometimes  upon  other  parts  of  the  body,  more  particularly  at 
the  base  of  the  nails  and  wherever  the  reflection  of  the  integument  upon 
itself  forms  natural  folds  in  the  skin. 

This  affection  is  one  of  the  earliest  and  most  frequent  secondary  mani- 
festations of  syphilis,  and  is  therefore  one  with  which  the  student  of  syph- 
ilis should  be  perfectly  familiar  ;  unfortunately,  obstacles  have  been 
placed  in  the  way  of  acquiring  a  knowledge  of  it  by  the  confusion 
which  has  been  introduced  in  its  classification  and  in  the  terms  which 
have  been  applied  to  it.  Different  authors,  according  to  the  views 
they  have  entertained  of  its  nature,  have  described  it  among  tubercles, 
pustules,  and  papules,  and  have  called  it  by  the  corresponding  names  of 
"mucous  tubercle,"  "pustule,"  or  "papule,"  But  the  first  two  of  these 
terms  are  entirely  inappropriate,  since  it  does  not  resemble  syphilitic  pus- 
tules or  tubercles  in  its  time  of  development,  its'  symptoms,  course,  or 
termination.  The  name  "  mucous  papule  "  is  less  objectionable,  since  it 
consists  in  most  instances  of  a  development  of  the  papillae,  forming  broad 
elevations  above  the  surrounding  surface  ;  but  it  is  not  always  elevated, 
and  may  even  be  excavated,  and  it  is,  moreover,  so  distinct  in  its  charac- 
ters from  ordinary  papules,  and  of  such  importance  as  an  indication  of 
constitutional  infection,  that  it  is  well  to  retain  the  name  "  mucous 
patch." 

As  regards  its  histology,  this  lesion  is  found  to  consist  mainly  in  a 
marked  hyperplasia  of  the  papillae,  and  an  abundant  proliferation  of  cells 
in  the  mucous  layer,  which  present  a  muddy  appearance  due  to  granular 
changes  in  their  protoplasm  and  segmentation  of  their  nuclei.  The 
sheaths  of  the  hair-bulbs  and  the  walls  of  the  vessels  are  likewise  infil- 
trated and  thickened.  The  surface  of  the  patch  may  retain  its  epithelium, 
or  the  latter  may  become  detached  and  removed  ;  it  may  either  become 
depressed  beloAv  the  surrounding  surface  of  the  process  of  ulceration,  or 
rise  above  the  same  in  consequence  of  further  development  of  the  papillae, 
whence  arise  the  various  appearances  which  this  lesion  may  present. 

As  already  stated,  this  lesion  is  found  at  the  outlet  of  mucous  canals 
and  upon  those  portions  of  the  external  integment  which  are  maintained 
by  contact  in  a  constant  state  of  warmth  and  moisture,  and  are  thus  very 
nearly  in  the  condition  of  mucous  surfaces. 

Erythema  axd  Mucous  Patches  of  the  Mouth. — Erythema  of 
the  buccal  cavity  is  usually  confined  to  the  neighborhood  of  the  fauces. 


AFFECTIONS  OF  THE   VARIOUS  MUCOUS  MEMBRANES       647 

It  may  readily  be  confounded  with  the  effects  of  an  ordinary  cold,  from 
which  it  often  can  be  distinguished  only  by  the  history  of  the  case.  The 
presence  of  narrow,  dusky-red  bands  of  inflammation  along  the  border 
of  the  velum,  ending  abruptly  at  the  base  of  the  uvula,  is  considered  by 
some  observers  to  be  characteristic  of  syphilitic  erythema.  Associated 
with  this  condition,  as  well  as  with  other  lesions,  there  is  often  a  general 
oedema,  especially  of  the  velum  and  uvula.  The  latter  organ  may  become 
very  much  swollen. 

The  most  common  syphilitic  lesions  of  the  mouth  are  mucous  patches. 
They  are  most  frequently  found  upon  the  tonsils,  the  uvula,  the  velum 
palati  and  its  pillars,  the  sides  of  the  tongue,  and  the  mucous  surfaces  of 
the  lips,  especially  the  lower.  At  the  angles  of  the  mouth  they  are  often 
continuous  with  a  pustular  eruption  upon  the  integument.  The  inner 
surface  of  the  cheek  near  the  last  molar  tooth  is  another  favorite  seat. 
The  dorsum  of  the  tongue  and  the  gums  are  less  frequently  affected. 
Their  most  characteristic  feature  is  the  grayish-white  color,  appearing  as 
if  they  had  been  pencilled  over  with  a  crayon  of  nitrate  of  silver,  which 
has  given  them  the  name  of  "  opaline  patches."  They  are  more  irreg- 
ular in  their  outline  than  condylomata,  and,  unlike  the  latter,  are  not, 
as  a  general  rule,  perceptibly  elevated  above  the  surface.  In  some  cases 
the  adventitious  deposit  which  gives  them  their  grayish  color,  and  which 
is  with  difficulty  removed,  is  confined  to  the  irregular  margin  of  the 
patch,  while  the  centre  remains  sound  ;  and  when  presenting  this  ap- 
pearance they  have  been  compared  to  the  track  of  a  snail. 

Papules  are  often  seen  in  the  mouth  coincidently  with  a  general  pap- 
ular eruption.  Owing  to  the  constant  maceration  of  the  mucous  mem- 
brane of  the  mouth,  the  formation  of  vesicles  is  rare  if  not  impossible. 

The  name  ''^plaques  des  fumeurs  "  has  been  given  to  certain  patches 
most  frequently  seen  on  the  mucous  lining  of  the  cheeks  near  the  angles 
of  the  mouth.  They  occur  most  frequently  in  the-  mouths  of  inveterate 
smokers,  and  are  due  to  the  proliferation  of  the  epithelium,  which  becomes 
opaline,  as  though  the  spots  had  been  touched  with  carbolic  acid  or  with 
nitrate  of  silver  ;  the  patches  are  sometimes  fissured,  and  may  become 
eroded,  although  the  epithelium  is  usually  very  adherent.  They  are  gen- 
erally quite  obstinate,  and  persist  long  after  the  apparent  extinction  of 
the  infection. 

Treatment. — Mucous  patches  of  the  mouth,  from  which  infection  so 
often  occurs  to  innocent  persons,  should  be  carefully  and  regularly 
treated.  The  morbid  parts  may  be  touched  with  a  tampon  moistened  in 
a  solution  of  nitrate  of  silver  (30  gr.  to  water  1  ounce),  or  this  may  be 
used  as  a  spray.  The  mouth  should  be  constantly  rinsed  and  the  throat 
gargled  with  strong  solutions  of  borax,  chlorate  of  potassa,  and  alum. 
Particular  attention  should  be  paid  to  the  condition  of  the  stomach,  and 
plain,  nutritious  food  should  be  allowed.  Smoking  is  to  be  absolutely 
interdicted,  and  the  use  of  stimulants  and  irritating  condiments  is  to  be 
suspended. 

In  some  cases  the  application  of  a  1  or  2  per  cent,  watery  solution  of 
chromic  acid  is  very  efficacious. 

Superficial  Affections  of  the  Tongue. — Coincidently  with 
pharyngeal  erythema  the  mucous  membrane  of  the  tongue  may  also 
become  hyper^mic.     In  some  cases  the  morbid  process  extends  over  the 


648  SYPHILIS. 

whole  tongue,  while  in  others  it  occurs  in  the  form  of  round  or  oval 
disks  scattered  over  the  dorsum.  From  these  hypersemic  patches  the 
epithelium  may  be  removed,  and  as  a  result  they  are  seen  eroded  or  even 
perfectly  smooth,  and  showing  plaques,  of  which  there  may  be  one  or  two 
or  several.  This  condition,  somewhat  frequently  seen  in  syphilis,  is  also 
observed  in  the  mouths  of  non-syphilitics,  particularly  in  those  who  suffer 
from  gastro-intestinal  troubles.  Excoriated  or  smooth  round  or  oval 
patches  of  the  tongue  are  not,  therefore,    pathognomonic  of  syphilis. 

Not  uncommonly  we  see  scattered  over  the  tongue  and  on  its  tip  and 
sides  little  irregular  patches  of  epithelial  hyperplasia  which  have  a 
bright  or  a  dull  pearly-white  surface.  These  lesions,  due  to  circum- 
scribed areas  of  hypersemia,  are  as  small  as  a  pin's  head  and  perhaps  of 
the  extent  of  one  or  two  lines.  They  are  usually  a  little  salient.  By 
means  of  local  and  general  treatment  these  lesions  may  be  removed,  but 
they  are  often  very  obstinate  and  persistent. 

Mucous  patches  of  the  tongue  are  not  at  all  infrequent,  and  are  found 
chiefly  on  its  tip  or  on  its  sides.  They  are  more  or  less  annoying  or 
painful,  and  in  smokers  and  persons  suffering  from  indigestion  they  show 
a  tendency  to  become  chronic  and  to  relapse  in  an  exasperating  manner. 
They  may  be  complicated  by  general  lingual  hypersemia. 

As  a  result  of  erythema  and  mucous  patches  of  the  tongue,  this  organ 
becomes  the  seat  of  fissures  which  are  developed  either  over  the 
dorsum  or  on  the  sides.  On  the  dorsum  of  the  tongue  these  fissures  are 
irregular  and  sinuous  in  shape,  while  on  the  sides  and  at  the  tip  they  are 
in  general  vertically  placed.  Coexistent  with  this  fissuration  of  the 
tongue  there  is  usually  mild  or  severe  epithelial   hyperplasia. 

These  lesions  are  obstinate  in  their  course,  and  they  present  decided 
evidence  of  being  of  epithelial  structure.  These  plaques  have  been 
variously  called  psoriasis,  ichthyosis  of  the  tongue,  and  leukoplakia. 
When  they  begin  in  the  secondary  period,  it  is  usually  not  difiicult  to 
establish  the  fact  that  they  originated  in  a  syphilitic  soil.  But  when  they 
develop  late  in  the  infection,  there  may  be  some  doubt  as  to  their 
etiology.  These  lesions  belong  to  the  class  of  parasyphilitic  manifesta- 
tions, Avhich  are  usually  processes  or  conditions  resulting  from  irritative 
changes  left  by  the  original  syphilitic  inflammation.  They  are  the  out- 
come, but  not  the  essential  derivatives,  of  syphilitic  infection. 

These  lingual  lesions  are  very  prone  to  lead  to  epitheliomatous  degen- 
eration, hence  their  bearers  are  always  in  jeopardy. 

Treatment. — The  treatment  of  mucous  patches  and  of  the  milder 
forms  of  epithelial  hyperplasia  of  the  tongue  is  similar  to  that  of 
mucous  patches  of  the  mouth. 

In  the  obstinate  cases  of  fissures  a  gargle  of  bichloride  of  mercury 
in  water,  1 :  1000,  is  sometimes  very  beneficial.  In  some  cases  these 
lesions  require  active  but  carefully  applied  cauterization,  either  with 
equal  parts  of  carbolic  acid  and  glycerin  or  nitrate  of  silver  and  water, 
even  as  high  as  10  per  cent.  Strong  applications  should  only  be  made  at 
intervals  of  several  days.  In  the  interim  mild  and  astringent  solutions 
of  alum  or  tannin  may  be  used. 

For  epithelial  plaques  it  may  be  necessary  to  apply  liquid  carbolic 
acid  or  a  solution  of  caustic  potassa  (sj  to  water  5J)-  These  cases  sorely 
tax  the  patience  of  the  afflicted  person  and  of  the  surgeon. 


AFFECTIONS  OF  THE   VARIOUS  MUCOUS  MEMBRANES       649 

In  all  cases  of  syphilitic  inflammation  of  the  tongue  it  is  most  im- 
portant that  every  source  of  irritation  shall  be  removed. 

Internal  treatment  has  no  influence  whatever  upon  the  psoriatic  or 
ichthyotic  patches  of  the  tongue. 

Affections  of  the  Nose. 

The  pituitary  membrane  may  be  the  seat  of  erythema,  superficial  ulcer- 
ations, and  mucous  patches,  which  give  rise  to  symptoms  resembling  those 
of  an  ordinary  catarrh.  Besides  these  lesions,  in  some  cases  an  adenoid 
tissue  is  developed  which  gives  much  trouble  and  annoyance  by  stopping 
up  the  nasal  passages.  Sometimes  an  ulcer  may  be  seen  just  within  the 
nasal  orifice,  surrounded  by  swollen  mucous  membrane  and  rendering  the 
aloe  nasi  tender  upon  pressure.  Plugs  of  inspissated  mucus,  mixed  with 
blood  and  pus,  which  obstruct  the  passages,  are  from  time  to  time  dis- 
charged. The  nasal  secretion  is  more  abundant  and  more  purulent  when 
ulcerations  or  mucous  patches  exist.  In  the  absence  of  other  lesions  of 
syphilis  upon  the  skin  or  elsewhere,  the  character  of  the  nasal  afi"ections 
mav  be  suspected  only  because  of  their  persistence. 

Treatment. — In  treating  erythematous,  exulcerous  conditions,  mucous 
patches,  and  adenoid  inflammation  in  the  nose  it  is  of  prime  importance 
not  to  use  strong  stimulating  applications,  except  under  certain  restric- 
tions. The  parts  should  be  sprayed  several  times  a  day  with  Dobell's 
solution.  The  very  mild  solution  of  nitrate  of  silver  (gr.  j  to  sviij  water) 
may  be  used,  and  very  frequently  insuflflations  of  equal  parts  of  iodoform 
and  boric  acid  are  very  beneficial.  In  all  cases,  as  a  rule,  an  active 
internal  treatment  should  be  administered. 

Affections  of  the  Larynx. 

In  the  secondary  stage  the  larynx  may  be  attacked  by  (1)  erythema, 
(2)  superficial  ulcerations,  (3)  mucous  patches,  (4)  chronic  inflammation, 
with  hypertrophy  of  the  mucous  membrane  and  vegetations. 

With  regard  to  laryngeal  syphilis  in  general,  it  seems  to  be  true  that 
the  more  remote  a  lesion  is  from  the  entrance  to  the  larynx  the  more 
serious  will  be  its  consequences,  and  that  the  subjective  symptoms  of  a 
lesion  are  by  no  means  commensurate  with  its  gravity.  For  instance,  a 
superficial  ulcer  may  be  complicated  by  an  acute  oedema  so  general  and  so 
excessive  as  to  threaten  life ;  on  the  other  hand,  a  destructive  process  may 
have  gone  on  to  a  considerable  degree  while  the  patient  is  in  ignorance  of 
his  condition.  The  invasion  of  the  larynx  by  syphilis  is  usually  very 
insidious,  and  the  subsequent  course  of  the  lesions  is  chronic  and  devoid 
of  pain.  It  is  very  probable  that  the  parts  of  the  vocal  organism  most 
often  in  contact  during  the  performance  of  its  function  are  more  frequently 
attacked  by  syphilis.  Hence  the  vocal  cords  and  the  arytenoids  are  the 
most  susceptible  structures. 

Erythema. — Erythema  of  the  larynx,  unless  it  be  very  acute  and 
attended  by  oedema,  may  be  so  slight  as  to  attract  no  attention,  the 
only  symptoms  being  slight  huskiness  of  the  voice  and  moderate  catarrh. 
No  doubt  it  occurs  during  early  skin  eruptions,  and  it  is  frequently  de- 
veloped at  more  advanced  stages,  either  independently  or  in  connection 
with  deep  laryngeal  lesions.     There  may  be  nothing  in  the  appearance 


650  SYPHILIS.    -■ 

of  the  affection  to  distinguisli  it  from  a  simple  catarrh.  It  occurs  either 
in  patches,  "which  give  the  mucous  membrane  a  mottled  appearance,  or 
it  may  be  limited  to  certain  regions,  or  it  may  be  diffuse,  the  lining  of 
the  larynx  having  a  uniform  dusky-red  hue.  There  may  be  superficial 
erosions  of  the  mucous  membrane.  The  vascularity  of  the  affected 
parts  is  much  increased,  the  blood-vessels  often  presenting  the  appear- 
ance referred  to  by  Krishaber  and  Mauriac  as  ^'-  arhorization."  When 
the  epiglottis  participates  in  the  affection  and  in  the  concomitant  oedema, 
it  may  be  much  tumefied  and  assumes  a  bilobed  shape. 

S'lqjerficial  Ulcerations. — The  superficial  ulcerations  observed  in 
laryngeal  syphilis  involve  only  the  mucous  membrane,  and.  according 
to  Baumler,  usually  begin  in  mucous  follicles  at  the  posterior  commis- 
sure. They  may  affect  phonation  to  some  extent,  but  are  generally 
very  sluggish,  persisting  with  slight  change  for  an  indefinite  period. 
Their  margins  are  well  defined,  quite  regular,  and  very  slightly  ele- 
vated above  the  surrounding  level.  The  surface  of  the  ulcers  is  usually 
concealed  by  a  layer  of  tenacious  secretion.  Frequently  general  eryth- 
ema of  the  mucous  membrane  coexists.  These  early  ulcerations, 
whose  appearance  is  quite  different  from  that  of  ulcers  occurring  at  a 
later  period,  maybe  confounded  with  incipient  tuberculous  ulcers.  They 
are  not  so  likely  as  are  the  later  ulcerations  to  be  mistaken  for  epitheli- 
oma. The  following  points  of  distinction  should  be  remembered :  Tu- 
berculous ulcers  begin  in  the  ventricular  bands  and  are  usually  paler 
than  those  of  syphilis.  They  are  bathed  in  a  copious  muco-purulent 
secretion.  There  are  decided  swelling  and  oedema  of  the  arytenoids, 
while  the  mucous  membrane  elsewhere  is  anaemic.  The  course  of  phthis- 
ical ulcers  is  more  rapid  and  painful,  and  pulmonary  symptoms  coexist 
or  are  soon  manifested.  Whistler  states  that  in  syphilis  the  voice  is 
rough  and  rasping,  while  in  phthisis  it  is  whispering  and  moist,  suggest- 
ing the  presence  of  excessive  secretion.  The  absence  of  ulceration  in 
the  mouth,  the  blanched  appearance  of  the  palate  and  fauces,  while  the 
pharynx  may  be  congested,  are  indicative  of  the  tubercular  character 
of  laryngeal  ulceration.  Symmetry  in  the  position  and  outline  of  syph- 
ilitic ulcers  is  considered  characteristic  by  some  authorities. 

Great  diversity  of  opinion  has  prevailed,  even  since  a  method  of  in- 
specting the  larynx  during  life  has  been  provided,  regarding  the  fre- 
quency of  mucous  patches.  Ferras  considers  them  very  rare,  having 
found  them  in  only  one  instance  among  nearly  100  cases  of  syphilis. 
Krishaber  and  Mauriac,  on  the  contrary,  found  10  cases  of  mucous 
patches  in  14  of  laryngeal  syphilis,  the  former  observer  discovering 
them  only  on  the  vocal  cords.  Whistler  states  that  he  has  met  with  24 
cases  of  this  lesion  among  88  of  syphilis  in  its  secondary  stage.  In  his 
experience  the  time  of  its  occurrence  varied  from  one  and  a  half  to 
twelve  months  after  primary  infection.  In  all  cases  mucous  patches  of 
the  mouth  or  genitals  coexisted;  in  7  cases  papular  or  papulo-squamous 
eruptions  were  found,  in  1  case  associated  with  a  roseola.  In  1  case 
six  weeks  after  infection  the  indurated  cicatrix  of  a  chancre  was  still 
present.  Enlarged  glands  and  alopecia  occurred  in  many  instances. 
In  10  cases  the  epiglottis  was  the  seat  of  the  lesion,  and  in  10  the  vocal 
cords ;  in  4  cases  the  arytenoids,  in  2  the  interarytenoid  fold,  in  2  the 
ventricular  band,  and  in  1  the  glosso-epiglottic  fold.     When  seated  on 


AFFECTIONS  OF  THE   VARIOUS  MUCOUS  MEMBRANES.       651 

parts  exposed  to  irritation,  either  in  respiration  or  in  phonation,  mucous 
patches  of  the  larynx  are  prominent  Avith  ragged  margins,  forming  what 
are  known  as  condylomata ;  in  other  regions  they  are  flatter  and  the 
ulceration  is  more  sharply  cut.  Their  surface  is  covered  by  a  scanty 
viscid  secretion.  The  removal  of  this  film  exposes  a  red,  excoriated 
surface  in  striking  contrast  with  the  paler  hue  of  the  surrounding  mu- 
cous membrane.  Sometimes  the  centre  of  a  patch  is  slightly  depressed, 
its  borders  remaining  prominent.  Besides  the  ulcerated  form  of  mucous 
patch,  we  also  meet  with  the  opaline  patch,  according  to  Whistler  more 
often  on  the  epiglottis  and  on  the  arytenoids.  In  these  lesions  the  epi- 
thelium is  thickened  and  still,  adherent,  the  deeper  tissues  being  infil- 
trated with  new  cells.  The  opalescent  appearance  is  attributed  by 
Cornil  to  minute  collections  of  pus  amidst  the   epithelial   cells. 

Chronic  inflammation  of  the  larynx  is  an  intermediate  lesion ;  it  may 
follow  an  early  catarrh  or  may  not  appear  until  three  or  four  years  after 
infection.  The  color  of  the  mucous  membrane  is  decidedly  darker  than 
in  the  early  erythemas,  although  Whistler  affirms  that  it  never  deserves 
the  name  "  coppery  "  which  has  been  applied  to  it  by  some  authors.  The 
affection  is  very  persistent,  and  commonly  leads  to  thickening  or  hyper- 
trophy of  the  mucous  membrane,  which,  according  to  Krishaber,  is  the 
only  one  of  the  early  lesions  which  does  not  disappear  spontaneously. 
This  thickening  is  quite  diff"erent  from  the  oedema  occurring  with  an 
erythema,  in  which  the  mucous  membrane  has  a  puffy  appearance.  The 
thickening  of  the  cords  may  be  so  great  as  to  require  operative  inter- 
ference for  the  relief  of  the  dyspnoea.  A  remarkable  instance  of  this 
condition  has  been  reported  in  which  tracheotomy  was  done  four  times 
during  a  period  of  five  years.  Associated  with  this  condition  chronic 
ulcers  are  almost  always  found.  These  ulcers  have  ragged  and  thickened 
edges ;  frequently  vegetations  spring  from  them  which  may  reach  a  con- 
siderable size,  even  to  the  degree  of  producing  aphonia  and  of  impeding 
respiration.  The  vocal  cords,  which  are  thickened  and  rough,  are  very 
often  the  seat  of  these  ulcers.  The  ventricular  bands  may  be  so  swollen 
as  to  overlap  the  cords.  The  vegetations,  which  may  grow  from  the  mar- 
gins of  an  ulcer  or  from  other  portions  of  the  mucous  membrane,  are 
often  difficult  to  distinguish  from  simple  polypoid  growths.  Their  favorite 
seat  is  at  the  insertion  of  the  inferior  vocal  cords.  Ferras  states  that  they 
may  appear  in  the  ventricles  of  the  larynx,  Avhere  natural  papillae  are 
scanty.  The  history  of  the  case,  or  even  the  empirical  use  of  specific 
treatment,  may  sometimes  be  required  to  determine  their  character. 

Symptoms. — There  are  certain  symptoms,  some  of  them  common  to 
many  of  the  lesions  of  laryngeal  syphilis,  which  deserve  special  attention. 
Spontaneous  pain  is  very  rare.  It  is  considered  an  indication  of  the  inva- 
sion of  fibrous  or  cartilaginous  tissues.  Cough  is  also  an  extremely  rare 
symptom,  and  expectoration,  if  present,  is  scanty,  mucous,  or  muco-puru- 
lent.  The  sputa  may  be  tinged  with  blood  from  an  ulcerative  lesion  or 
from  ruptured  capillaries.  In  cases  of  caries  or  necrosis  they  may  con- 
tain fragments  of  cartilage  or  bone.  In  the  latter  condition  also  the 
breath  is  likely  to  have  a  fetid  odor.  Alteration  in  the  volume  and 
quality  of  the  voice  may  be  very  slight,  even  in  severe  lesions.  Fre- 
quently the  voice  becomes  hoarse  or  assumes  a  character  called  by  the 
French  '■''  crapuleuse."     Sometimes  it  is  reduced  to  an  almost  inaudible 


652  SYPHILIS. 

"whisper.  Dysphagia  is  quite  infrequent  except  in  very  advanced  stages 
of  disease  or  when  the  epiglottis  is  attacked.  Dyspnoea  may  supervene 
in  consequence  of  stenosis  due  to  various  causes,  chief  of  which  are 
oedema,  growths  Avhich  invade  the  air-passages  or  occlude  them  by  pres- 
sure from  without,  and  cicatricial  contractions.  Probably  spasm  may 
be  an  occasional  and  temporary  cause  of  dyspnoea.  CEdema  may  occur 
with  any  lesion  of  syphilis.  The  submucous  effusion  may  take  place 
rapidly,  in  which  case  the  danger  to  life  is  imminent,  or  it  may  be 
gradual.  In  the  latter  case  the  patient  may  accommodate  himself  to  a 
very  considerable  diminution  in  the  calibre  of  the  larynx.  The  disap- 
pearance of  an  acute  oedema  is  usually  proportionately  rapid,  while  a 
slowly-formed  effusion  may  persist  for  a  long  time.  Among  new  growths 
which  may  cause  stenosis  of  the  larynx  are  to  be  included  vegetations, 
hypertrophy  of  the  mucous  membrane  following  chronic  inflammation, 
gummy  tumors,  and  exostoses.  The  most  intractable  cases  of  stenosis 
are  those  due  to  gradual  contraction  of  cicatrices.  This  unfortunate 
result  usually  follows  only  the  deep  ulcerations  of  the  later  stages  of  syph- 
ilis. Superficial  ulceration  may  involve  quite  extensive  surfaces,  producing 
complete  aphonia  and  other  pronounced  subjective  symptoms,  yet  a  cure 
may  be  obtained  with  entire  restoration  of  the  functions  of  the  larynx. 
It  is  in  these  cases  of  stenosis  from  cicatricial  contraction  that  the  opera- 
tion of  tracheotomy  is  sometimes  necessitated.  The  experience  of  Krish- 
aber,  however,  authorizes  confident  delay  of  surgical  means  of  relief,  even 
in  the  case  of  alarming  dyspnoea  from  other  causes,  the  energetic  use  of 
specific  remedies,  especially  by  the  hypodermic  method,  having  been 
promptly  efficacious  in  many  instances. 

The  larynx  may  also  be  occluded  by  the  formation  of  false  membrane 
between  the  vocal  cords.  This  is  rather  a  rare  cause  of  stenosis.  Elsberg 
stated  that  in  about  270  cases  of  laryngeal  syphilis  he  had  met  with 
this  condition  six  times.  It  may  result  from  superficial  ulceration,  and, 
on  the  contrary,  has  been  observed  in  conjunction  with  destruction  of  the 
cartilages  and  other  late  lesions.  The  process  appears  to  begin  usually  at 
the  anterior  commissure,  leaving  a  passage  for  the  air  posteriorly.  It  may 
take  place  in  a  reverse  direction,  or  an  aperture  may  be  left  in  the  middle 
of  the  rima  glottidis  or  along  the  edge  of  the  vocal  cord. 

Treatment.— The  early  efflorescences  in  the  larynx  usually  disappear 
quite  promptly  under  the  influence  of  internal  treatment.  If  they  are 
obstinate,  they  usually  yield  rapidly  to  the  nitrate-of-silver  spray  (gr.  j- 
iv  to  5viij  water). 

Deeper  lesions  should  be  treated  by  occasional  moderately  strong  cau- 
terization (nitrate  of  silver  or  carbolic  acid),  followed  by  spraying  with 
Dobell's  solution.  When  there  is  ulceration, .  insufflation  of  equal  parts 
of  iodoform  and  boric  acid  is  required. 

Mucous  Patches  and  Condylomata  of  the  Genital  Organs. 

The  most  frequent  seat  of  mucous  patches  in  men  is  around  the  anus 
and  within  the  mouth,  and  in  women  upon  the  vulva.  It  has  been 
asserted  that  they  are  much  more  frequent  in  the  latter  than  in  the  former 
sex,  but  the  difference  is  probably  not  so  great  as  has  been  supposed. 
There  is  certainly  no  more  common  symptom  in  male  patients  affected 


AFFECTIONS  OF  THE   VARIOUS  MUCOUS  MEMBRANES.       653 

with  syphilis.  They  are  also  present  in  most  cases  of  hereditary  syphilis 
in  infants,  and,  in  consequence  of  the  moist  condition  of  the  integument 
at  this  early  age,  are  not  confined  to  the  regions  above  mentioned,  but 
may  be  scattered  over  the  whole  surface  of  the  body,  and  especially  the 
nates  and  thighs. 

The  development  of  mucous  patches  is  everywhere  favored  by  inatten- 
tion to  cleanliness,  and  in  the  mouth  by  the  use  of  tobacco,  either  by 
smoking  or  chewing :  in  men  who  are  habituated  to  these  practices  they 
constitute  one  of  the  most  persistent  and  troublesome  symptoms  we  have 
to  deal  with,  and  in  dirty  prostitutes  of  the  lower  class  they  are  equally 
abundant  and  obstinate  about  the  genital  organs. 

Mucous  patches  vary  in  appearance  according  to  their  situation.  The 
chief  points  of  difference  are  found  between  those  seated  upon  the  exter- 
nal integument  and  those  upon  membranes  which  are  strictly  mucous. 

The  former,  which  are  met  with  for  the  most  part  around  the  anus  and 
genital  organs  in  the  two  sexes,  consist  of  rounded  disks,  either  single  or 
aggregated,  of  a  reddish  or  grayish  color,  granulated  and  elevated  to  the 
height  of  about  a  line  above  the  integument,  upon  which  they  appear  to 
be  superimposed  like  a  number  of  cones  laid  upon  the  part.  They  then 
receive  the  name  of  condylomata.  Their  appearance  is  so  peculiar  that 
when  once  seen  it  cannot  be  forgotten. 

Condylomata  Lata. 

The  mode  of  development  of  condylomata  lata  is  as  follows :  A  red 
spot  first  appears  upon  the  skin,  and  a  slight  effusion  takes  place  beneath 
the  epidermis — sufficient  to  loosen  it  from  the  derma,  but  not  to  raise  it 
in  the  form  of  a  vesicle  or  bulla ;  the  epidermis  is  removed  by  friction  or 
falls  off,  and  exposes  a  raw  surface,  upon  which  a  moist  grayish  pellicle 
is  formed ;  the  surface  is  elevated  by  hypertrophy  of  the  superficial  layers 
of  the  skin,  and  gives  rise  to  the  broad,  flat,  wart-like  disks  above  re- 
ferred to. 

In  Fig.  206  condylomata  lata  situated  around  the  vulva  and  anus  are 
graphically  portrayed.  In  Fig.  207  condylomata  lata  of  the  anus  of  a 
man  are  well  shown. 

Another  and  a  very  singular  mode  of  origin  of  mucous  patches  is  from 
the  surface  of  a  chancre,  which  during  the  reparative  process  may  granu- 
late above  the  surrounding  integument  and  become  covered  with  a  thin, 
translucent,  and  grayish  pellicle.  This  transformation  of  a  primary  into 
a  secondary  symptom  has  already  been  described  in  the  chapter  upon 
Chancre. 

When  originating  from  a  chancre,  mucous  patches  are  seated  upon  an 
indurated  base,  but  otherwise  the  tissues  beneath  them  are  found  on  pres- 
sure to  retain  their  normal  suppleness.  Contrary  to  the  statements  of 
some  authors,  they  never  present  the  copper  color  of  other  syphilitic 
eruptions,  but  are  either  of  a  reddish-  or  grayish-white  color.  If  the 
patient  happen  to  be  jaundiced,  the  pellicle  covering  them  may  be  tinged 
with  yellow.  They  are  usually  smeared  with  a  very  offensive  muciforra 
secretion,  which  is  peculiarly  unpleasant  when  the  patches  are  seated  in 
the  neighborhood  of  the  genitals.  The  odor  is  so  strong  as  to  pervade 
the  whole  room.     In  a  few  exceptional  instances  the  patches  are  dry. 


654  SYPHILIS. 

Mucous  patches  readily  become  ulcerated.  When  exposed  to  friction 
against  the  clothes  or  the  opposed  integument,  the  pellicle  covering  the 
patch  is  removed,  and  a  red,  superficial,  but  depressed  ulceration  takes 
the  place  of  the  elevated  disk.  Such  is  the  origin  of  the  raw  surfaces 
frequently  seen  upon  the  sides  and  front  of  the  scrotum  in  syphilitic 
patients. 

Ulcerated  mucous  patches  upon  the  margin  of  the  anus  closely  resem- 
ble ordinary  anal  fissures,  from  which  they  may  be  distinguished  by  their 
more  prominent  and  rounded  edges  and  by  the  grayish  pellicle  which  is 

Fig.  206. 


Condylomata  lata  of  the  vulva  and  anal  region.    On  the  latter  they  present  a  papillomatous  or 

vegetating  appearance. 

generally  visible  upon  the  sides  of  the  cleft.  When  situated  between  the 
toes,  they  yield  a  thin,  brownish,  and  very  offensive  discharge,  and  they 
often  project  upon  the  dorsum  or  palmar  surface  of  the  foot  in  the  form 
of  a  crescent  at  the  base  of  the  interdigital  sulci.  Ulcerated  and  fissured 
mucous  patches  upon  the  margin  of  the  anus,  between  the  toes,  or  else- 
where are  called  rJiagades. 

Condylomata  upon  the  vulva  are  generally  elevated  and  of  a  reddish 
color.  Those  that  occur  within  the  vagina  and  upon  the  cervix  uteri 
more  closely  resemble  mucous  patches  upon  the  external  integument  than 
those  situated  upon  other  mucous  membranes,  as,  for  instance,  within  the 
buccal  cavity.  Mucous  patches  upon  the  genital  organs  in  both  sexes 
sometimes  give  rise  to  a  discharge  resembling  gonorrhoea  from  the  neigh- 
boring mucous  membrane,  which  is  not  unfrequently  observed  about  the 


AFFECTIONS  OF  THE  VARIOUS  MUCOUS  MEMBRANES.       655 


time  that  early  secondary  symptoms  appear  or  when  a  relapse  of  general 
symptoms  takes  place. 

Unlike  most  syphilitic  eruptions,  mucous  patches  are  frequently  at- 
tended by  pruritus,  especially  when  seated  upon  the  scrotum  or  perineum, 
and  when  proper  attention  is  not  paid  to  cleanliness  or  the  parts  have 
become  warm  and  moist  from  exercise  or  prolonged  contact  in  bed.  The 
unquestionably  infectious  character  of  these  lesions  has  previously  been 
mentioned. 

Mucous  patches  may  react  upon  the  neighboring  lymphatic  ganglia  in 
the  same  manner  as  syphilitic  eruptions  situated  upon  the  scalp,  but  only 

Fig.  207. 


Condylomata  of  the  anus. 

in  case  their  development  is  attended  by  acute  inflammation.  Thus,  the 
submaxillary  glands  are  frequently  swollen  from  sympathy  with  mucous 
patches  upon  the  fauces,  and  the  inguinal  glands  may  be  enlarged  in  con- 
sequence of  the  presence  of  condylomata  upon  the  scrotum,  but  the  effect 
upon  the  latter  is  less  readily  perceived,  because  they  are  generally  indu- 
rated from  their  anatomical  connection  with  the  primary  sore. 

Treatment. — In  all  cases  of  mucous  patches  or  of  condylomata  lata  on 
or  about  the  genitals  an  energetic  systemic  treatment  should  be  adopted. 
Locally,  the  prime  essentials  are  absolute  cleanliness,  as  much  dryness  as 
can  be  obtained,  and  the  covering  of  the  parts  by  some  protective  sub- 
stance, or  the  interposition  of  some  absorbent  material,  cotton  or  gauze, 
between  coapted  surfaces.  Black  or  yellow  wash,  applied  on  absorbent 
cotton,  is  very  efficacious. 

For  anal  condylomata  in  men  Ricord's  favorite  treatment,  which  con- 
sists in  washing  them  twice  a  day  with  Labarraque's  solution  of  chlori- 
nated soda,  then  sprinkling  them  with  calomel,  and  separating  the  opposed 
surfaces  by  the  interposition  of  lint,  is  generally  very  successful,  but  it  is 
sometimes  rather  painful. 

When  these  lesions  are  very  large  and  papillomatous,  they  may  be 
lightly  and  carefully  touched  with  a  solution  of  nitrate  of  silver  (3j  to 


656  SYPHILIS. 

"ft-ater  sj),  with  cUoroacetic  acid,  carbolic  acid,  or,  in  very  exuberant 
cases,  with  the  acid  nitrate  of  mercury.  After  these  active  cauterizations 
the  parts  should  be  well  washed  and  dried,  and  then  dusted  with  some 
inert  powder,  over  which  a  layer  of  absorbent  cotton  should  be  placed. 
Aristol,  resorcin,  or  calomel  in  combination  with  starch  or  boric  acid  forms 
a  pleasant  and  effective  application  for  continual  use. 

In  women  especially  the  parts  should  be  kept  extremely  clean  and 
dry.  Hot  intra  vaginal  injections  of  bichloride  of  mercury  and  water 
(1 :  3000  or  5000)  should  be  used  several  times  daily.  The  parts  should 
then  be  dried  and  dusted  with  equal  parts  of  calomel  and  starch,  and  an 
abundance  of  absorbent  cotton  should  be  kept  on  by  means  of  a  bandage 
if  possible.  In  some  of  these  cases  active  cauterization,  preferably  with 
carbolic  acid,  should  be  made. 


CHAPTEK  LXIIL 

AFFECTIONS    OF    THE    HAIR. 

Alopecia  is  one  of  the  most  common  symptoms  of  syphilis.  By  rea- 
son of  its  prominence  and  of  its  compromising  character  it  is  the  source 
of  constant  worry  and  annoyance  to  its  bearer.  It  varies  from  slight  to 
almost  complete  loss  of  hair,  which  is  rarely  permanent,  and  its  course 
may  be  rapid  or  chronic.  It  is  attended  by  no  subjective  symptoms,  such 
as  heat  or  itching,  and  in  most  cases  there  are  no  marked  lesions  of  the 
scalp,  while  in  other  cases  the  hair-follicles  may  be  involved  by  macules, 
papules,  pustules,  or  ulcers.  The  eyebrows,  the  beard,  and  moustache, 
the  hair  of  the  pubes  and  axillse,  may  also  be  involved.  The  eyelashes 
are  seldom  attacked,  except  by  ulcerative  lesions,  and  alopecia  never  exists 
elsewhere  without  affecting  the  scalp.  These  may  be  called  the  essential 
alopecise,  while  loss  of  hair  due  to  destructive  or  inflammatory  lesions  is  a 
secondary  form. 

There  are  two  varieties  of  syphilitic  alopecia — one  consisting  of  a 
simple  thinning  or  more  or  less  complete  shedding  of  the  hair,  and  the 
other  of  loss  of  the  hair  in  tolerably  circumscribed  patches.  They  both 
occur  with  about  equal  frequency. 

The  first  form  of  alopecia  begins  rather  abruptly,  and  on  each  combing 
many  hairs  usually  come  away.  On  the  scalp  the  result  of  this  alopecia 
is  generally  striking,  but  it  may  be  so  slight  as  to  pass  unnoticed,  the  hair 
merely  being  thinned.  The  hair  may  be  lost  in  one  or  more  patches, 
which  vary  in  size  and  occur  without  symmetry  or  order;  they  may  be 
as  large  as  the  palm  of  one's  hand,  and  several  may  fuse  together.  Their 
outline  is  irregular,  and  they  show  no  tendency  to  assume  a  circular  form. 
The  surface  of  the  patches  is  rather  dry  and  somewhat  scaly ;  the  follicles 
are  quite  prominent,  and  scattered  irregularly  may  be  a  few  long  hairs, 
sometimes  one  or  more  tufts,  and  minute  hairs.     The  surface  of  the  scalp 


AFFECTIONS  OF  THE  HAIR.  657 

is  dry  and  presents  a  few  furfuraceous  scales.  In  patients  who  have  been 
subject  to  seborrhoea  capitis — or,  as  it  is  generally  known,  pityriasis 
capitis — this  condition  is  often  much  more  marked. 

Patients,  especially  men,  who  have  suffered  from  this  form  of  baldness 
not  infrequently  get  into  a  state  of  mind  in  which,  after  the  cessation  of 
the  fall,  nothing  can  ,  convince  them  that  it  does  not  yet  continue.     They 

Fig.  208. 


The  diffuse  shedding  form  of  syphilitic  alopecia. 

come  regularly  with  their  complaints  and  sorrows,  and  often  vainly  pass 
their  fingers  through  their  hair,  hoping  to  bring  away  a  few  with  which 
to  convince  the  surgeon  that  the  affection  is  still  active.  In  most  cases 
this  delusion  is  dispelled  after  a  time.  In  Fig.  208  this  form  of  alopecia 
is  well  shown.  The  general  diffuse  shedding  of  the  hair  of  the  scalp  is 
typically  portrayed.  In  this  case  there  was  loss  of  eyebrows  and  eyelashes. 
The  second  or  patchy  form  of  syphilitic  alopecia  presents  such  striking 
features  that  when  it  is  once  seen  it  is  thereafter  readil}'-  recognized  by  the 
surgeon.  The  surface  of  the  scalp  presents  a  moth-eaten  or  mangy  appear- 
ance. The  hairs  are  generally  dry  and  lustreless,  giving  the  appearance 
of  malnutrition.  The  bahl  patches  are  of  irregular  round  or  oval  outline, 
and  from  fusion  they  become  gyrate.  The  scalp  is  dry,  scaly,  and  gener- 
ally unhealthy  in  appearance.  Tlie  hair-follicles  are  prominent,  and  from 
some  of  them  stumpy  hairs  protrude. 

42 


658 


SYPHILIS. 


This  form  of  alopecia  (admirably  portrayed  in  Fig.  209)  is  usually 
most  severe  on  the  back  and  upper  portions  of  the  head,  and  less  so  on 
the  sides  and  frontal  region.     It  runs  a  chronic,  sluggish  course. 

The  hair-follicles  may  be  involved  by  erythematous  spots,  papules,  or 
pustules  coincidently  with  a  general  eruption.  In  such  cases  the  loss  of 
hair  is  generally  slight  and  scattered.  The  arch  of  the  eyebrows  may  be 
interrupted  by  the  fall  of  a  few  hairs  or  may  be  totally  destroyed,  giving 

Fig.  209. 


The  moth-eaten  form  of  syphilitic  alopecia. 


the  patient  a  very  peculiar  appearance.  In  the  beard,  in  the  axillae,  and 
upon  the  pubes  the  loss  of  hair  may  also  be  partial,  complete,  or  in 
patches. 

Syphilitic  alopecia  is  peculiar  to  the  secondary  period,  and  generally 
begins  about  the  third  month,  at  the  decline  of  the  earlier  secondary  symp- 
toms. It  may  occur  at  any  time  before  the  end  of  the  second  year,  and 
is  very  frequently  associated  with  cachexia. 

The  pathological  anatomy  of  the  hair-follicles  has  been  studied  by 
Giovannini,^  who  found  a  small  cell-infiltration  in  the  connective-tissue 

^  "  Delle  Alterazione  Anatomo-patholo.dclie  di  una  forma  di  Alopecia  sifilitica," 
Giorn.  delle  Mai.  Ven.  e  della  Pelle,  Dec,  18b9,  pp.  460  et  seq. 


AFFECTIONS  OF  THE  HATE.  659 

cells  of  the  periplier}^^  of  the  follicle,  particularly  around  the  vessels.  This 
infiltration  is  seated  in  the  lower  two-thirds  of  the  follicles,  and  extends 
to  the  inferior  limits  of  the  bulb.  The  infiltration  penetrates  even  be- 
tween the  epithelial  cells,  Avhich  are  altered  at  this  point.  As  a  result, 
the  nutrition  of  the  follicle  is  impaired  and  the  hairs  fall. 

Darier^  made  microscopical  examinations  of  the  hairs  in  syphilitic 
alopecia.  He  found  the  following  conditions:  (1)  in  the  majority  of 
cases  the  shaft  and  bulb  seem  normal,  but  there  is  less  pigment  and 
the  medullary  portion  may  be  absent ;  (2)  the  hairs  at  the  bulb  are 
smaller  than  the  shaft  to  the  extent  of  one-half  or  one-fourth  the  nor- 
mal size ;  (3)  the  shaft  is  uniformly  thin,  except  at  the  bulb,  where  it 
is  pointed. 

When  ulcerative  changes  occur  in  the  follicles,  or  when  pustules  attack 
the  scalp,  and  sometimes  even  when  erythematous  spots  and  papules  occur, 
the  papillae  may  be  destroyed  and  the  follicles  become  obliterated,  perma- 
nent baldness  resulting.  This  happens  in  a  marked  degree  in  connection 
"with  late  tubercles  and  gummatous  ulcers. 

Diagnosis. — The  diagnosis  of  syphilitic  alopecia  is  to  be  made  from 
pityriasis  capitis  (seborrhoea),  senile  baldness,  and  alopecia  areata.  The 
suddenness  of  invasion  and  the  generally  marked  character  of  the  bald- 
ness in  syphilitic  alopecia  and  its  non-inflammatory  course  are  in  marked 
contrast  with  the  chronic  course  and  the  scaly  and  somewhat  pruritic  con- 
dition of  pityriasis  capitis.  Moreover,  the  suspicion  of  syphilis  is  con- 
firmed by  the  history  of  the  case  and  the  discovery  of  other  specific 
lesions. 

Senile  alopecia — incorrectly  so  called,  since  it  usually  begins  in  middle 
life — extends  backward  from  the  forehead  or  begins  at  the  vertex,  and  is 
wholly  unlike  the  syphilitic  aff"ection.  Moreover,  the  scalp  is  smooth  and 
shiny,  and  the  follicular  openings  are  no  longer  visible. 

Alopecia  areata  is  much  more  common  in  children  than  in  adults,  and 
occurs  in  round,  oval,  or  serpiginous  patches,  the  hair  on  other  parts  of 
the  scalp  being  preserved.  The  surfaces  of  the  patches  are  very  smooth 
and  polished,  and  of  a  yellowish-white  color ;  they  are  not  scaly,  and  they 
are  completely  destitute  of  hair. 

The  prognosis  of  syphilitic  alopecia  is  in  general  good.  In  some  cases 
the  loss  of  hair  is  so  extensive  and  its  renewal  so  slow  that  permanent 
baldness  seems  to  be  inevitable.  The  main  points  upon  which  to  ba,se 
the  prognosis  are  the  extent  of  the  baldness,  its  duration,  and  the  patient's 
general  health.  If  the  affection  has  been  severe  and  has  existed  for  some 
time,  if  treatment  has  been  neglected  and  incomplete,  and  if  cachexia  has 
taken  place,  the  prognosis  must  be  very  guarded. 

Treatment. — Cases  of  syphilitic  alopecia  call  for  a  vigorous  local  and 
constitutional  treatment.  If  possible,  inunctions  should  be  used  on  the 
neck  and  especially  upper  parts  of  the  body.  The  hair  of  the  scalp  should 
be  cut  off"  quite  close,  and,  if  expedient,  should  be  shaved,  and  frequent 
shampooing  is  very  beneficial.  Every  day  the  morbid  parts,  and  indeed 
the  whole  scalp,  should  be  well  rubbed  with  an  ointment  composed  of 
white  precipitate  30  grains  and  cold  cream  1  ounce.  This  application 
may  be  made  at  night.     The  parts  should  be  well  washed  with  soap  and 

^    "Sur  I'Examen  microscopique  des  Cheveux  dans  I'Alop^cie  sypliilitique,"  Anruiles 
de  Derm,  el  de  SyphiL,  1889,  pp.  198  et  seq. 


660  SYPHILIS. 

water  in  the  morning,  and  twice  during  the  day  they  should  be  vigorously 
rubbed  with  the  following  lotion,  applied  with  a  sponge : 

"S^.  Hydrarg.  bichlor.,  gr.  iv-viij  ; 

Tr.  cantharidis,  §j  ; 

Tr.  capsici,  §ss ; 

Liq.  coloniensis,  §ij  ; 

Aquae,  ^iv. — M. 


CHAPTEE  LXIV. 

AFFECTIONS    OF   THE   NAILS. 

Syphilitic  affections  of  the  nails  are  of  two  varieties :  in  one,  called 
onychia,  the  disease  begins  in  the  nails  themselves  ;  and  in  the  other, 
called  perionychia,  it  begins  in  their  vicinity  and  involves  them  second- 
arily. Their  course  is  chronic,  and  may  be  mild  or  severe  and  destructive. 
They  generally  appear  within  the  first  two  years  of  syphilitic  infection, 
but  their  invasion  may  occur  much  later. 

In  syphilitic  onychia  the  changes  may  be  dry  and  confined  to  the  nail- 
substance  or  the  nail  may  be  separated  from  its  bed. 

In  the  dry  form,  onychia  sicca,  called  by  Fournier  "  friable  onychia" 
{onyxis  craquete),  the  nail  gradually  loses  its  lustre  and  transparency  at  its 
free  edge  and  assumes  a  dull-yellow  color ;  sometimes  the  disease  is 
limited  by  a  distinct  line  of  demarcation  or  the  Avhole  nail  may  be  in- 
volved. The  edge  of  the  nail  becomes  thickened  and  brittle,  readily 
cracks,  and  may  be  deeply  serrated  (Fig.  210). 

Its  surface  is  rough,  and  presents  shallow,  longitudinal  fissures  and 
minute  depressions,  which  collect  the  dirt.  In  some  cases  the  mor- 
bid process  begins  as  a  small  pinkish,  perhaps  scaly,  spot  limited  to  one 
segment  of  the  reflection  of  the  integument,  just  at  the  sulcus.  From 
this  focus  the  chronic  inflammatory  process  extends  both  along  the  sulcus 
and  into  the  nail,  Avhich  it  literally  destroys.  The  epidermis  under 
and  beyond  the  free  margin  is  usually  thickened  and  scaly.  Very  often 
there  is  but  slight  inconvenience  from  the  disease,  and  the  deformity  may 
be  remedied  by  careful  paring  of  the  nail.  In  some  cases,  however, 
the  process  becomes  so  intense  that  the  Avhole  nail  is  converted  into  an 
irregular  rough  plate,  causing  great  deformity  of  the  hands,  which  is  very 
annoying  to  patients. 

Treatment  results  in  the  gradual  pushing  forAvard  of  the  diseased  por- 
tion, leaving  a  healthy  nail.  In  neglected  cases,  especially  if  the  parts 
are  irritated,  the  whole  of  the  affected  nail  may  be  lifted  off  or  pushed 
forward  by  a  new  nail,  which  may  at  first  be  imperfect. 

There  is  also  an  hypertropldc  onychia,  in  which  the  thickening  of  the 
nail  is  excessive.     It  involves  the  nails  of  the  fingers  more  frequently 


AFFECTIONS  OF  THE  NAILS 


661 


than  those  of  the  toes,  and  usually  attacks  more  than  one  nail.  He 
thinks  women  are  more  subject  to  it  than  men.  This  hypertrophic  state 
is  well  shown  on  the  nail  of  the  thumb  in  Fig.  210. 

There  is  also  an  affection  of  the  nails,  of  which  I  have  seen  several 
well-marked  instances  in  men  suffering  with  syphilitic  cachexia,  which 
seems  to  be  a  local  necrosis.     The  nail  becomes  opaque  and  whitish,  in 

Fig.  210. 


Dry  onychia. 

spots  the  size  of  a  pinhead.  These  spots,  of  which  there  may  be  from 
two  or  three  to  ten,  are  formed  by  depressions  of  the  surface  of  the  nail, 
which  finally  reach  the  matrix,  leaving  minute  and  sharply-cut  holes.  In 
some  cases  the  necrosis  is  superficial,  and  the  whole  thickness  of  the  nail 
is  not  perforated.  When  this  occurs  the  nail  presents  much  the  appear- 
ance of  the  roughened  surface  of  a  thimble. 

Separation  of  the  nail  takes  place  not  infrequently  in  the  early  part 
of  the  secondary  stage  of  syphilis,  and  may  be  partial  or  complete.  The 
process  may  be  so  insidious  and  it  may  cause  so  little  inconvenience, 
especially  with  careless  persons  and  when  the  toe-nails  are  affected,  that 
several  nails  may  fall  without  attracting  the  notice  of  the  patient.  It 
begins  at  the  free  border  of  the  nail,  being  limited  at  first  to  a  portion  of 
its  breadth  (Fig.  211). 

It  gradually  extends  toward  the  base  of  the  nail,  involving  one-third 
to  one-half  its  length,  and  possibly  its  entire  breadth.  In  neglected 
cases  the  whole  nail  may  be  affected  and  thrown  off.  The  diseased  por- 
tion of  the  nail  assumes  a  greenish-brown  color,  and  the  matrix  beneath 
presents  more  or  less  healthy  granulations.  When  the  destruction  of  the 
nail  has  been  partial  the  healthy  portion  pushes  forward  and  covers  the 
denuded  parts ;  when  it  has  been  complete,  an  entirely  new  nail  is 
formed.  Only  one  nail  may  be  affected,  or  several  may  be  involved 
simultaneously  or  in  succession,  those  of  the  hands  more  frequently  than 
those  of  the  feet.     (See  Fig.  211.) 


662 


SYPHILIS. 


There  are  three  forms  of  perionychia — an  ulcerative,  an  indolent  form 
which  is  usually  non-ulcerative,  and  a  diffuse  form. 

The  non-ulcerative  form  may  attack  the  entire  attached  margin  of  the 
nail  or  its  lunula  or  one  of  its  lateral  margins.  The  border  of  the  nail, 
to  the  width  of  about  one  line,  is  thickened  in  consequence  of  specific 
infiltration,  and  there  is  a  more  or  less  complete  papular  rim  around  it. 
The  color  is  dull  red,  which  pales  on  pressure,  and  the  surface  is  slightly 
scaly.  This  condition -may  persist  for  a  long  time,  until  the  nail  becomes 
of  a  dull  color  and  is  traversed  by  shallow  transverse  furrows,  showing 

Fig.  211. 


Separation  of  the  nails. 


impaired  nutrition.  As  a  result  of  pressure  or  irritation  ulceration  may 
occur  at  the  angle  of  reflection  of  the  skin,  and  may  extend  beneath  the 
nail,  which  is  finally  loosened  and  thrown  off.  Sometimes,  when  only  a 
lateral  margin  is  afi"ected,  the  ulceration  reaches  but  a  short  distance,  and 
the  nail  remains  and  excites  a  chronic  suppurative  inflammation,  which  is 
cured  only  after  its  partial  or  complete  ablation.  In  two  well-marked 
forms  the  first  is  chronic  and  subacute,  and  the  second  is  of  rapid  inva- 
sion and  of  diffuse  extent. 

Ulcerative  perionychia  occurs  at  any  time  during  the  secondary  period, 
and  varies  greatly  in  severity.  It  may  begin  as  a  papule  or  a  pustule  at 
some  part  of  the  nail-margin,  or  a  small  ulceration  or  fissure  at  the  lunula 
is  the  change  first  noticed.  In  either  case  the  inflammation  gradually 
increases,  and  ulceration  extends  along  the  sulcus  at  the  attached  margin 
of  the  nail.  The  process  may  be  limited  to  the  lunula  or  to  a  portion 
of  the  nail-border,  or  it  may  involve  the  entire  length  of  the  sulcus. 
When  the  lunula  is  invaded  the  affection  is  very  obstinate ;  the  base  of 


AFFECTIONS  OF  THE  NAILS.  663 

the  nail  soon  loses  its  transparency  and  becomes  detached  to  the  extent 
of  about  a  line.  The  ulceration,  which  extends  under  the  nail  itself, 
and  may  be  for  a  time  inaccessible,  constantly  secretes  an  offensive  pus. 
The  whole  nail  may  be  gradually  undermined,  or  the  parts  may  be  de- 
nuded to  a  limited  extent  by  destruction  of  the  attached  margin.  Much 
depends  on  the  early  treatment  of  the  ulceration :  if  it  be  speedily 
checked,  a  new  nail  forms  and  covers  the  diseased  parts,  pushing  the 
old  nail  before  it. 

When  the  ulceration,  which  is  likely  to  be  particularly  intense  at  the 
lunula,  is  severe,  the  whole  matrix  becomes  involved,  and  after  the  nail 
has  been  thrown  off  it  presents  a  yellowish,  somewhat  pultaceous  surface, 
surrounded  by  the  swollen  and  ulcerated  nail-margin.  Soon  the  ulcera- 
tion shows  a  tendency  to  localize  itself  at  the  basal  margin,  while  the  sur- 
face of  the  matrix  becomes  covered  with  a  dirty-yellow,  firm,  and  uneven 
epithelial  tissue.  Unless  ulceration  involves  the  lateral  margins,  which 
it  seldom  does,  a  thin  spicula  of  nail  forms  along  the  whole  length  of 
the  sulcus.  In  such  a  typical  case  the  whole  phalanx  is  swollen  and 
bulbous,  and  the  matrix  is  hypertrophied,  pulpy,  and  of  a  reddish-yellow 
color.  Attempts  at  formation  of  a  new  nail  are  seen  upon  the  matrix 
and  at  its  margins.  Owing  to  its  dense  structure  the  matrix  itself  is 
very  resistant,  and  if  left  Avithout  treatment  it  becomes  thickened  as  the 
ulceration  increases. 

If  the  base  of  the  nail  has  not  been  too  extensively  destroyed,  it  re- 
tains a  surprising  degree  of  reparative  power.  A  new  nail  appears  and 
covers  the  matrix,  unless  it  be  excessively  hypertrophied,  and  may  be 
quite  as  good  as  the  original  nail.  In  some  cases  a  perfect  nail  results 
only  after  several  renewals.  It  sometimes  happens  that  the  nail-pro- 
ducing poAver  of  the  distal  portion  of  the  matrix  is  impaired,  so  that 
the  new  nail  fails  to  cover  as  much  of  the  finger  as  did  its  predecessor. 
When  this  condition  coexists  with  total  destruction  of  the  base  the  whole 
matrix  is  converted  into  a  cicatrix. 

When  the  inflammation  attacks  the  base  and  one  side  of  the  nail,  it 
involves  the  subjacent  matrix,  and  if  its  intensity  in  the  latter  region 
equals  that  at  the  base,  separation  of  the  nail  at  the  side  soon  takes 
place,  and  permits  the  free  application  of  remedies.  Such  cases  are  of 
much  less  gravity. 

In  persons  whose  hands  are  exposed  to  irritants  perionychia  may 
begin  under  the  free  edge  of  the  nail,  generally  of  the  index  or  middle 
finger.  Slight  pain  attracts  the  attention  of  the  patient,  and  he  finds 
a  brownish-red  crust  beneath  the  nail,  removal  of  which  exposes  an 
ulcer  extending  along  more  or  less  of  the  nail's  breadth.  On  removal 
of  the  irritation  and  the  use  of  proper  remedies  the  ulcer  soon  heals ; 
in  case  of  neglect  it  extends,  and  rapidly  involves  the  whole  of  the 
matrix,  or  it  creeps  slowly  along,  the  nail  assuming  a  dull,  yellowish- 
brown  color,  the  matrix  exhibiting  a  yellow,  ulcerated  appearance,  and 
the  whole  phalanx  becoming  enlarged  until  the  base  of  the  nail  is 
reached,  when  a  condition  similar  to  that  of  inflammation  of  the  lunular 
region  is  induced. 

The  third  or  diffuse  form  of  perionychia  begins  as  a  hyperemia 
which  is  bright,  diffuse,  and  not  limited  to  the  nail.  For  two  or  three 
weeks  the  case  may  present  simply  a  reddened  condition  of  the  distal 


664 


SYPHILIS. 


portion  of  the  affected  fingers.  There  may  be  no  pain  at  first.  In  this 
very  subacute  manner  the  bright  red  deepens  into  a  coppery  hue,  and 
the  affected  parts  become  swollen  and  bulbous  or  of  the  shape  of  an 
Indian  club,  due  to  syphilitic  inflammation  and  infiltration.  Coinci- 
dently  with  the  intensification  of  the  disease  the  nails  become  affected 
and  are  destroyed,  seemingly  as  if  struck  by  a  blight. 

This  rapid  necrosis  is  peculiar  to  this  form  of  perionychia.  The 
nail  first  loses  its  color,  which  becomes  dull  and  dark,  then  its  attach- 
ment at  each  border  gives  Avay  first,  and  after  that  in  its  whole  extent, 
ulceration  with  the  formation  of  a  thick,  ill-smelling  pus  taking  place 
beneath  it.  The  nail  then  rapidly  becomes  considerably  swollen,  uneven, 
and  puckered,  and  of  a  black  and  green  color,  well  shown  in  Fig.  212. 

Fig.  212. 


Diffuse  perionychia. 

With  the  onset  of  the  nail-affections  pain  becomes  an  important  ele- 
ment in  the  case,  and  the  fingers  are  then  useless  for  any  function.  The 
imbedded  portion  of  these  appendages  is  the  one  which  gives  the  most 
trouble.  Here  the  destructive  process  is  usually  not  sufficiently  great 
to  cause  the  spontaneous  extrusion  of  the  nail,  and  this  sequestrum 
remains,  causing  severe  pain,  acting  as  a  foreign  body,  and  keeping  up 
the  ulcerative  process.  Frequently  in  these  cases  so  severe  is  the  in- 
flammation that  the  forearm  and  arm  become  red,  swollen,  and  painful, 
with  sympathetic  implication  of  the  axillary  glands,  attended  \>y  high 
fever,  malaise,  and  much  suffering.  This  lymphangitis  is  observed  in 
some  cases.  When,  however,  the  dead  nail  is  removed  and  appropriate 
treatment  is  adopted,  the  coppery-red  phalanx  loses  its  tension,  becomes 
superficially  wrinkled,  and  of  a  purplish-red  color.  The  ulcerated  sur- 
face left  by  the  fall  of  the  nail  becomes  less  anfractuous,  and  healthy 
granulations  spring  up.  Then  from  the  basal  sulcus  in  a  few  months, 
usually  about  two,  the  encroaching  end  of  a  new  nail  shows  itself,  and 
it  'progresses  in  a  more  or  less  perfect  manner  until  finally  the  whole 
nail-matrix  is  covered.     Fretjuently  the  new  nail  at  first  is  wrinkled 


AFFECTIONS  OF  THE  NAILS.  665 

and  far  less  comely  than  its  predecessor,  but  under  favorable  circum- 
stances it  gradually  becomes  normal.  In  severe  and  uncared-for  cases 
the  matrix  of  the  nail  is  entirely  destroyed,  and  then  no  new  nail  is 
formed.  This  result  is  often  seen  when  the  intensity  of  the  ulceration 
is  spent  at  the  basal  portion  of  the  lunula. 

All  forms  of  syphilitic  perionychia  are  very  chronic,  rarely  lasting 
less  than  one  or  two  months,  and  sometimes  continuing  a  year.  At 
first  they  may  cause  scarcely  any  inconvenience,  and  for  this  reason 
they  are  often  neglected. 

The  nails  of  the  fingers  and  of  the  toes  are  attacked  with  equal  fre- 
quency, those  most  used  and  most  exposed  being  the  most  liable.  In 
general,  only  one  finger  is  affected,  sometimes  a  finger  of  each  hand,  or 
two  fingers  of  the  same  hand,  either  simultaneously  or,  more  commonly, 
in  succession.     In  many  cases  several  or  all  the  nails  become  affected. 

Diagnosis. — Chronic  eczema  and  psoriasis  of  the  hand  are  sometimes 
followed  by  changes  in  the  nail  similar  to  those  of  syphilitic  friable 
onychia.  The  question  may  be  settled  by  the  previous  history  of  the 
case. 

I  have  seen  two  cases  of  separation  of  the  nail,  in  every  particular 
similar  to  that  produced  by  syphilis,  in  Avhich  that  infection  did  not 
exist. 

Ulcerative  perionychia  has  been  mistaken  for  the  initial  lesion  of 
syphilis. 

A  chancre  of  the  finger  is  seldom  met  with  except  in  the  case  of 
midwives  and  surgeons,  and  is  always  accompanied  by  characteristic 
enlargement  of  the  epitrochlear  or  axillary  ganglia. 

Severe  perionychia  resembling  the  syphilitic  form  is  sometimes  seen 
in  broken-down  and  cachectic  subjects.  Its  occurrence  should  always 
excite  the  suspicion  of  syphilis. 

The  prognosis  of  friable  and  of  hypertrophic  onychia  is  good,  since 
its  course  is  generally  mild  and  transient.  The  same  is  true  when 
separation  of  the  nail  occurs,  the  morbid  condition  being  soon  relieved 
by  proper  treatment. 

The  non-ulcerative  form  of  perionychia  usually  distresses  the  patient 
on  account  of  its  attacking  several  nails,  but  it  occasions  slight  inconveni- 
ence and  is  readily  cured. 

The  ulcerative  forms  are  always  troublesome  and  often  very  painful 
affections,  and  the  prognosis  should  always  be  guarded.  The  earlier 
separation  of  the  nail  occurs  and  the  focus  of  disease  at  the  base  of  the 
nail  is  reached  by  local  applications,  the  sooner  may  relief  be  expected. 
New  and  comely  nails  sometimes  develop  even  after  prolonged  and  in- 
tense basal  ulceration.  In  nearly  all  cases  where  the  perionychia  is 
lateral  or  at  the  free  border  of  the  nail  a  perfect  nail  may  be  pre- 
dicted. 

The  growth  of  the  new  nail  is  very  slow,  and  the  spicuhie  at  the 
edges  and  the  uneven  plates  which  often  form  on  the  surface  of  the 
matrix  are  important  indications  of  retention  of  the  nail-producing 
power.  The  new  nail  is  often  imperfect  at  first,  being  ridged  and 
irregular,  and  it  is  sometimes  permanently  shorter  than  the  old  one. 

Treatment. — Active  internal  treatment  is  required  in  all  forms  of 
syphilitic  affections  of  the  nails. 


666  SYPHILIS. 

Friable  onychia  calls  for  no  other  local  treatment  than  careful  trim- 
ming of  the  nails  and  prevention  of  irritation.  The  severe  forms  of 
dry  onychia  are  often  very  intractable,  and  require  active  local  treat- 
ment. The  fingers  should  be  soaked  twice  daily  in  hot  bichloride  solu- 
tion (1  :  2000),  and  mercurial  ointment  should  be  well  rubbed  in  and 
kept  on  the  parts. 

In  case  of  separation  of  the  nail  exposure  of  the  matrix  and  the 
application  every  day  or  two  of  liquor  potassae,  followed  by  the  use  of 
an  ointment  composed  of  one  part  of  mercurial  and  two  parts  of  diach- 
ylon ointment,  will  arrest  the  disease.  The  simple  form  of  perionychia 
may  be  cured  by  the  use  of  this  ointment. 

In  ulcerative  perionychia  the  diseased  surface  should  be  exposed  as 
soon  as  possible,  and  cauterized  with  nitric  acid  or  a  strong  solution  of 
nitrate  of  silver,  allaying  inflammatory  reaction  with  water  dressings. 
Subsequently  iodoform  or  powdered  nitrate  of  lead  may  be  applied,  and 
the  phalanx  be  enveloped  in  diachylon  ointment.  The  profuse  granula- 
tions of  the  matrix  may  require  the  use  of  a  strong  solution  of  caustic 
potassa  (sj-Sij  or  iv).  Prolonged  immersion  of  the  hand  in  very  warm 
bichloride  solution  (1  :  2000)  diminishes  the  swelling  and  removes  the 
secretions.  The  application  of  a  bandage  over  the  ointment.  India- 
rubber  finger-stalls,  or  gutta-percha  tissue,  may  serve  to  reduce  the 
swelling.     Care  must  be  taken  to  apply  the  pressure  gradually. 

In  addition,  zinc  and  belladonna  ointments  or  Goulard's  extract  may 
be  used  to  meet  special  indications. 


CHAPTER    LXV. 

REINFECTION  WITH  SYPHILIS ;  SYPHILIS  IN  ELDERLY  AND  OLD 
PERSONS;  AND  THE  IMMUNITY  OF  ANIMALS. 

Reinfection  with  Syphilis. 

As  a  general  rule,  syphilis,  like  small-pox,  scarlet  fever,  measles,  etc., 
attacks  the  individual  but  once  in  his  lifetime.  On  this  subject  Ricord 
was  quite  explicit,  and  his  statement  is  now  generally  known  as  Ricord's 
law.^  It  reads  as  follows  :  '■'■General  Rule. — A  patient  who  has  had  for 
the  first  time  an  indurated  chancre  does  not  have  another.  It  is  probable 
that  this  law  may  have  exceptions."  Though  it  is  claimed  by  some 
French  authors  that  this  law  has  no  exceptions,  a  sufficient  number  of 
well-attested  cases  has  been  published  to  warrant  the  statement  that  in 
certain  rare  instances  syphilis  does  attack  the  individual  twice  in  his  life- 
time. There  have  been  published  up  to  date  about  one  hundred  and 
sixty  cases  of  syphilitic  reinfection,  and  it  is  safe  to  say,  allowing  much 
latitude,  that  not  thirty  of  the  whole  number  are  really  authentic  cases. 
^  Lettres  sur  la  Syphilis,  3d  ed.,  Paris,  1863,  p.  262. 


REINFECTION  WITH  SYPHILIS,  ETC.  667 

On  this  subject  the  following  cases,  taken- from  my  note-book,  will,  I 
think,  throw  much  light.  These  cases  were  all  brought  to  my  notice  for 
review  during  a  long  stretch  of  years  as  instances  of  syphilitic  reinfection. 
In  every  case  the  history  of  a  primary  attack  of  syphilis  was  clearly  made  out : 

1.  Chancroids  irritated  by  caustics,  followed  later  on  by  an  erythema- 
tous rash,  due  to  iodide  of  sodium. 

2.  Indurated  nodule  of  the  lip  in  late  secondary  syphilis,  due  to  the 
irritation  of  a  pipe,  which  was  followed  by  a  sparse  and  annular  erythema- 
tous eruption. 

3.  A  relapsing  induration  of  the  lip  of  the  meatus,  followed  by  an 
eruption  of  simple  impetigo  of  the  arms  and  lips. 

4.  Inflammatory  nodules  of  the  penis,  due  to  the  acarus  scabiei,  and 
resembling  in  a  measure  hard  chancres,  followed  by  a  generalized  (strange 
to  say,  non-pruritic)  papular  eruption. 

5.  A  relapsing  induration  (fifth  year),  followed  by  a  quite  general 
papular  eczema  and  dry  scaling  eczematous  eruptions  of  the  palms,  which 
were  considered  pathognomonic. 

6.  Mild  form  of  Hodgkin's  disease,  with  general  adenopathy,  followed 
by  a  subacute  form  of  papular  urticaria. 

7.  Herpes  of  the  prepuce,  much  irritated  by  the  nitrate-of-silver  stick. 
A  short  time  after  an  eruption  of  pityriasis  versicolor  was  discovered  and 
the  case  was  pronounced  syphilitic. 

8.  Herpes  of  the  lip,  irritated  by  caustics  and  presenting  a  nodular 
consistence,  was  followed  by  a  generalized  psoriasis  of  the  trunk  and  arms 
in  an  old  syphilitic. 

9.  A  relapsing  induration,  followed  by  a  lichenoid  rash,  due  to  heat 
and  salt-water  bathing.     Later  on  a  serpiginous  syphilide. 

10.  An  indurated  follicle  of  the  free  end  of  the  prepuce  (gonorrhceal), 
and  pityriasis  rosea  et  annulata  of  the  trunk  and  arms. 

Many  other  instances  could  be  cited,  but  the  foregoing  are  sufficient  to 
indicate  in  a  general  way  the  comparative  frequency,  as  well  as  the  sources 
of  error  in  this  subject.  One  point  has  struck  me  very  forcibly,  and 
that  is  that  the  smallest  amount  of  adenopathy,  if  indeed  any  exists,  in 
a  given  case  is  regarded  by  many  physicians,  when  in  association  with  a 
genital  lesion,  as  satisfactory  evidence  of  a  second  infection  with  syphilis. 

The  great  source  of  error  on  this  subject  is  to  be  attributed  to  the 
relapsing  indurations,  which  unalterably  convince  many  men  that  they 
have  a  second  hard  chancre  before  them.  As  the  knowledge  of  these 
lesions  becomes  more  clear  and  extended  there  will  be  fewer  reported 
cases  of  second  infection  with  syphilis. 

Hudelo^  has  submitted  all  the  reported  cases  (to  1891)  of  syphilitic 
reinfection  to  a  rigid  analysis,  and  has  rejected  all  except  those  reported 
by  the  following  authors :  Delestre,^  Gascoyen  ^  (second  case),  Caspary  * 
(second  case),  R.  W.  Taylor^  (1877),  Pellizzari,«  R.  W.  Taylor^  (1883 
and  1885),  Hutchinson,^  and  R.  W.  Taylor «  (1890). 

'  "De  rimmunity  syphilitique,"  Annakf;  de  Da-m.  et  de  Syphil.,  1891,  pp.  353  and  470. 
^  Moniteur  des  Sciences  medicales,  Jan.  14,  1860. 

^  Med.  Times  and  Gazette,  Dec.  -5,  1874.  *  Deut.  med.  Wochenschnft,  No.  7,  1875. 

*  Archives  of  Dermatology,  1877,  p.  119  et  seq.      ®  Lo  Sperimentale,  March,  1882. 
^  Transactions  of  Amer.  Dermat.  Association,  p.  35,  1885,  and  Journal  of  Cut.  mid  Ven. 
Diseases,  1882  and  1883,  p.  205.  8  Syphilis,  chap.  xv.  p.  466  et  seq. 

^  Jour,  of  Cutan.  and  Gen.-urin.  Diseases,  1890,  vol.  viii.  p.  457. 


668  SYPHILIS. 

With  very  many  exceptions  and  much  reservation  we  must  admit, 
therefore,  that  true  second  attacks  of  syphilis  occur,  but  that  they  are 
very  rare.  All  suspected  and  putative  cases  should  be  approached  with 
caution  and  reserve,  rather  than  with  a  sanguine  and  credulous  spirit. 
We  need  much  further  light  on  this  important  subject,  and  scientific 
evidence  can  only  be  obtained  by  a  rigid  examination  and  study  of  each 
case.  Before  a  given  case  shall  be  accepted  as  true  and  beyond  con- 
troversy the  following  facts  must  be  established  as  clearly  as  possible : 
In  the  first  attack,  the  existence  of  a  true  hard  chancre  followed  by 
characteristic  adenopathies  and  a  clear  history  of  the  secondary  stage 
and  its  lesions,  and  perhaps  of  a  tertiary  stage.  Then  a  sufiiciently 
long  period  of  time  should  elapse  in  order  to  show  that  the  diathesis  has 
become  extinct.  Many  cases  have  been  reported  in  which  one,  two,  or 
three  years  only  have  elapsed  between  the  two  so-called  separate  attacks 
of  syphilis.  Such  cases  are  without  doubt  apocryphal.  In  the  light 
of  the  cases  already  published  it  is  not  too  much  to  say  that  no  case  is 
worthy  of  consideration  in  which  the  interval  between  the  cure  or  ap- 
parent cessation  of  the  first  attack  and  the  onset  of  the  second  one  is  at 
least  not  under  five  or  six  years.  Very  long  intervals  will  inspire  one 
with  moderate  credulity. 

The  further  requirements  are  that  the  history  and  characteristics  of 
the  second  chancre  shall  be  satisfactorily  made  clear,  and  the  involve- 
ment of  the  ganglia  established  beyond  a  doubt.  Then  a  clear  clinical 
picture  of  the  period  of  general  manifestations  must  be  given  before  we 
accept  the  case  as  one  of  second  infection  with  syphilis.  If  these  re- 
quirements are  fulfilled,  it  is  safe  to  say  that  in  the  future  we  shall  not 
be  favored,  as  we  have  of  late  about  once  in  two  or  three  months,  with 
a  new  case  of  syphilitic  reinfection. 

It  is  stated  by  a  number  of  writers  that  second  attacks  of  syphilis 
run  a  very  mild  course.  Since  this  statement  is  largely  based  upon  the 
features  oifered  by  apocryphal  cases,  it  is  not  worthy  of  consideration. 
In  my  five  cases  the  second  attack  was  very  severe,  and  in  two  instances 
it  ended  quite  promptly  in  death.  It  is  unAvise,  however,  to  draw  con- 
clusions from  a  few  cases;  therefore  it  is  well  to  wait  for  future  observa- 
tions as  to  the  intensity  of  the  course  of  cases  of  second  infection  with 
syphilis. 

Syphilis  contracted  at  Late  Periods  of  Life. 

It  may  be  stated,  as  a  quite  well-recognized  fact,  that  syphilis  con- 
tracted at  and  beyond  the  fiftieth  year  of  life  is  more  severe  than  at 
earlier  periods.  This  condition  is  particularly,  noticeable  in  previously 
debilitated  and  intemperate  persons,  and  especially  so  in  patients  of  the 
lower  walks  of  life  who  have  neither  good  habits,  good  food,  nor  good 
surroundings.  Syphilis  as  observed  in  the  aged  has  been  well  studied, 
more  particularly,  by  Quinquaud  and  Ullmann  ^  and  R^nault,^  whose  con- 
clusions are  largely  in  accord  with  my  own  on  this  subject. 

In  general,  the  first  period  of  incubation  of  the  chancre  is  quite  long. 

1  "  Etude  clinique  sur  la  Syphilis  des  Vieillards,"  Annales  de  Derm,  et  de  Syphil,  1881, 
pp.  247  and  502. 

2  "  Etude  sur  la  Syphilis  conlractee  il  un  Age  avanc^,"  i6ic/.,  1889,  pp.  165,  288,  and  428. 


REINFECTION  WITH  SYPHILIS,  ETC.  669 

The  initial  lesion  is  not  usually  exuberantly  large  and  indurated,  but 
more  commonly  slight  in  character,  parchment-like  in  thickness,  with  a 
tendency  to  superficial  necrosis  and  sloughing.  In  some  cases  gangrene 
and  phagedena  are  observed.  The  inguinal  adenopathies  usually  appear 
later  and  develop  slowly,  and  the  swollen  ganglia  are  very  rarely,  if 
€ver,  very  large  and  nodular.  The  second  period  of  incubation  is  also 
usually  quite  prolonged,  so  that  two,  two  and  a  half,  and  even  three 
months  or  longer  may  elapse  between  the  appearance  of  the  chancre  and 
the  onset  of  general  manifestations.  Quinquaud  truly  says  that  "  syph- 
ilis acquired  after  sixty  years  of  age  is  a  drama,  the  successive  stages  of 
which  are  slower  in  their  evolution  than  those  of  syphilis  acquired  in 
€arly  life." 

Secondary  lesions  of  the  skin  and  mucous  membrane  do  not  present 
that  amount  of  hypergemia  and  exuberance  which  may  be  seen  in  the 
same  affections  in  early  life.  The  skin  lesions  may  be  generally  distrib- 
uted, and  perhaps  more  or  less  confluent,  but  they  always  show  more  or 
less  evidence  of  senectitude.  This  is  especially  Avell  shown  in  the  ery- 
thematous and  papular  syphilides.  Then  these  lesions  show  a  marked 
tendency  to  remain  in  an  indolent  condition,  and  are  frequently  very 
rebellious  to  treatment.  Further  than  this,  they  show  an  exasperating 
tendency  to  relapse  even  when  a  vigorous  treatment  is  being  followed. 

It  is  not  uncommon  to  see  secondary  and  tertiary  skin  lesions  com- 
mingled. Thus,  roseola  papules  and  gummatous  nodules,  the  latter  show- 
ing a  tendency  to  break  down  and  suppurate,  may  not  uncommonly  be 
seen  scattered  over  the  integument  of  elderly  persons. 

Malignant  precocious  lesions  of  the  skin,  bones,  and  mucous  mem- 
branes are  not  at  all  uncommon,  some  of  Avhich  show  a  tendency  to  gan- 
grene and  necrosis. 

Quite  early  in  the  secondary  stage  nervous  and  psychical  troubles  with 
paralysis  are  not  uncommon,  and  headache,  neuralgic  and  rheumatoid 
pains,  may  also  be  complained  of.  Cerebral  accidents,  with  symptoms 
resembling  typhoid  fever,  may  also  be  observed. 

Quinquaud  lays  stress  on  the  occurrence  of  gummatous  infiltration  into 
the  ganglia,  which  may  undergo  degeneration  in  old  persons. 

Another  marked  feature  of  syphilis  in  the  aged  is  the  multiplicity  of 
the  tissues  and  organs  attacked  at  the  same  time,  such  as  the  skin,  mucous 
membranes,  bone,  viscera,  and  the  cerebro-spinal  axis. 

Quinquaud  noticed  that  after  seventy  years  of  age  the  pharynx  is 
rarely  attacked,  that  the  brain  and  scalp  are  usually  unaff"ected,  and  that 
the  gums  are  more  free  from  mercurial  action  than  in  earlier  years. 

All  these  significant  facts  concerning  syphilis  contracted  late  in  life 
should  be  clearly  borne  in  mind,  and  a  more  than  usual  Avatchful  care 
should  be  exercised  over  these  venerable  patients.  It  is  well  to  empha- 
size the  fact,  however,  that  in  some  old  persons  of  both  sexes  syphilis  runs 
a  tolerably  mild  course,  and  is  measurably  amenable  to  treatment.  Con- 
sequently, it  is  not  well  to  always  give  a  gloomy  prognosis  in  these  cases. 

On  account  of  its  rarity,  it  is  Avell  to  mention  the  case  reported  by 
Cohn.^  It  was  that  of  a  virile  man  who  at  eighty  years  of  age  contracted 
syphilis,  which,  though  severe,  was  cured  by  specific  treatment.  It  is  said 
that  the  veteran  is  now  enjoying  good  health. 

1  Dennat.  Zdtsckrift,  1894,  p.  435. 


670  SYPHILIS. 

The  Immunity  of  Animals  to  Syphilis. 

Though  the  opinion  has  long  been  held  that  animals  are  immune  to 
syphilitic  infection,  Martineau  about  fifteen  years  ago  claimed  that  he  had 
communicated  the  disease  to  pigs  and  monkeys.  Koch  so  utterly  demol- 
ished Martineau's  conclusions,  and  made  such  ridicule  of  his  technical 
methods,  that  his  inoculation-experiments  went  for  naught. 

Rebatel  ^  made  incisions,  into  the  groin  of  a  perfectly  healthy  bitch, 
and  in  the  cellular  tissue  he  placed  portions  of  a  fresh  hard  chancre,  and 
then  closed  the  wound.  There  was  an  ephemeral  swelling  of  the  parts,  but 
in  a  few  days  nothing  abnormal  was  to  be  seen.  No  glandular  swelling 
occurred  in  a  period  of  many  months.  He  also  injected  150  grammes  of 
defibrinated  blood-serum  from  a  patient  with  active  syphilis  into  the  jug- 
ular vein  of  a  young  dog,  without  any  effect  whatever.  These  animals 
subsequently  procreated  healthy  offspring. 

Kobner^  was  successful  in  inoculating  rabbits  with  chancroidal  pus,  but 
he  failed  to  infect  dogs  and  rabbits  by  means  of  inoculations  with  active 
syphilitic-bearing  vehicles. 

Horand  and  Cornevin^  tried  very  assiduously  to  infect  the  pig  with 
syphilis,  but  they  reached  the  conclusion  that  the  tissues  of  this  animal 
are  refractory  to  this  disease. 

Cognard*  claimed  that  he  had  inoculated  a  monkey  with  syphilis,  but 
his  colleagues  thought  that  he  had  simply  produced  septicaemia  in  that 
unfortunate  animal. 

Vittone^  inoculated  without  success  the  fragments  of  six  chancres 
upon  rabbits,  guinea-pigs,  cats,  and  dogs. 

Neumann  ^  inoculated  active  syphilitic  material  into  three  apes,  three 
rabbits,  a  horse,  a  hare,  a  white  rat,  a  martin,  and  a  cat.  Though  he 
made  fifty-four  inoculations  in  all,  his  experiments  were  uniformly  un- 
successful. 

HaenselF  claims  that  he  injected  syphilitic  products  into  the  anterior 
chamber  of  the  eyes  of  rabbits,  and  produced  iritis  and  little  nodules 
which  appeared  from  twenty-five  days  to  one  and  three  months  after  the 
inoculation.  These  nodules  were  looked  upon  as  gummata,  and  the  con- 
clusion of  the  experimenter  was  that  he  had  produced  syphilis ;  but  there 
is  no  evidence  offered  of  the  existence  of  a  general  infection.  This  pre- 
liminary paper  of  Haensell  has  not,  as  far  as  I  can  learn,  been  followed 
by  the  second,  which  by  implication  we  assume  was  promised ;  conse- 
quently, it  may  be  said  that  the  claim  that  animals  are  immune  to 
syphilis  has  not  as  yet  been  disproved. 

^  "Edcherches  experimentales  snr  I'lnoculation  des  Maladies  vfoeriennes  aux  Ani- 
maux,"  Lyon  medical,  vol.  xxxix.,  1882,  pp.  41  et  seq. 

^  Wiener  med.  Wochenschrift,  1883,  vol.  xxxiii.  pp.  897  et  seq. 

^  Annates  de  Derm,  et  de  Syph.,  1884,  pp.  393  et  seq. 

*  Lyon  medical,  June  S,  1884. 

5  Gaz.  Med.  Hal.  Lombard,  1884,  p.  315. 

8  Wien.  med.   Wochenschrift,  vol.  xxiii.,  1883,  pp.   209  and  243. 

'  "  Vorlaufige  Mittheilung  iiber  Versuche  von  Impf  syphilis  der  Iris  und  Cornea  des 
Kaninchen,"  Arch,  fiir  Ophthalmol.,  vol.  xxvii.,  1881,  pp.   93  et  seq. 


THE  INFLUENCE  OF  SYPHILIS,  ETC.  671 


CHAPTER    LXVL 

THE  INFLUENCE  OF  SYPHILIS  UPON,  AND    ITS   RELATIONS  TO, 
VARIOUS  DISEASES  AND  MORBID  CONDITIONS. 

Syphilis  may  exert  an  influence  upon  various  intercurrent  diseases — 
first  on  those  of  an  acute  course,  second  on  chronic  diseases,  and  third  on 
those  of  traumatic  origin. 

Influence  on  Acute  Diseases. — Very  little  is  known,  beyond  a  few 
isolated  facts,  as  to  its  influence  on  acute  diseases.  Bamberger  and  Fron- 
miiller  speak  of  the  transformation  of  variola-pustules  into  syphilitic 
ulcers  and  tubercles  in  infected  subjects,  and  Lancereaux  thinks  that  in 
an  epidemic  of  small-pox  observed  by  him  there  were  more  cases  of  the 
hemorrhagic  variety  in  syphilitic  patients  than  in  those  not  infected  with 
syphilis.  In  an  epidemic  of  scarlet  fever  Woakes  observed  a  fatal  result 
particularly  in  infants  afflicted  with  hereditary  syphilis.  Acute  rheuma- 
tism, occurring  in  the  early  months  of  the  syphilitic  diathesis,  has  been 
observed  to  run  an  exceptionally  severe  course  and  to  be  prone  to  relapse. 
Pneumonia,  bronchitis,  and  pleurisy  during  the  course  of  syphilis  are 
liable  to  be  more  or  less  modified.  Pneumonia,  complicating  a  severe 
cachexia  in  the  early  months  of  syphilis,  is  a  most  serious  accident  and 
often  leads  to  a  fatal  result.  In  later  stages,  though  less  malignant,  these 
diseases  are  often  rendered  much  more  severe  and  protracted.  Little  can 
be  said  of  the  influence  of  syphilis  upon  the  specific  fevers.  It  is  safe  to 
assume  that  the  severity  of  the  fever  will  be  proportionate  to  the  gravity 
of  the  syphilitic  cachexia. 

Gout  and  Rheumatism. 

Among  other  important  chronic  diseases,  gout  and  rheumatism  are  no 
doubt  largely  affected  by  syphilis,  particularly  in  its  late  period  of  cachexia. 
It  may  be  safely  predicted  that  when  a  person  subject  to  chronic  inflam- 
mation becomes  infected  with  syphilis  he  will  suff"er  in  after  years  from  a 
combination  of  the  two  diseases  unless  treatment  be  most  thoroughly 
followed.  It  is  useless  to  speculate  concerning  the  reason  of  this  fact, 
but  as  to  its  being  a  fact  we  have  positive  evidence.  Such  a  patient  is 
especially  liable  to  recurrent  attacks  of  muscular  pains,  more  severe  at 
night.  They  come  on  at  varying  intervals,  often  seemingly  influenced  by 
damp  and  cold  weather,  and  are  seldom  accompanied  by  febrile  movement. 
Chronic  inflammation  of  the  fibrous  tissues  of  the  joints  is  especially, 
common  and  persistently  recurrent.  Periostitis,  particularly  of  the  long 
bones,  is  common  in  these  cases,  and  the  development  of  a  marked  form 
of  cachexia  is  especially  noticeable.  This  cachexia  is  attended  by  all  the 
symptoms  of  profound  systemic  depression  :  it  may  become  rapidly  fatal, 
or  health  may  be  established  after  a  tedious  convalescence,  recurrences, 
however,  being  not  uncommon.  Some  of  these  cases  are  seriously  com- 
plicated by  visceral  aff'ections,  especially  of  the  liver. 

A  gouty  subject  in  whom  syphilis,  after  running  a  chronic  course, 
settles  into  a  state  of  cachexia,  presents  a  condition  characterized  by 


672  SYPHILIS. 

inflammation  of  fibrous  tissues  and  of  joint-structures,  recurring  at  inter- 
vals, or,  in  other  words,  a  modified  form  of  gout.  Moreover,  cerebral 
symptoms,  not  often  congestive,  but  still  quite  formidable,  are  frequently 
present,  while  disturbances  of  respiration,  of  the  heart,  and  of  the 
stomach,  referable  to  gout,  may  be  manifested.  The  etiology  of  cases  of 
this  kind  should  be  carefully  studied,  the  subject  being  one  of  the  most 
important  in  syphilography. 

In  patients  suff'ering  from  scorbutus  and  the  hemorrhagic  diathesis 
syphilis  has  been  known  to  be  very  severe.  Its  lesions  are  likely  to  be 
complicated  by  hemorrhage  and  ulceration,  and  a  severe  cachexia  is  not 
infrequent.  Eff'usion  into  serous  cavities  often  occurs,  and  joint-afiections 
are  peculiarly  distressing. 

In  cases  of  Bright's  disease  syphilis  usually  takes  a  very  rapid  course, 
and  has  an  especially  adynamic  influence. 

Malaria. 

Many  well-authenticated  observations  have  been  made  which  clearly 
show  that  malaria  may  seriously  complicate  and  unfavorably  modify  early 
and  late  syphilis.  Lepers^  has  studied  this  subject,  having  as  his  basis 
25  cases,  and  he  concludes  that  a  morbid  symbiosis  is  produced  which 
results  in  grave  cachexia  and  perhaps  visceral  diseases. 

Patients  with  an  hereditary  or  an  acquired  predisposition  to  nervous 
diseases  are,  after  infection,  especially  liable  to  syphilitic  afi"ections  of  the 
brain  and  nerves. 

Traumatisms. 

The  question  of  the  influence  of  syphilis  upon  traumatisms  is  one  of 
much  surgical  importance.  In  the  same  line  the  question  of  the  expedi- 
ency or  propriety  of  performing  operations  on  syphilitic  subjects  is  also 
worthy  of  consideration.  Though  much  has  been  written  on  these  sub- 
jects, the  essential  facts  can  be  presented  with  much  brevity. 

Both  questions  hinge  upon  three  important  points — namely,  first,  the 
grade  of  severity  and  activity  of  the  syphilitic  infection ;  second,  the 
antiseptic  care  Avhich  is  given  to  a  traumatism ;  and,  third,  the  asepsis 
and  antisepsis  which  are  employed  in  operations  upon  syphilitics.        ... 

On  consulting  the  various  brochures  upon  traumatism  and  syphilis  it 
will  be  found  that  the  parts  injured  were  active  syphilitic  lesions  or  were 
lesions  of  continuity  in  syphilitic  subjects.  As  a  result  of  the  damage 
inflicted  on  the  tissues,  ulceration  was  produced  which  was  really  due  to 
the  action  of  extraneous  pyogenic  microbes  upon  a  favorable  syphilitic 
soil.  The  logical  inference  is,  that  where  syphilitic  lesions  are  submitted 
to  traumatism  thorough  antiseptic  measures  should  be  adopted  to  prevent 
ulceration. 

In  these  days  of  rigid  antisepsis  it  is  very  rare  indeed  to  hear  of  an 
operation  failing  by  reason  of  the  syphilitic  condition  of  the  patient. 
Except  in  very  much  broken-down  subjects  operations  on  syphilitics  can 
be  performed  with  nearly  as  much  success  as  upon  non-syphilitics,  pro- 
vided the  wound  is  aseptic.  In  any  cases  of  prospective  operations,  par- 
ticularly of  major  ones,  it  is  well  to  institute  an  efiicient  antisyphilitic 
1  "  Syphilis  et  Paludisme,"  Th^e  de  Lille,  1889. 


THE  INFLUENCE  OF  SYPHILIS,  ETC.  673 

treatment,  and  to  improve  the  general  condition  of  the  patient  as  much 
as  possible. 

In  all  countries  where  syphilis  has  existed  for  many  years  its  course 
is  much  less  severe  than  it  was  originally,  and  the  disease  of  to-day  is 
really  mild  in  comparison  with  what  it  was  when  first  observed  in  Europe. 
It  is  well  established  that  syphilis  is  especially  malignant  when  appearing 
for  the  first  time  in  a  community.  Numerous  instances  are  recorded  of 
the  frightful  ravages  produced  by  it  under  such  circumstances.  The 
initial  lesions  are  said  to  have  been  phagedenic,  and  to  have  been  fol- 
lowed by  severe  secondary  symptoms,  while  necroses  and  visceral  lesions 
were  almost  invariable  and  precocious.  This  malignancy  gradually 
diminishes  in  successive  generations  until  a  comparatively  mild  form  of 
the  disease  is  established.  It  seems  that  a  certain  protective  influence  is 
secured  to  progeny  by  the  occurrence  of  syphilis  in  their  ancestors, 
which,  although  not  conferring  absolute  immunity,  decidedly  modifies  the 
course  of  the  disease.  Thus  our  ideas  of  the  nature  of  syphilis  are  free 
from  that  fear  with  which  our  forefathers  were  accustomed  to  regard  it, 
and  we  no  longer  look  upon  it  as  an  incurable  disease. 

Various  circumstances  have  contributed  to  this  change.  Undoubtedly, 
the  progress  of  civilization  has  been  of  signal  influence  in  establishing 
improved  hygienic  and  sanitary  conditions.  Thus  the  standard  of  nutri- 
tion has  been  raised  and  the  ability  to  resist  disease  increased.  In  our 
own  country  the  people  of  the  poorer  classes  are  in  general  better 
nourished  and  better  cared  for  than  in  many  European  communities.  It 
thus  happens  that  among  us  scrofula,  rickets,  and  other  adynamic  con- 
ditions are  much  less  frequent  than  abroad. 

Another  potent  influence  in  lessening  the  severity  of  syphilis  is  found 
in  our  improved  knowledge  of  its  treatment.  Within  the  past  twenty 
years  great  advances  have  been  made  in  the  therapeutics  of  this  disease. 
Many  errors  have  been  eliminated,  and  new  principles  have  been  estab- 
lished on  a  more  correct  basis. 

The  severity  of  syphilis  is  largely  modified  by  the  constitution  and 
temperament  of  the  patient.  As  a  rule,  in  persons  of  good  health  and 
habits  its  course  is  mild,  and,  provided  treatment  be  followed,  it  becomes 
extinct  in  a  few  years.  It  is  likely  to  be  more  severe  in  persons  of  light 
complexion  and  reddish  hair,  and  who  have  a  nervous  temperament,  than 
in  those  of  dark  complexion. 

Syphilis  aff"ects  persons  variously  at  different  ages.  The  hereditary 
disease  is  often  very  malignant,  but  acquired  syphilis  in  children  is 
usually  not  remarkably  severe.  About  the  age  of  puberty  the  lesions  of 
syphilis  are  apt  to  be  very  extensive,  and  the  consequent  impairment 
of  nutrition  very  great.  In  females  its  course  is  generally  severe,  espe- 
cially at  puberty.  After  maturity  the  constitution  is  less  affected,  and, 
fortunately,  the  disease  is  most  often  contracted  at  this  period,  when 
the  vital  processes  are  most  active  and  the  powers  of  resistance  most 
energetic. 

It  is  obviously  difficult  to  determine  positively  whether  the  severity  of 
syphilis  depends  or  not  on  the  intensity  of  the  infecting  poison.  It 
would  certainly  seem  very  natural  tliat  virus  from  a  recent  and  active 
syphilis  is  likely  to  produce  an  intense  form  of  the  disease,  and  vice  versa, 
but  we  have  no  facts  to   confirm   the  opinion.     On   the    other  hand,  we 

43 


674  SYPHILIS. 

often  see  two  patients,  who  derive  their  disease  from  the  same  source, 
presenting  one  a  mild  and  the  other  a  severe  form  of  syphilis.  We  are 
therefore  warranted  in  believing  that  the  constitution  of  the  patient  has 
much  more  influence  in  shaping  the  character  of  his  disease  than  the 
quality  of  the  virus  absorbed.  With  rare  exceptions  the  severity  of  the 
disease  is  in  proportion  to  the  general  health  of  the  patient.  Persons  in 
whom  the  process  of  metabolism  is  weak,  and  who  are  of  poor  fibre  and 
flabby  structure,  are  particularly  liable  to  active  and  prolonged  attacks  of 
svphilis.  They  exhibit  an  especial  tendency  to  ulceration  and  destruction 
of  tissue.  The  debility  and  impaired  nutrition  left  by  the  continued 
fevers,  diphtheria,  and  other  exhausting  diseases  have  a  very  unfavorable 
influence  on  the  course  of  syphilis.  Alcoholism  seems  to  increase  the 
gravity  of  the  cachexia  and  the  destructive  tendencies  of  the  lesions.  It 
is  in  alcoholic  cases  that  we  meet  with  many  of  the  instances  of  malignant 
syphilis  called  by  the  French  ^'•galloping''  {syiohilis  galloipante). 

As  we  have  already  observed,  the  course  of  syphilis  is  in  a  great 
measure  governed  by  the  treatment.  If  the  use  of  mercurials  be  begun 
early  and  carefully  continued,  even  in  those  whose  constitution  is  not 
very  good,  the  disease  may  be  cured,  if  we  may  be  allowed  to  assume  a 
person  cured  who  for  years  is  equally  as  healthy  as  an  uninfected  indi- 
vidual, and  who  presents  no  manifestations  of  the  disease  and  propagates 
healthy  children.  The  majority  of  authorities  now  hold  the  opinion  that 
syphilis  is  a  curable  disease.  In  this  I  concur,  and  I  believe  it  right 
to  promise  any  patient,  whose  health  is  not  seriously  undermined  by  some 
other  disease,  that  he  may  expect  complete  recovery  by  undergoing  treat- 
ment for  the  first  three  years  of  his  disease  and  by  paying  ordinary  atten- 
tion to  hygiene.  The  importance  of  the  early  use  of  mercury  after  the 
development  of  secondary  lesions  cannot  be  overestimated.  A  far  better 
efi'ect  is  secured  than  if  its  use  is  postponed.  In  my  experience  tertiary 
lesions  have  been  almost  unknown  where  the  disease  has  been  gradually 
and  carefully  treated  from  the  outset.  In  the  vast  majority  of  cases  of 
tertiary  syphilis  under  my  care  for  many  years  the  histories  showed 
neglect  or  inadequacy  of  treatment,  and  in  many  of  them  the  iodide  of 
potassium  had  been  relied  upon  during  the  first  year,  when  mercury 
should  almost  always  be  given. 

Vulnerability  of  the  Skin  and  Mucous  Membranes. 

In  the  early  stages  of  syphilis  the  skin  and  mucous  membranes  are 
peculiarly  susceptible  to  inflammation  ;  the  tendency  becomes  less  marked 
as  the  diathesis  grows  older.  It  is  greater  in  some  subjects  than  in  others, 
those  having  a  delicate  white  skin  possessing  it  more  decidedly.  The  in- 
tegument of  those  who  have  had  pustular  and  ulcerating  syphilides  is 
more  liable  to  become  inflamed  from  a  slight  cause  than  that  of  those  who 
have  had  erythematous  and  papular  rashes.  This  altered  condition  of  the 
skin  and  mucous  membranes  is  seen  in  its  most  simple  form  in  the  ex- 
treme inflammation  attending  slight  cuts  and  abrasions,  and  in  a  greater 
degree  in  the  excessive  ulceration  and  suppuration  during  the  course  of 
certain  non-specific  skin  diseases,  such  as  acne,  eczema,  impetigo,  and 
pemphigus.  It  is  also  strikingly  seen  in  the  tendency  shown  by  some 
patients  to  the  development  of  boils.     Some  patients  in  the  secondary 


THE  IXFLUE^X'E  OF  SYPHILIS,  ETC.  675 

stage  of  syphilis,  and  even  later,  are  attacked  by  inflammatory  nodulations 
and  boils  at  the  back  of  the  neck  and  at  the  nucha. 

Irritation  of  the  skin  of  syphilitics  may  also  cause  infiltration  with  or 
without  ulceration.  A  splinter  of  wood  imbedded  in  the  skin  has  been 
known  to  give  rise  to  a  tubercle  having  all  the  appearance  and  charac- 
ter of  a  specific  lesion.  In  many  cases  of  artificially  produced  ulceration 
infiltration  coexists,  and  remains  long  after  cessation  of  the  destructive 
process.  Wounds,  bruises,  and  ulcers  are  liable  to  become  complicated 
by  this  nodular  infiltration.  This  tendency  to  infiltration  ceases  with  the 
extinction  of  the  syphilitic  diathesis,  whereas  the  tendency  to  ulceration 
persists  long  after  the  completion  of  cure.  This  fact  is  exemplified  in  the 
ulcerations  and  fissures  occurring  in  the  mouths  of  smokers  when  syphi- 
litic manifestations  have  long  since  disappeared. 

This  peculiar  condition  of  the  skin  is  worthy  of  special  consideration 
in  connection  with  the  serpiginous  syphilides.  These  creeping  ulcers  un- 
doubtedly originate  in  true  syphilitic  lesions,  but  the  decided  absence  of 
characteristic  features  in  their  future  course  warrants  the  suspicion  that 
they  become  simple  chronic  ulcers  developed  upon  a  favorable  soil. 

The  fact  that  during  syphilis  slight  abrasions  and  herpetic  vesicles 
may  give  rise  to  ulcers  resembling  chancroids  is  of  great  practical  im- 
portance, and  its  thorough  recognition  will  enable  the  physician  to  avoid 
doing  injustice  to  innocent  persons. 

Syphilis  and  Tuberculosis. 

Syphilis  in  its  early  and  later  stages  induces  in  the  tissues  a  condition 
which  is  favorable  to  the  development  of  tuberculosis,  and  it  becomes  a 
factor  of  greater  or  less  gravity.  This  remarkable  symbiosis  is  one  of 
the  most  frequent  and  far-reaching  morbid  states  to  which  the  human  race 
is  liable.  Succinctly  stated,  the  tubercular  bacillus  takes  root,  fructifies, 
and  luxuriates  in  some  syphilitic  individuals  who  seem  to  be  peculiarly 
predisposed  to  this  malignant  combination.  One  of  the  gravest  dangers 
— and,  fortunately,  not  of  the  commonest — of  syphilis  in  some  subjects 
is  the  development  of  pulmonary  tuberculosis.  In  some  cases,  early  in 
the  secondary  stage  the  patient  begins  to  lose  ground,  becomes  thin, 
coughs,  and  rapidly  passes  into  tuberculosis,  which  promptly  ends  in 
death.  In  other  cases  the  mixed  infection  runs  on  slowly,  and  several 
months  may  elapse  before  death  ensues.  Besides  these  lethal  cases  we 
see  some  later  in  the  disease  in  which  there  is  evidence  of  mild  and  local- 
ized pulmonary  tuberculosis,  which  may,  under  favorable  climatic  condi- 
tions, become  cured.  Even  in  the  tertiary  stage  this  morbid  predisposition 
exists  in  some  cases,  and  leads  to  chronic  pulmonary  tuberculosis  and  death. 

In  this  connection  it  is  well  to  mention  that  Saalfeld  ^  has  published 
an  interesting  and  clinically  well-observed  case  in  which  he  made  a 
careful  microscopical  study  of  the  post-mortem  specimens. 

As  might  be  expected  from  their  exposed  positions,  the  syphilitic 
eruptions  of  the  skin  are  liable  to  be  attacked  by  the  bacillus  of  tuber- 
culosis.^    Neisser    has  reported  an  interesting  case  of  mixed  tubercular 

^"Die  Lungensyphilis  und  ihre  Verhiiltniss  zur  Tuberculose,"  Berl.  Min.  Wochen- 
schrift,  1894,  No.  15,  pp.  657  et  seq. 

^  "Fall  von  Mischinfection  von  Lupus  und  Tubero-serpiginosem  Syphilid.,"  Seperat 
Abdruck  aus  der   Verhandlungen  des  iv.  Deul.  Dermal.  Congresse,  1894. 


676  SYPHILIS. 

and  syphilitic  infection  in  a  case  of  serpiginous  syphilide,  in  whicli  he 
details  his  microscopical  findings. 

In  the  tertiary  stage  of  syphilis  the  coexistence  of  tubercular  inflam- 
mation with  gummatous  infiltration  is  very  common.  This  is  well  shown 
in  the  numerous  carefully-made  autopsies  of  cases  of  visceral  syphilis 
within  the  past  ten  years,  in  Avhich  the  details  of  the  mixed  and  compli- 
cating morbid  changes  are  well  brought  out.  The  syphilitically  infiamed 
and  infiltrated  bones,  fasciae,  joints,  and  tendinous  sheaths  are  in  some 
cases  especially  prone  to  become  the  seat  of  tubercular  inflammation.  I 
have  seen  two  well-marked  instances  of  tertiary  syphilitic  orchitis  in 
which  the  testes  were  attacked  by  tuberculosis,  which  also  involved  some 
of  the  viscera.  In  one  case  death  was  produced,  and  in  the  second  a 
salubrious  climate  and  treatment  produced  a  restoration  of  the  patient's 
health. 

Fabry  ^  reports  a  case  of  great  interest  in  this  line  of  thought.  It 
was  that  of  a  man  who  suifered  from  chronic  syphilis,  and  who  presented 
a  gummatous  ulcer  of  the  prepuce,  which  was  attacked  by  tuberculosis. 
This  lesion  was  found  by  Fabry  to  be  a  mixed  tubercular  and  syphilitic 
process,  which  he  clearly  demonstrates  by  a  micro-photograph. 

Syphilis  and  Cancer. 

Syphilis  is  in  no  sense  of  the  term  an  etiological  factor  in  the  develop- 
ment of  cancer,  but  in  some  cases  it  acts  as  the  forerunner  and  the  pre- 
disposing cause  of  the  latter  disease  by  means  of  the  chronic  irritative 
processes  which  it  establishes.  As  a  rule,  cancer  consecutive  to  syphilitic 
processes  develops  in  the  mouth,  particularly  on  the  tongue  and  near  its 
muco-cutaneous  junctions.  It  may  also  appear  on  the  skin  proper,  fol- 
lowing certain  chronic  inflammatory  syphilitic  processes.  As  a  result,  a 
hybrid  disease  is  produced,  usually  in  the  tertiary,  and  exceptionally  in 
the  late  secondary,  period  of  syphilis. 

As  cancer  appears  in  the  mouth  and  upon  the  tongue,  the  clinical 
division  of  its  symptomatology  of  Ozenne^  is  in  my  judgment  worthy 
of  acceptance.  This  observer  makes  three  classes  of  syphilis-cancer  of 
the  mouth — namely,  cancero-sclerous,  cancero-gummatous,  and  cancero- 
sclero-gummatous. 

In  cancero-sclerous  glossitis  the  tongue  is  usually  for  a  long  time  the 
seat  of  chronic  syphilitic  inflammation.  (See  chapter  Syphilitic  Sclero- 
glossitis.)  The  organ  is  enlarged,  superficially  infiltrated,  covered  with 
a  thick  layer  of  epithelium,  with  nodules  or  plaques  of  greater  or  less 
hardness.  There  may  be  interstitial  nodules  seated  in  the  substance  of 
the  tongue,  which  are  usually  quite  hard,  sometimes  very  well  defined, 
and  again  merging  imperceptibly  into  the  surrounding  tissues.  In  some 
cases  it  is  very  difficult  to  determine  which  is  the  cancerous  nodule  and 
which  the  mass  of  sclerous  glossitis.  In  some  cases,  instead  of  enlarge- 
ment of  the  tongue,  there  is  distinct  atrophy,  and  then  we  may  find  deep- 
seated  nodules  or  superficially  exulcerated  lumps  on  the  dorsum  or  at  the 
sides  of  the  tongue.     Then,  again,  the  morbid  new  growths  may  be  seated 

^  "  Ueber  einen  Mischfall  von  lues  und  tnberculose  seltener  Localization,  etc.," 
Arch,  fur  Derm,  und  Syph.,  vol.  xxv.,  1893,  pp.  925  et  seq. 

^  "Du  Cancer  chez  les  Syphilitiqiies:  de  I'hybridite  cancero-syphilitique  de  la  cavit4 
buccale  en  particulier,"  ITi^se  de  Paris,  1884. 


THE  INFLUENCE  OF  SYPHILIS,  ETC.  677 

on  the  superficial  parts  of  the  organ  in  the  shape  of  hard,  angry -looking, 
perhaps  papillomatous  plaques.  In  all  these  instances  there  is  much  epi- 
thelial hyperplasia  and  many  shallow  or  deep  fissures  on  the  dorsum  and 
at  the  sides  of  the  tongue,  together  with  exulcerated  and  perhaps  deeply 
ulcerated  patches.  In  these  cases  the  chronicity  of  the  morbid  process, 
together  with  the  well-marked  swelling  of  the  glands  under  the  jaw, 
should  tend  to  excite  a  suspicion  of  malignant  disease. 

Cancero-gummatous  glossitis  begins,  as  a  rule,  insidiously.  There  may 
or  may  not  be  epithelial  hyperplasia.  A  nodule  first  forms,  either  deeply 
in  the  substance  and  near  the  centre  of  the  tongue  or  near  its  edge,  but 
more  commonly  near  or  on  the  sides.  This  lesion  is  the  gumma,  which 
under  active  treatment  may  undergo  absorption.  It  may,  however,  from 
neglect,  break  down,  and  then  remain  as  a  deep,  foul  ulcer,  the  periphery 
of  which  may  undergo  cancerous  degeneration.  This  is  the  usual  clinical 
history  of  cases  of  cancero-gummatous  glossitis.  As  a  rule,  the  glands 
become  much  enlarged,  and  in  spite  of  surgical  intervention  the  cancer 
extends  and  causes  the  patient's  death. 

In  exceptional  cases  the  hybrid  morbid  condition  causes  the  tongue  to 
become  exceedingly  large. 

Cancero-sclero-gummatous  glossitis  offers  in  its  clinical  picture  a  com- 
bination of  the  foregoing  two  forms  of  degeneration.  In  any  of  these 
forms,  by  means  of  extension  of  the  morbid  process,  the  tonsils,  the 
cheek,  and  the  lips  may  be  attacked.  Pain  in  varying  degree  is  a  special 
feature  in  these  cases,  particularly  in  their  late  stages. 

Other  points  of  the  mouth — namely,  the  hard  palate  and  the  floor — 
may  also  be  thus  attacked. 

Lang^  reports,  together  with  microscopical  findings,  two  cases  of 
syphilis-cancer  of  the  lip  and  one  of  the  floor  of  the  mouth. 

Doutrelepont^  has  reported  a  case  of  serpiginous  syphilide  of  the  cheek 
which  gave  rise  to  epitheliomatous  degeneration.  Lang  reports  a  similar 
case,  and  I  observed  a  case  in  which  the  syphilide,  having  travelled  well 
over  the  trunk,  caused  an  enormous  epitheliomatous  growth  upon  the 
hypogastric  region.  Doutrelepont  also  records  the  case  of  a  Avoman 
having  an  ulcer  of  the  labia  majora  which  underwent  similar  degenera- 
tion. Many  years  ago  I  had  under  my  care  a  case  of  old  syphilis  in  a 
woman  who  had  had  much  hyperplasia  of  the  anal  region,  which  under- 
went cancerous  degeneration  and  then  extended  to  the  genital  parts. 
Doutrelepont  also  speaks  of  a  case  in  which  a  warty  growth  of  the  lower 
eyelid  in  an  old  syphilitic  became  cancerous.  I  have  further  seen  three 
cases  of  cancer  of  the  tongue,  one  of  the  lower  lip,  one  at  the  right  labial 
commissure,  and  one  upon  the  hard  palate,  all  of  which  followed  chronic 
syphilitic  inflammatory  processes.  It  follows,  therefore,  that  these  old  and 
persistent  syphilitic  processes  should  be  carefully  attended  to  and  cured. 

There  is  further  one  point  which  should  never  be  forgotten — namely, 
that  when  a  syphilitic  lesion  in  any  of  the  localities  mentioned  shows  evi- 
dence of  chronicity  and  exuberant  growth,  particularly  if  warty,  papil- 
lomatous, or  nodular,  the  surgeon  should  be  on  the  watch  for  cancerous 
degeneration. 

'  "  Ueber  Combination  von  Sypbilis  und  Krebs,"  Wien.  med.  Blatter,  Nos.  41  and  42, 
1886,  and  No.  10,  1888. 

^  "Syphilis  und  Carcinoma,"  Deut.  med.  Wochensck,  1887,  No.  47,  p.  1016. 


678  SYPHILIS. 

Murzin  ^  details  the  case  of  a  man  syphilitic  for  fourteen  years  who 
presented  a  nodule  of  the  ala  nasi  Avhich  was  removed,  and  under  the 
microscope  the  tissue  was  found  to  be  a  gumma  transformed  into  an 
epithelioma. 

Syphilis  and  Aneurysm. 

Within  the  past  twenty  years  the  conviction  has  been  growing  in  the 
medical  mind  that  syphilis  is  an  active  and  frequent  factor  in  the  pro- 
duction of  aneurysms.  This  view,  at  first  based  on  clinical  observations, 
has  since  been  confirmed  and  strengthened  by  the  results  of  microscopi- 
cal studies.  With  the  expansion  of  our  knowledge  of  the  pathology  of 
syphilis  the  fact  that  this  infection  in  its  whole  course  largely  attacks 
the  blood-vessels  has  called  particular  attention  to  it  as  a  prime  cause 
of  aneurysm.  The  first  authoritative  essay,  according  to  my  reading, 
on  the  subject  was  read  by  an  English  army  surgeon,  Mr.  F.  J.  Welch,^ 
before  the  Royal  Medical  and  Chirurgical  Society  of  London.  In  117 
cases  of  aneurysm  in  soldiers,  Welch  found  that  46.1  per  cent,  occurred 
in  syphilitic  subjects;  6.8  per  cent,  in  subjects  probably  syphilitic ;  21.3 
per  cent,  in  phthisical  subjects;  14.2  per  cent,  without  determinate 
cause;  5.9  per  cent,  with  heart  disease;  and  6.7  per  cent,  with  various 
other  diseases. 

While  it  may  be  urged  that  these  statistics  may  not  be  wholly  accu- 
rate, they  are  nevertheless  important  in  establishing  the  fact  of  the  fre- 
quency of .  occurrence  of  aneurysm  in  syphilitic  subjects. 

The  aorta  is  the  vessel  most  frequently  attacked,  but  the  radial,  tem- 
poral, cerebral,  and  popliteal  arteries  are  also  frequently  involved. 

Many  cases  have  been  reported,  in  some  of  which,  undoubtedly, 
syphilis  was  the  etiological  factor.  Then,  again,  there  are  cases  reported 
in  which  it  is  difficult  to  eliminate  the  influence  of  trauma,  gout,  rheu- 
matism, lead-poisoning,  alcoholism,  and  arterio-sclerosis.  In  some  cases 
there  can  be  no  doubt  that  several  factors,  with  syphilis,  were  the  under- 
lying cause  of  the  arterial  degeneration. 

Jaccoud^  reports  a  case  of  aneurysm  of  the  ascending  aorta  in  a 
woman  forty-five  years  old  who  had  been  syphilitic  twenty  years.  In 
this  case  trauma,  gout,  lead-poisoning,  and  alcohol  were  excluded  as 
pathogenic  conditions. 

Two  very  interesting  cases  have  been  reported  by  Buchwald.^  The 
first  was  that  of  a  man  forty-four  years  old  and  six  years  syphilitic. 
He  at  first  suffered  from  dyspnoea  and  dulness  in  the  mediastinum,  and 
dilatation  of  the  veins  of  the  overlying  skin  was  observed.  Later  he 
had  more  severe  dyspnoea,  cyanosis,  and  compression  of  the  bronchi. 
At  the  autopsy  an  aneurysm  as  large  as  a  man's  fist  was  found.  For  a 
time  the  man  was  relieved  by  the  internal  use  of  the  iodide  of  potassium. 

The  second  case  was  that  of  a  man  forty  years  of  age  Avho  suffered 
with  the  usual  symptoms,  and  was  for  a  time  relieved  by  treatment. 

^  Bolnitsch,  Oaz.  Boikina,  vol.  v.  pp.  457  et  seq. 
2  Lancet,  Nov.  27,  1875,  pp.  769  et  seq. 

*  "  Aortite  et  Aneur3'sme  cle  I'Aorte  d'Origine  syphilitique,"  La  Scmaine  mecL,  No.  2, 
1887.     See  also  Jaccoud,  Lemons  de  Clin.  med.  faifes  in  l' Hopilal  de  la  Pitie,  Paris,  1887. 

*  "  Ueber  Syphilitische  Aorten-aneurysrna'  nebst  Bemerkungen  iiber  Herz-syphilis," 
Dent.  med.  Woc'henschr.,  No.  52,  1889,  p.  1057. 


AFFECTIONS  OF  THE  EYE.  679 

Buchwald  very  properly  lays  stress  on  the  fact  that  in  these  cases  of 
aneurysm  there  is  frequently  concomitant  heart-  and  vessel-changes. 

In  this  connection  the  following  case,  reported  by  Frankel,^  is  inter- 
esting :  A  Avoman  thirty-six  years  old  suffered  from  angina  pectoris 
and  the  results  of  aortic  insufficiency.  At  the  autopsy  the  anterior 
coronary  artery  was  found  to  be  free,  while  the  left  was  obliterated  by 
sclerosis  at  its  embouchure  in  the  aorta.  The  interventricular  septum 
contained  a  gumma.  The  sclerosis  involved  the  aorta  as  far  as  the 
bifurcation  of  the  iliac  arteries. 

Friinkel  states  that  in  19  autopsies  in  patients  who  suffered  from 
aneurysm,  9  of  them  were  syphilitics  under  fifty  years  of  age,  making 
an  average  of  47  per  cent,  in  favor  of  syphilis  as  the  cause. 

In  considering  the  influence  of  syphilis  in  the  causation  of  aneurysm 
it  is  not  only  necessary  to  bear  in  mind  the  factors  already  mentioned, 
but  also  the  conditions  of  life  of  the  patients.  In  soldiers  there  is  an 
enforced  constriction  of  the  chest  which  may  predispose  them  to  aortic 
degeneration.  In  other  walks  of  life  a  man's  duties  may  require  him 
to  assume  positions  which  may  react  upon  the  vessels  of  the  chest. 

It  is  necessary  to  remember  that  although  tubercular  complications 
and  cancerous  and  aneurysmal  degeneration  are  usually  of  late  develop- 
ment, they  may  occur  early  and  during  the  secondary  period. 


CHAPTER    LXVII. 

AFFECTIONS  OF  THE  EYE.'' 

A  LARGE  number  of  tissues  enter  into  the  composition  of  the  orbit 
and  its  contents,  and  syphilitic  affections  of  this  region  are  corre- 
spondingly numerous  ;  but  a  minute  description  of  all  of  them  would  be 
inconsistent  with  the  limits  of  this  work,  and  I  shall  therefore  merely 
allude  to  several  of  them,  and  dwell  chiefly  upon  those  which  are  the 
most  common  and  most  likely  to  fall  under  the  care  of  the  general  prac- 
titioner. 

Affections  of  the  Bones  of  the  Orbit. 

These  may  show  themselves  either  as  periostitis,  caries,  or  necrosis, 
They  produce  the  same  general  symptoms  and  appearance  as  in  other 
parts  of  the  body,  but,  from  the  very  seat  of  the  trouble  and  the  prox- 
imity of  the  inflammatory  action  to  the  delicate  and  complex  organ  of 
the  eye  on  the  one  hand  and  the  sensorium  on  the  other,  the  symptoms  are 
apt  to  be  graver  and  the  results  more  disastrous  here  than  elsewhere 
except  within  the  cavity  of  the  cranium  itself. 

^  "Priiparaten  von  Herz-syphilis,"  J5er/.  klin.  Wochenfichr.,'^o.  12,  1894,  pp.  29G  et  seq. 
^  By  the  late  Dr.  E.  G.  Loring. 


680  SYPHILIS. 

The  inflammation  is  very  liable  to  be  propagated  from  the  bony  walls 
to  the  contents  of  the  orbit,  and  there  give  rise  either  to  a  superficial  or 
deep-seated  cellulitis,  which,  if  unchecked,  may  result  in  the  formation 
of  an  abscess,  and  this,  in  its  turn,  may  either  seriously  threaten  the 
integrity  of  the  eye  or  cause  its  total  destruction.  Again,  sinuses  may 
be  formed  in  different  directions  in  the  lids  or  their  surroundings,  through 
which  the  products  of  inflammation  may  be  discharged  for  an  almost 
indefinite  period,  accompanied  by  ulceration  and  contraction  of  the  soft 
parts,  with  eversion  or  displacement  of  the  lids. 

The  favorite  seat  of  these  troubles  is  the  inner  portion  of  the  orbital 
plate  of  the  frontal  bone,  the  orbital  border,  superior  and  inferior,  and 
the  OS  unguis,  in  which  latter  they  often  lead  to  troubles  in  the  lachrymal 
passages. 

The  results  of  orbital  cellulitis  may  be  the  same  here  as  in  the 
idiopathic  form,  and  the  surgeon  must  be  prepared,  in  case  a  deep-seated 
abscess  forms,  to  evacuate  this  with  a  bold,  free  incision  into  the  orbit,  in 
order  to  save  the  eye,  or  it  may  be  the  life,  of  the  patient. 

The  constitutional  disturbances  in  these  affections  of  the  bones,  espe- 
cially when  of  a  chronic  form,  are  sometimes  very  great,  and  the  patient 
often  becomes  reduced  in  a  marked  degree  through  pain  and  general 
nervous  prostration,  so  that  the  attending  physician  is  often  fearful  of 
subjecting  him  to  a  rigorous  course  of  specific  treatment.  This,  I  am 
convinced,  is  a  mistake,  for  there  is  no  occasion  where  the  good  effects  of 
a  vigorous  antisyphilitic  course  are  more  marked  than  here,  as  well  in 
regard  to  mercury  as  to  iodide  of  potassium.  Very  large  doses  of  this 
latter  drug  (3j),  two  or  three  times  a  day,  are  indeed  often  the  only  thing 
which  seems  to  effect  a  change  for  the  better. 

Syphilitic  nodes  may  be  met  with  upon  either  of  the  four  walls  of  the 
orbit.  They  are  most  frequent  near  the  anterior  opening  of  the  socket, 
but  may  occur  at  a  greater  or  less  depth  within  its  cavity,  and  cause  pro- 
trusion of  the  eyeball  and  loss  of  vision,  consequent  upon  the  stretching 
of  the  optic  nerve. 

Real  exostoses  may  form  in  the  bones  of  the  orbit  as  the  result  of 
syphilis. 

Affections  of  the  Lachrymal  Passages. 

Syphilis  not  unfrequently  gives  rise  to  changes  in  the  lachrymal 
passages,  causing  obstruction  to  the  flow  of  tears,  epiphora,  and  lach- 
rymal abscess  and  fistula.  Since  these  passages  are  not  exposed  to 
direct  observation,  the  exact  nature  of  the  changes  in  their  walls  is  not 
always  apparent.  In  a  few  instances  the  disease  appears  to  be  confined 
to  the  mucous  membrane  and  submucous  tissue,  and  to  consist  in 
catarrhal  inflammation,  consequent  oedema,  and  ulceration ;  in  the 
majority  of  cases,  however,  it  commences  in  the  bony  wall  or  peri- 
osteum, and  the  mucous  membrane  is  affected  secondarily  —  changes 
which  correspond  to  those  met  with  in  other  mucous  membranes  con- 
tiguous to  bony  tissue.  The  character  of  the  coexistent  syphilitic  sj^mp- 
toms  may  afford  some  idea  of  the  changes  in  the  tear-passages,  which, 
however,  can  only  be  accurately  determined  by  direct  exploration. 

The  symptoms  are  sufficiently  obvious.     The   tears,  meeting  with 


AFFECTIONS  OF  THE  EYE.  681 

obstruction  to  their  transit  through  the  lachrymal  passages,  collect  upon 
the  conjunctival  surface;  if  profuse,  they  flow  over  upon  the  cheek, 
especially  when  the  patient  is  exposed  to  the  wind,  and  the  eye  is  evi- 
dently more  moist  than  its  fellow,  whence  the  name  "  Avatery  eye " 
applied  to  this  disease.  Soon  pressure  over  the  lachrymal  sac  causes  a 
reflux  into  the  eye  of  the  lachrymal  secretion  mixed  with  more  or  less 
purulent  matter,  or  the  same  result  takes  place  spontaneously :  the  con- 
junctiva, especially  that  of  the  lower  lid  and  inferior  portion  of  the 
globe,  is  maintained  in  a  constant  state  of  irritation  and  inflammation, 
and  the  puncta  are  abnormally  red,  swollen,  and  prominent.  In  extreme 
cases  an  abscess  forms  in  the  lachrymal  sac  or  neighboring  cellular  tissue, 
opens,  and  gives  rise  to  one  or  more  fistulse. 

These  affections  of  the  lachrymal  passages  may  occur  at  any  period 
of  the  constitutional  taint ;  but  here,  as  elsewhere,  the  catarrhal  inflam- 
mation of  the  mucous  membrane  coincides,  as  a  rule,  with  the  secondary 
stage  of  the  disease,  while  the  deeper-seated  troubles  of  the  periosteum 
and  the  bones  are  the  development  of  the  tertiary  period. 

Much  may  be  done  for  the  relief  and  permanent  removal  of  obstruc- 
tions of  the  lachrymal  passages  by  the  persevering  and  long-continued 
use  of  specific  remedies.  The  bichloride  of  mercury  and  iodide  of 
potassium  may  give  satisfactory  results.  Most  cases,  however,  refuse  to 
yield  to  internal  remedies  alone,  and  in  all  a  cure  may  be  expedited  by  a 
resort  to  the  improved  local  treatment  for  which  ophthalmic  surgery  is  so 
largely  indebted  to  Mr.  Bowman  of  the  Moorfields  Ophthalmic  Hospital.^ 

The  treatment  consists  in  slitting  up  the  canaliculi  as  far  as  the 
caruncle,  and  afterward  dilating  the  passage  into  the  nose  by  means  of 
graduated  probes,  as  we  would  a  stricture  of  the  urethra.  The  first  part 
of  the  above  procedure  is  often  sufficient  to  afford  great  relief  to  the 
patient  by  opening  a  free  communication  between  the  conjunctiva  and 
sac,  and  by  preventing  collections  of  matter  in  the  latter  or  facilitating 
their  evacuation.  One  or  both  canaliculi  having  been  slit  up,  an  oppor- 
tunity is  afforded  to  explore  the  nasal  passages  with  a  full-sized  probe 
(about  one-twentieth  of  an  inch  in  diameter)  and  to  ascertain  the  nature 
of  the  obstruction.  If  this  be  due  to  swelling  of  the  mucous  and  sub- 
mucous tissues  alone,  the  passage  of  a  probe,  repeated  every  two  or 
three  days  for  a  few  weeks,  and  retained  on  each  occasion  for  about 
half  an  hour,  will  in  most  cases  suffice  to  re-establish  the  patency  of  the 
canal ;  but  when  denuded  bone  can  be  felt,  showing  that  the  disease  is 
seated  in  the  periosteal  or  osseous  tissues,  Mr.  Bowman's  method  will 
sometimes  prove  unsuccessful,  and  it  becomes  necessary  to  resort  to  the 
following  mode  of  treatment :  If,  after  the  canaliculus  has  been  slit  up, 
explorations  with  a  small  Bowman's  probe  show  that  the  seat  of  the 
trouble  is  in  the  lining  membrane  or  periosteum  of  the  canal,  whether 
this  be  from  simple  thickening  or  from  an  actual  stricture,  then  the  upper 
canaliculus  should  also  be  slit  up  and  the  orifice  made  by  the  juncture 
of  the  two  wounds  enlarged,  and  a  long  slender  knife,  such  as  Agnew's  ^ 

'  "See  Mr.  Bowman's  papers  in  the  Medical  and  Chirurr/ical  Transactions,  1851,  and  in 
the  Ophthalmic  Hospital  Reports  for  October,  1857;  also  "  Remarks  on  Diseases  of  the 
Lachrymal  Passages,"  by  the  author  in  the  report  of  the  N.  Y.  Eye  Inlirmary,  N.  F. 
Jo'urn.  of  Med.,  July,  1859. 

■^  For  an  admirable  article  on  "The  Treatment  of  Lachrymal  Diseases,"  see  the  Amer- 
ican Practitioner,  Jan.,  1871,  p.  1,  C.  R.  Agnew,  M.  D. 


682  SYPHILIS. 

lachrymal  knife,  should  be  passed  the  entire  length  of  the  canal,  and 
the  membrane  freely  incised  down  to  the  bone.  After  the  bleeding 
which  relieves  the  congestion  of  the  parts  has  ceased,  the  largest  size  of 
Bowman's  probes  should  be  passed  so  as  to  fully  dilate  the  canal.  This 
having  been  accomplished,  it  is  usually  a  comparatively  easy  matter  to 
keep  the  canal  open  by  the  occasional  use  of  a  smaller  probe. 

In  long-standing  chronic  cases,  where  there  is  not  much  active 
inflammation,  instead  of  a  probe,  a  piece  of  lead  wire  of  the  same  size 
as  a  probe  may  be  inserted  and  left  for  a  day  or  two,  or  even  for  a 
week  or  more,  until  the  divided  stricture  and  membrane  have  healed. 
Weak  injections  of  nitrate  of  silver  through  the  sac  and  nasal  canal  by 
means  of  a  small  syringe,  such  as  is  used  for  hypodermic  injections,  may 
often  be  used  with  benefit  once  or  twice  a  week.  These  should,  how- 
ever, never  be  stronger  than  a  grain  to  the  ounce. 

Sometimes  cases  occur  with  every  appearance  of  a  severe  trouble 
in  the  sac  and  canal,  showing  a  large  and  reddened  tumefaction,  which 
is  exquisitely  painful  to  the  touch,  and  in  which  there  is  a  slight  sense 
of  fluctuation,  with  every  indication  of  confined  pus.  There  is,  how- 
ever, little  or  no  epiphora,  and  no  pus  escapes  when  the  canaliculi  are 
slit  up.  Moreover,  the  probe  shows  that  there  is  no  stricture  or  even 
narrowing  of  the  canal.  The  real  seat  of  the  trouble  is,  then,  not  in 
the  sac  or  canal,  but  in  the  periosteum  of  the  nasal  process  of  the 
superior  maxillary  bone  and  contiguous  parts.  In  this  case  the  incision 
should  be  made  from  the  outside,  and  be  deep  enough  to  go  through  the 
periosteum.  The  cut  should  be  kept  open  for  a  day  or  two,  and  small 
poultices  used,  for  only  twenty  minutes  or  so  once  or  twice  a  day.  Some- 
times, though  rarely,  we  see  a  permanent  thickening  of  the  bones  in  this 
region,  which  makes  a  distressing  deformity. 

Should  this  treatment  not  suffice,  it  sometimes  becomes  necessary  ta 
resort  to  obliteration  of  the  sac  and  canaliculi  (which  should  always  be 
included)  by  the  actual  cautery,  or  to  Avait  for  the  slow  elimination  of 
the  carious  portions  of  bone  under  the  internal  administration  of  iodide 
of  potassium.  The  old-fashioned  style  has  been  entirely  abandoned. 
The  danger  and  inconvenience  attending  its  employment  far  more  than 
counterbalance  any  benefit  that  can  be  derived  from  it. 

Syphilitic  Affections  of  the  Lachrymal  Gland. 

The  only  recorded  case  of  affection  of  this  gland  is,  according  to 
Dr.  R.  W.  Taylor,^  that  reported  by  Chalons  ^  of  Luxembourg :  "  This 
case  was  that  of  a  person  in  the  first  year  of  his  disease,  having  lesions 
of  an  exanthematous  character  and  an  iritis.  Coincidently,  these 
glands  were  observed  to  become  swollen,  and  their  increased  size  was 
very  perceptible,  as  they  pushed  the  upper  lids  forward.  The  gland  on 
the  right  side  w^as  much  more  tumefied  than  its  fellow,  and  caused  the 
eyelid,  which  was  slightly  reddened,  to  droop  down  over  the  eye  as  in 
the  aifection  named  ptosis.  There  was  no  pain,  and  the  symptoms  were 
of  a  mild  character.  The  appearance  of  the  person  is  described  as 
being  very  peculiar.  The  swellings  subsided  under  the  influence  of  a 
mercurial  treatment." 


^  American  Jour 
^  "  Adenitis  Lach 


"anl  of  the  Medical  Sciences,  vol.  Ixix.,  1875,  p.  370. 
chrymalis  Syphilitica,"  Preuss.  Vereins  Zeitung,  No.  42,  1859. 


AFFECTIONS  OF  THE  EYE.  683 

The  writer  has  seen  one  or  two  similar  cases  in  Avhich  inflammation 
of  the  lachrymal  gland  or  surrounding  tissue  was  supposed  to  exist. 
In  all  these  cases,  however,  excepting  one,  there  was  no  specific  history 
and  no  concurrent,  nor  had  there  been  any  anterior,  manifestations  of 
syphilis.  In  one  case  there  was  a  doubtful  specific  history  in  a  man  of 
forty  years,  and  the  trouble,  which  had  lasted  a  long  time,  yielded  at 
once  to  very  large  doses  of  iodide  of  potassium.  In  all  the  trouble  was 
one-sided.  Dr.  Taylor  also  mentions  in  the  same  paper  two  unique 
cases  where  there  was  gummy  infiltration  into  the  caruncles. 

Syphilitic  Affections  of  the  Eyelids. 

These  lesions  are  very  rare,  but  when  they  do  occur  they  present 
the  same  general  appearances  and  characteristics  that  the  same  lesions 
present  in  the  corresponding  tissues  elsewhere  in  the  body,  and  they 
may  for  clinical  purposes  be  divided  into  eruptions,  infiltrations,  and 
ulcerations. 

An  eruption  of  a  pustular  syphilide,  of  ecthyma,  of  ulcerating  rupia, 
and  other  forms  may  occur  on  the  eyelids,  and  especially,  according  to 
Lancereaux,  in  the  tertiary  period  the  external  surface  of  the  lid  may 
be  the  seat  of  ulcerating  or  even  serpiginous  syphilides,  which  by  cica- 
tricial contraction  may  cause  ectropion  or  other  displacements  of  the 
lid.  Lawrence  states  that  the  lining  mucous  membrane  may  share  in 
the  eruption,  which,  as  a  rule,  affects  it  superficially.  He  mentions  a 
case  of  general  papular  eruption  in  a  man  with  specific  iritis,  in  whom 
papules  were  also  seen  on  the  inner  surface  of  the  lid.  The  writer  has 
seen  a  similar  case  where  the  papules,  which  covered  the  external  sur- 
face, extended  a  little  beyond  the  juncture  of  the  mucous  membrane 
with  the  edge  of  the  lid. 

Syphilitic  eruptions  of  the  eyelids  are  more  frequent  in  infants 
affected  with  hereditary  syphilis  than  in  adults.  The  external  surface 
of  the  lids  is  the  seat  of  an  eruption  of  pustules,  which  run  into  each 
other,  break,  and  leave  the  skin  excoriated  and  red.^  The  conjunctiva 
of  the  lid  and  the  globe  may  become  involved  through  extension  of  the 
inflammation,  and  the  cornea  destroyed  by  infiltration  of  pus.  This 
affection  may  be  distinguished  from  ophthalmia  neonatorum  by  its  later 
development — the  latter  appearing  about  the  third  day  and  the  former 
several  weeks  after  birth — and  by  the  presence  of  the  eruption  upon 
the  external  surface  of  the  lids,  to  which  the  conjunctivitis  is  only 
secondary. 

Sypliilitic  Ulcerations. — These  may  be  due  either  to  a  chancroid  or 
to  true  syphilis,  and  they  may  be  primary  or  secondary. 

Soft  chancres  upon  the  lids  are  of  extreme  rarity.  I  have  never 
seen  any  myself,  but  Galezowski  ^  and  Hirscher^  have  each  reported  a 
case. 

In  the  secondary  period  syphilitic  lesions  of  the  inner  surface  of  the 
lids  appear  as  small,  circumscribed,  prominent  spots,  usually  of  a  moderate 
degree  of  vascularity,  though  not  always,  as  the  surrounding  tissue  some- 

^  Figured  by  Devergie,  CUmqne.  ric  In  Mahdie  syphilitique,  PI.  37. 

^  Journal  d'  Ojihthnlmolof/ic;  mai  et  juin,  1872. 

^  Wiener  rned.  Wochenschrift,  Nos.  72,  73,  74,  18G6. 


684  SYPHILIS. 

times  becomes  congested,  and  the  congestion  may  then  extend  to  the 
ocular  conjunctiva.  The  color  of  these  spots  sometimes  varies  from  a 
grayish-red  to  a  yellow  or  even  copper  color.  Mucous  patches,  pure  and 
simple,  may  occur  on  the  palpebral  conjunctiva,  and  they  present  the 
same  characteristics  as  they  do  elsewhere  on  the  body. 

Secondary  ulcerations  of  the  eyelids  usually  begin  as  gummy  tumors 
or  as  submucous  infiltrations.  They  are  very  destructive  of  tissue,  and 
often  leave  behind  them  a  scar,  which,  with  the  destruction  of  the  hair- 
follicles  and  the  consequent  loss  of  hair,  is  for  some  a  diagnostic  mark. 
Still,  the  fact  should  not  be  lost  sight  of  that  the  same  result  may  occur 
from  a  simple  furuncle  or  an  aggravated  stye. 

Secondary  ulcers  are  almost  always  situated  near  the  free  border,  en- 
croaching upon  the  mucous  membrane  or  upon  the  skin,  and  sometimes, 
as  in  a  number  of  cases  collected  by  Mackenzie,^  causing  complete  de- 
struction of  the  lid.  I  have  seen  but  one  case,  in  a  lad  aged  nineteen 
affected  with  syphilitic  disease  of  the  lachrymal  passages  and  nodes  upon 
the  tibia,  and  who  had  several  small  excavated  ulcers  upon  the  mucous 
membrane  of  the  lower  lid  bordering  upon  its  free  margin.  His  disease 
could  be  traced  to  a  chancre  contracted  three  years  previously,  and  dis- 
appeared under  iodide  of  potassium  and  mercurials.  These  ulcerations 
may  be  mistaken  for  ophthalmia  tarsi  and  epithelial  cancer,  or,  when 
situated  near  the  inner  canthus,  for  disease  of  the  lachrymal  passages. 

Moreover,  Zeissl  declares  that  the  gross  and  microscopical  appearances 
of  the  initial  lesion  are  so  similar  that  they  can  hardly  be  distinguished, 
and,  moreover,  the  rapid  and  enormous  growth  of  a  papule  on  the  lid 
sometimes  causes  it  to  resemble  a  gumma. 

Sometimes  infiltrations  into  the  substance  of  the  lid  between  the 
cartilage  and  the  external  surface  do  not  ulcerate,  but  remain  for  a  long 
time  as  nodules,  varying  in  size  from  a  shot  to  a  large-sized  filbert. 
Under  these  circumstances  the  skin  over  these  nodules  is  but  slightly  if 
at  all  reddened,  and  in  this  case  these  protuberances  bear  a  close  resem- 
blance to  tarsal  tumors  or  chalaza,  for  which  they  have  been  mistaken. 
These  masses  usually  resolve  themselves  under  the  free  use  of  anti- 
syphilitic  remedies,  especially  the  mercurials. 

Syphilitic  inflammation  of  the  tarsal  cartilage  has  been  reported 
latterly  by  various  observers  under  the  name  of  tarsitis  syphilitica 
(Magawby,  Fuchs,  Vogel,  Bull,  and  others).  It  is  characterized  by  a 
thickening  from  inflammatory  infiltration  of  the  cartilage,  which  usually 
maintains  its  shape,  and  swelling  of  the  lid,  in  which  the  skin  may  or 
may  not  be  involved.  As  a  rule,  it  is  found  that  after  the  acute  stage 
has  passed  and  the  tumor  has  disappeared  the  cartilage  has  lost  its 
normal  elasticity  and  resistance.  The  affection  is  very  obstinate,  lasting 
over  several  weeks,  if  not  months,  and  it  is  apt  to  be  followed  by  a  more 
or  less  complete  loss  of  the  cilise. 

Finally,  inflammation  due  to  constitutional  syphilis  may  attack  the 
tendons  and  fasciae  of  the  muscles  of  the  globe,  and  especially  the  cap- 
sule of  Tenon.  This  is  always  a  grave  lesion,  as  deep-seated  abscesses 
are  liable  to  form,  hemmed  in  by  the  fascias  and  thecae. 

Besides  constitutional  treatment,  these  affections  often  require  surgical 
interference    in    the    way    of    deep  and    broad  incisions    into  the  orbit, 

^  Diseases  of  the  Eye,  Philad.  ed.,  1855,  p.  160. 


AFFECTIONS  OF  THE  EYE.  685 

especially  in  the  line  of  the  muscles  and  close  to  the  globe.  They  are 
apt  to  end,  in  spite  of  all  care  and  skill,  in  total  destruction  of  the  globe 
through  panophthalmitis. 

Affections  of  the  Conjunctiva. 

If  we  except  the  ulcerations  of  the  lids,  already  described  as  some- 
times encroaching  from  the  mucous  membrane  of  the  internal  surface 
upon  the  cul-de-sac,  the  conjunctiva — that  is,  the  ocular  conjunctiva — is 
very  rarely  the  seat  of  syphilitic  manifestations. 

Savy,^  however,  reports  a  case  of  a  syphilitic  papule  developed  upon 
the  ocular  conjunctiva  three  millimetres  above  the  cornea.  The  patient 
contracted  syphilis  six  months  before,  and  had  over  the  whole  body  an 
obstinate  lenticular  eruption ;  the  eyelids  were  red,  the  lashes  had  fallen 
off,  and  the  papular  eruption  had  extended  to  the  under  surface  of  the 
lids.  A  cure  was  obtained  after  three  weeks'  specific  treatment.  Savy 
quotes  two  similar  cases  from  P.   Horteloup  and  from  Lailler. 

Infants  tainted  with  hereditary  syphilis  are,  indeed,  more  frequently 
than  others  the  subjects  of  ophthalmia  neonatorum,  to  Avhich  they  are 
peculiarly  exposed  from  their  general  cachectic  condition  and  the  fre- 
quency of  vaginal  discharges  in  their  syphilitic  mothers ;  but  there  is  no 
direct  connection  between  their  hereditary  taint  and  the  purulent  inflam- 
mation of  the  conjunctiva,  which  usually  makes  its  appearance  before  the 
development  of  other  symptoms. 

Mr.  Smee^  and  Mr.  France^  have  met  with  "  blotches  "  upon  the  con- 
junctiva coinciding  with  syphilitic  eruptions  upon  the  integument,  and 
disappearing  under  mercurial  treatment.  The  appearances,  as  described 
by  Mr.  France,  are  as  follows :  "  This  form  of  disease  presents  itself  as  a 
limited  and  well-defined  discoloration  of  the  mucous  membrane  of  the 
globe,  which,  within  the  aff"ected  area,  is  slightly  thickened  and  raised, 
but  not  conspicuously,  if  at  all,  more  vascular  than  the  neighboring  sur- 
face. There  does  not  seem  to  be  any  disposition  to  ulceration,  as  when 
the  margin  of  the  lid  is  attacked  with  syphilis ;  there  are  no  pain  and  no 
morbid  discharge."  Mr.  France  met  with  two  cases,  of  Avhich  he  gives 
a  plate — Mr.  Smee  with  only  one. 

There  would  appear  to  be  no  reason  why  the  ocular  conjunctiva  should 
not  be  affected  both  by  true  chancre  and  chancroid.  I  have  never  seen 
the  occurrence  of  either,  but,  as  this  work  is  passing  through  the  press, 
Boucheron  reports  a  well-authenticated  ease  of  a  true  chancre  of  the  semi- 
lunar fold  conveyed  in  a  kiss  from  mucous  patches  in  the  mouth,  and 
refers  to  another  in  the  same  situation  in  a  physician  who  rubbed  his  eye 
to  relieve  itching  with  his  fingers  soiled  in  examining  a  case  of  syphilis.* 

1  have  seen  several  times  what  I  have  taken  to  be  ulcerations  of  a 
secondary  nature,  such  as  have  been  described  by  Magni,  Noyes,^  and 
others.  The  latter  says  the  common  site  for  these  ulcerations  is  near  the 
margin  of  the  cornea,  Avhere  a  reddened  and  elevated  spot  appears,  resem- 
bling a  severe  phlyctenule.  It  rises  higher  and  is  more  extensive  than 
such  eruptions  usually  are,  and  it  soon  begins  to  ulcerate.     The  surface 

^  "Contribution  &.  I'Etude  des  Eruptions  de  la  Conjunctive,"  TASse  de  Paris,  1876. 

2  London  Medical  Gaz.,  1844,  pp.  347,  348.         ^  Guy's  Hasp.  Repls.,  3d  Series,  vol.  vii. 
*  Gaz.  des  Hop.,  14  juin,  1879.  *  Syphilis  of  the  Eye,  1874,  p.  4. 


686  SYPHILIS. 

not  only  becomes  excavated,  but  shoAvs  a  jelly-like,  semi-transparent 
tissue  about  the  eroded  part,  and  this  may  spread  to  the  cornea,  which 
then  often  has  a  hazy  appearance  in  the  neighborhood  of  the  ulceration, 
giving,  especially  just  before  the  surface  of  the  protuberance  begins  to 
ulcerate,  the  picture  of  episcleritis.  The  search  for  corroborative  symp- 
toms of  syphilis  in  other  parts  of  the  body  will  usually  be  rewarded  by 
success. 

Magni  describes  an  affection,  under  the  name  of  kerato-conjunctivitis 
gummosa,  in  a  woman  who  was  affected  with  constitutional  syphilis. 
There  appeared  on  the  ocular  conjunctiva  several  semi-globular  tumors, 
varying  from  the  size  of  a  pinhead  to  that  of  a  bean.  These  were  of 
a  whitish  color  at  their  summits  and  red  at  the  base,  and,  except  when 
situated  near  the  cornea,  were  freely  movable  with  the  conjunctiva. 

The  ocular  membrane,  moreover,  according  to  Desmarres,^  is  some- 
times the  seat  of  syphilitic  tubercles  coexisting  with  a  similar  eruption 
upon  the  skin.  This  author  relates  the  case  of  a  patient  aflFected  with 
syphilitic  iritis,  in  whom  one  of  the  so-called  condylomata  of  the  iris,  situ- 
ated near  its  external  margin,  penetrated  the  sclerotic  and  formed  a  pro- 
tuberance beneath  the  conjunctiva,  which,  moreover,  was  studded  on  every 
side  with  small,  indolent,  hard,  and  oblong  tumors,  exactly  similar  to  an 
eruption  of  syphilitic  tubercles  upon  various  portions  of  the  integument. 
The  disease  disappeared  under  mercurial  treatment. 

The  mass  which  penetrated  the  sclera  was  probably  a  gummy  tumor 
of  the  ciliary  body,  about  which  more  will  be  said  a  little  later. 

Wecker,  Estlander,  Bull,  and  others  have  reported  eases  of  gummy 
infiltration  of  the  ocular  conjunctiva.  In  most  of  these  the  product  in 
the  conjunctiva  has  appeared  to  be  simply  the  extension  of  that  in  the 
sclera  from  continuity  of  tissue.  Dr.  Bull's  ^  case  is  worthy  of  note,  as 
possessing  what  would  appear  to  be  an  independent  focus  of  infiltration 
in  the  conjunctiva  proper,  or,  at  least,  in  the  limbus.  This  was  in  the 
case  of  a  man  the  victim  of  a  combination  of  constitutional  syphilitic 
manifestations,  among  which  "  there  was  a  peculiar  eruption  upon  the 
hands  and  face,  composed  of  elevated  spots  with  flat  tops,  some  round, 
others  oval,  yellowish-red  in  color,  with  a  narrow  dark-red  areola,  neither 
painful  nor  tender  to  the  touch,  and  presenting  a  mid-state  between  vesic- 
ulation  and  pustulation. 

"  The  eyes  were  almost  identical  in  appearance.  Surrounding  the 
cornese  there  was  a  growth,  most  marked  on  the  outer  and  lower  sides, 
varying  in  height  from  one  and  a  half  to  two  lines,  seated  in  and 
beneath  the  ocular  conjunctiva.  This  growth  extended  away  from  the 
cornea  on  all  sides  about  one-third  of  an  inch,  was  pale  yellow  in  color, 
moderately  hard  to  the  touch,  with  an  irregular,  knobby  surface,  and 
apparently  destitute  of  vessels.  The  conjunctiva  was  firmly  adherent 
to  this  growth,  and  the  cornea  was  imbedded  in  this  wall  like  a  watch- 
crystal  in  its  frame.  On  being  incised,  it  cut  like  brawn  and  the  hem- 
orrhage was  very  slight.  Upon  the  sclera  of  each  eye,  between  the 
tendons  of  the  superior  rectus  and  external  rectus  muscles,  and  partially 
covering  the  latter,  was  an  extensive  and  extremely  well-marked  gummy 
infiltration  of  the  sclera,  very  vascular,  very  tender  to  the  touch,  and 

^  Traite  des  Maladies  den  Yeux,  t.  ii.  p.  216. 

^  American  Journal  of  Medical  Sciences,  October,  1878. 


AFFECTIONS  OF  THE  EYE.  687 

especially  painful  when  the  eyes  were  turned  outward.  This  infiltration 
extended  backward  symmetrically  in  the  two  eyes,  but  was  somewhat 
more  extensive  in  the  right  eye.  The  media  was  clear,  and  an  ophthal- 
moscopic examination  revealed  nothing  abnormal  in  the  deeper  tunics 
of  the  eyes." 

Syphilitic  Affections  of  the  Cornea. 

While  ulceration  of  the  cornea  wath  loss  of  tissue  is  in  non-specific 
cases  the  commonest  form  of  disease  to  which  this  membrane  is  liable 
in  syphilis,  ulceration  rarely — according  to  some  never — occurs  as  the 
direct  result  of  the  constitutional  taint.  When,  therefore,  an  inflam- 
mation of  this  membrane  does  occur,  it  is  usually  in  the  substance  of 
the  cornea,  and  in  this  form  it  is  known  as  parenchymatous  kera- 
titis. And  this  interstitial  aifection,  again,  may  show  itself  as  diffuse 
or  punctate.  In  these  forms,  moreover,  it  is,  as  a  rule,  the  result  of 
hereditary  syphilis. 

Diffuse  keratitis  is  generally  ushered  in  by  a  slight  pericorneal  injec- 
tion, and  with  a  slight  grayish  opacity  near  the  centre  of,  and  in  the 
substance  of,  the  cornea.  The  haziness  gradually  increases  until  the 
greater  part  of  the  cornea  is  involved,  giving  to  this  membrane  the 
appearance  of  ground  glass,  especially  when  the  epithelial  layer  is  im- 
plicated. It  is,  as  a  rule,  in  the  beginning  not  accompanied  by  much 
pain  or  photophobia,  though  both  may  be  present,  together  with  abun- 
dant lachrymation,  particularly  as  the  disease  progresses  to  the  deeper 
parts  of  the  cornea.  There  is  little  vascularity  as  a  rule,  though, 
especially  at  the  periphery,  minute  vessels  may  be  descried,  which, 
increasing  in  number  and  extent,  may  give,  at  a  little  distance,  a  rosy 
hue  to  the  cornea.  I  have  seen  cases  in  which  there  has  appeared  to  be 
an  interstitial  hemorrhage,  so  deep  and  close  was  the  injection.  In  one 
case,  indeed,  the  entire  cornea  was  a  blood-red  mass,  as  if  the  bleeding 
had  occurred  into  the  very  substance  of  the  membrane,  the  epithelial 
layer  retaining  its  polish.  Diffuse  keratitis  is  the  form  which  the  dis- 
ease usually  takes  in  young  children,  while  the  punctate  variety  appears 
later  in  life,  or,  at  least,  such  has  been  my  observation.  Mr.  Jonathan 
Hutchinson^  has  expressed  the  opinion,  founded  upon  a  lengthy  and 
ably  conducted  series  of  observations,  that  the  peculiar  inflammation  of 
the  cornea  met  with  for  the  most  part  between  the  ages  of  three  and 
twenty,  and  known  by  the  name  of  "strumous  corneitis,"^  is  always 
due  to  hereditary  syphilis.  In  his  attempt  to  establish  this  point  Mr. 
Hutchinson  has  attached  no  little  importance  to  certain  peculiarities  in 
the  form,  size,  and  color  of  the  permanent  incisor  teeth  which  he  re- 
gards as  diagnostic  of  inherited  syphilitic  taint,  and  which  he  states  are 
all  but  invariably  coexistent  with  strumous  keratitis. 

It  has  been  the  custom  from  time  to  time  since  Mr.  Hutchinson 
made  his  observations  to  question  the  validity  of  his  views,  both  as  to 
the  fact  of  interstitial  keratitis  being  due  to  hereditary  syphilis  and  the 
diagnostic  value  of  the  so-called  characteristic  teeth.  Thus,  it  has  been 
asserted,  not  only  in  England,  but  on  the  Continent,  and  especially  in 

'  Ophlh.  Hosp.  Rep.,  vol.  i.  p.  229. 

'^  The  name  "  keratitis  "  is  much  preferable  to  "  coriieitis." 


SYPHILIS. 

Germany,  that  the  disease  may  be  the  result  of  malnutrition  in  scrof- 
ulous and  rickety  subjects,  and  it  has  been  maintained  that  the  malfor- 
mation of  the  teeth  is  the  simple  arrest  of  development  in  a  perverted 
constitution  from  other  causes  than  syphilis.  Thus,  Maunther  ^  declares 
that  "  the  German  ophthalmologists  have  in  no  way  been  able  to  endorse 
the  theory  of  Hutchinson;"  while,  on  the  other  hand,  Forster,^  an  emi- 
nent German  authority,  states  at  a  still  more  recent  date  just  the  contrary, 
and  maintains  that  "  the  view  that  interstitial  and  parenchymatous  kera- 
titis is  frequently  due  to  hereditary  syphilis  is  constantly  gaining  more 
adherents." 

It  Avould  be  out  of  place  in  a  work  like  the  present  to  go  deeply  into 
a  discussion  in  regard  to  matters  about  which  there  is  so  great  a  difference 
of  opinion,  but  I  may  state  briefly  that  I  believe  that  the  hereditary 
taint,  though  not  the  only,  is  still  the  predominating,  cause  of  interstitial 
keratitis.  And  this  I  consider  important  in  a  clinical  point  of  view,  for 
I  can  fully  confirm  Mr.  Hutchinson's  statement  that  the  most  efficacious 
treatment  of  this  disease  in  the  majority  of  cases  is  by  means  of  mild 
mercurials  and  iodide  of  potassium,  assisted  by  a  nourishing  diet,  fresh 
air,  and  tonics. 

Keratitis  punctata  differs  from  the  diff'use  in  that  the  opacity  is  arranged 
in  small  circumscribed  spots  or  points.  These,  as  a  rule,  do  not  show  a 
tendency  to  coalesce.  Still,  this  may  occur,  so  that  the  masses  become 
large  enough  to  occupy  a  quadrant,  or  even  the  half,  of  the  corneal  tissue. 
It  also  differs  from  the  diffuse  in  being  deeper-seated  and  usually  of  a 
deeper  grayish  or  yellowish  color. 

Maunther  describes  a  form  of  keratitis  punctata  which  is  worthy  of 
notice  from  the  fact  that  it  appears  to  be  even  more  pathognomonic 
of  syphilis  than  the  ordinary  keratitis  punctata, '  and,  according  to  my 
experience,  rather  the  expression  of  the  acquired  than  of  the  hereditary 
disease.  This  form  consists  in  the  cornea  being  studded  with  a  multitude 
of  minute  dots  not  larger  than  a  pin-point.  These  are  not,  as  one  would  be 
inclined  at  first  sight  to  infer,  on  the  membrane  of  Descemet,  but  in  the 
substance  of  the  cornea  itself.  I  have  at  the  present  moment  a  most 
beautifully  marked  case  of  this  disease  in  a  young  woman  of  three-and- 
twenty,  who,  when  I  first  saw  her  some  three  months  ago,  had  a  secondary 
eruption  on  the  legs,  arms,  and  neck.  Externally,  nothing  whatever  was 
visible  which  would  suggest  the  slightest  trouble  with  either  eye,  and  the 
only  complaint  which  the  patient  made  was  that  she  had  noticed  accident- 
ally that  she  did  not  see  as  well  as  formerly  with  her  left  eye.  There  was 
no  pain  and  no  lachrymation,  and  not  the  slightest  injection  of  the  con- 
junctiva. The  cornea  and  anterior  chamber,  moreover,  seemed  to  have 
their  normal  clearness,  and  the  iris  was  normal  in  every  respect.  A  glance 
with  the  ophthalmoscope  showed,  however,  the  cornea  to  be  the  seat  of  a 
multitude  of  most  minute  dots,  none  of  which  were  larger  than  a  pin's 
point.  By  means  of  oblique  illumination  the  most  anterior  of  these  could 
be  seen  in  their  real  color,  which  was  of  a  dingy  gray  or  dirty  white. 
The  trouble  continued,  without  any  perceptible  change  and  without  any 
inflammatory  symptom  whatever,  for  nearly  three  months,  when  on  catch- 
ing cold  there  was  some  pain  in  the  eye  and  a  slight  pericorneal  injection, 

1  Zeissl's  Lehrbuch  der  Syphilis,  1875,  p.  288. 

^  Handbuch  der  gesam.  Augenheil/cunde,  vol.  vii.  p.  186,  1876. 


AFFECTIONS  OF  THE  EYE.  689 

which  rapidly  subsided.  A  vigorous  antisyphilitic  treatment  has  been 
pursued  from  the  first,  and  within  the  last  week  or  two  the  dots  have 
begun  to  disappear,  these  only  remaining  now  in  the  central  portion  of  the 
cornea. 

The  treatment  of  these  syphilitic  affections  does  not  differ  from  that 
in  the  idiopathic  form,  and  consists  in  the  use  of  atropine  instillations, 
with  protection  from  light  by  means  of  colored  glasses,  antisyphilitic 
remedies,  with  a  judicious  administration  of  tonics,  diet,  and  fresh  air. 

It  is,  moreover,  sometimes  necessary  to  perform  paracentesis  or  even 
iridectomy. 

Syphilitic  Affections  of  the  Sclera. 

These,  like  the  non-specific,  may  be  divided  into  two  principal  classes 
— those  affecting  the  superficial  tissue,  or  episcleritis,  and  those  affecting 
the  interstitial  layers,  or  parenchymatous  scleritis.  To  these  some  syphil- 
ographers  add  a  third,  or  scleritis  gummosa,  when  the  sclera  is  the  seat 
of  this  specific  infiltration  or  product.  Episcleritis  begins  commonly  as  a 
small  hyper^emic  spot,  usually  about  a  line  from  the  margin  of  the  cornea. 
As  the  inflammation  increases  in  extent  and  degree  the  spot  looks  very 
much  like  a  phlyctenula,  though  the  coloration  is  more  subdued,  and,  after 
a  while,  assumes  a  violet  or  purple  tinge.  On  close  inspection  the  con- 
junctiva is  seen  to  be  but  little  if  at  all  implicated,  and,  as  a  rule,  the 
new  formation  has  the  appearance  of  a  bulging  of  the  surface,  which 
merges  gradually  into  the  surrounding  tissue,  rather  than  a  circumscribed 
growth,  though  even  this  may  occur,  so  that  it  resembles  a  defined  tumor 
the  size  of  half  a  pea  or  even  larger.  The  favorite  spot  for  the  develop- 
ment of  this  localized  inflammation  is  near  the  insertion  of  the  external 
rectus  muscle  or  between  this  and  the  superior  rectus.  Still,  any  part  of 
the  anterior  portion  of  the  sclera  may  be  affected,  or  more  parts  than  one, 
either  successively  or  at  the  same  time.  In  this  case  the  spots  may  spread 
and  then  coalesce,  until  the  greater  part  of  the  circumference  near  the 
cornea  is  affected. 

When  the  inflammation  is  confined  to  the  episcleral  tissue  there  is,  as  a 
usual  thing,  but  little  pain,  lachrymation,  or  photophobia,  though  all  three 
may  be  present. 

The  trouble  is,  however,  apt  to  propagate  itself  to  the  neighboring 
tissues,  so  that  the  cornea,  iris,  and  ciliary  body,  one  or  all,  may  become 
implicated.  In  the  last  case  a  kerato-irido-cyclitis  is  produced,  than  which 
there  is  no  condition  of  ocular  trouble  more  to  be  dreaded,  or  one  which 
will  more  tax,  even  if  it  does  not  overcome,  the  skill  and  resources  of  the 
surgeon.  The  implication  of  the  cornea  is  usually  shown  by  a  grayish 
diffuse  opacity,  corresponding  to  the  seat  of  the  inflammatory  spot,  and 
extending  usually  in  a  triangular  shape  into  the  clear  area  of  the  cornea ; 
the  participation  of  the  iris  manifests  itself  by  adhesions,  and  sometimes 
by  exudation  into  the  papillary  space,  and  that  of  the  ciliary  body  by  the 
usual  signs  of  cyclitis.  When  the  episcleritis  is  due  to  a  gummy  deposit, 
it  may  resolve  itself  gradually,  which  is  the  rule  under  specific  remedies, 
or  it  becomes  eroded  at  its  apex,  forming  an  excavation  with  more  or  less 
ragged  edges,  while  the  area  is  occupied  by  a  jelly-like  substance  of  a 
grayish  or  yellowish  color ;  and  it  is  more  than  probable  that  some  of  the 
infiltrations  which  present  these  appearances,  and  which  have  been  de- 

44 


690  SYPHILIS. 

scribed  as  belonging  to  the  conjunctiva  proper,  have  had  their  origin  in 
the  episcleral  tissue. 

Rare  as  the  above  affections  are,  those  due  to  parenchymatous  scleritis 
are  rarer  still.  That  such  exist,  however,  I  think  there  can  be  no  doubt. 
The  trouble  usually  begins  by  a  circumcorneal  zone  of  injection  of  a  very 
delicate  rose  or  pink  color,  -which  often,  after  the  disease  has  continued  a 
short  time,  passes  into  a  violet  or  purplish  tinge,  which  close  inspection 
shows  to  be  due  not  to  vascularity  of  the  conjunctiva,  but  of  the  sclera 
itself.  The  injection  gradually  extends  backward  until  the  whole  anterior 
zone  of  the  eye  presents  the  delicate  rosy  hue  mentioned  above,  which 
differs  entirely  from  the  coarser  meshlike  injection  of  an  early  conjunc- 
tivitis on  the  one  hand  or  the  deep  red  of  iritis  on  the  other.  The  trouble 
may  continue  for  a  long  time  in  a  low  chronic  type,  without  much  photo- 
phobia, pain,  or  lachrymation,  though  the  latter  two  may  be  present  in 
an  intense  degree,  and  then  the  disease  forcibly  reminds  one  of  the  descrip- 
tion of  what  the  older  writers  called  rheumatic  ophthalmia.  Strange  to 
say,  through  it  all  the  iris  may  not  become  implicated,  dilating  ad  max- 
imum under  atropine,  apparently  even  to  an  abnormal  degree,  as  sometimes 
the  merest  possible  trace  of  the  membrane  remains  visible.  This  is  due, 
I  think,  to  the  fact  that  the  limbus  becomes  congested  and  slightly  salient, 
thus  encroaching  upon  and  narrowing  the  area  of  the  clear  cornea.  I 
have  several  times  seen  this  affection  in  those  who  had  recently  recovered 
from  a  severe  and  protracted  attack  of  gonorrhoea,  and  thus  perhaps  repre- 
senting the  analogue  of  the  much-disputed  gonorrhoeal  rheumatism.  Here, 
as  elsewhere,  there  is,  of  course,  always  a  danger  that  the  inflammation 
may  extend  itself  to  the  neighboring  tissue,  and  its  early  origin  and 
destructive  features  may  thus  be  concealed  in  the  signs  and  symptoms  of 
the  participating  parts.  Resolution  of  these  foci  of  inflammation  usually 
occasions  a  localized  resorption  and  thinning  of  the  sclera,  which  shows 
itself  by  a  bluish  area,  that  may  subsequently  become  the  seat  of  a  staphy- 
lomatous  projection. 

Gummy  infiltration  into  the  stroma  of  the  tissue  merely  differs  from 
the  episcleral  in  its  locality. 

Syphilitic  Iritis. 

Of  all  the  affections  of  the  eye,  there  is  none  which,  taken  as  a  whole, 
is  more  serious  in  its  immediate  effects  or  more  disastrous  in  its  subsequent 
results  than  iritis. 

It  is  estimated,  from  carefully  prepared  statistics,  that  over  one-fourth 
of  the  cases  of  total  blindness  proceed  from  inflammation  of  this  mem- 
brane, and  when  it  is  taken  into  consideration  that  between  60  and  70^ 
per  cent,  of  all  cases  of  iritis  are  due  to  syphilitic  infection,  the  important 
role  which  the  specific  virus  plays  in  this  class  of  diseases  becomes  at  once 
manifest,  and  strongly  emphasizes  the  fact  that,  since  the  integrity  of  one 
of  the  most  important  organs  of  the  human  frame  is  involved,  syphilitic 
iritis  should  be  familiar  to  every  student  of  venereal,  in  order  that  he  may 
early  be  able  to  recognize  and  treat  it, 

^  My  friend,  Dr.  Henry  D.  Noyes,  of  the  Infirmary,  informs  me  that,  according  to 
statistics  collected  and  reported  in  his  lectures  by  Prof.  Graefe,  about  60  per  cent,  of  all 
cases  of  iritis  occur  in  persons  affected  with  syphilis.  See  also  Wecker,  Etudes  ophthaL, 
tome  i.  p.  394. 


AFFECTIONS  OF  THE  EYE.  691 

Let  rae  premise  by  saying  that  we  have  no  certain  means  of  distin- 
guishing syphilitic  iritis  from  that  dependent  upon  injury,  rheumatism,  or 
other  causes,  although  there  are  certain  symptoms,  presently  to  be  de- 
scribed, which,  when  observed,  render  the  former  origin  probable.  More- 
over, the  majority  of  cases  of  iritis  are  doubtless  due  to  syphilitic  taint, 
so  that  the  existence  of  this  disease  should  always  excite  suspicion,  and 
lead  the  surgeon  to  make  a  thorough  examination  of  the  present  condition 
and  past  history  of  the  patient. 

In  accordance  with  the  teachings  of  pathological  anatomy,  modern 
ophthalmologists  have  divided  inflammation  of  the  iris  in  general  into 
three  classes : 

(1)  Simple  or  plastic  iritis  ; 

(2)  Serous  iritis ; 

(3)  Parenchymatous  or  suppurative  iritis. 

It  is  to  this  last  division  that  the  so-called  syphilitic  iritis,  as  a  rule, 
belongs ;  still,  as  the  disease  may,  and  often  does,  assume  either  of  the 
above  forms,  a  short  description  of  each  will  be  given,  omitting  the 
more  minute  details,  which  are  chiefly  of  interest  to  the  ophthalmol- 
ogist, and  which  are  apt  to  confuse  the  mind  of  one  who  has  not  made 
a  special  study  of  the  eye. 

Simple  or  Plastic  Iritis. — This  form  is  characterized  by  congestion 
of  the  membrane,  but  diff"ers  from  simple  hypersemia  of  the  iris  by  the 
production  of  an  exudation  either  from  the  pupillary  border,  surface,  or 
stroma  of  the  iris,  and  in  some  cases  by  an  increase  in  the  elements  of 
the  connective  tissue. 

This  variety  of  the  disease  may  assume  a  very  mild  character,  pre- 
senting but  a  very  moderate  degree  of  subconjunctival  injection,  and 
accompanied  with  but  little  discoloration  of  the  iris,  pain,  or  dread  of 
light.  Indeed,  it  may  happen  that  the  entire  trouble  escapes  detection 
till  the  use  of  atropine  brings  to  light  the  existence  of  one  or  more 
adhesions  of  the  iris  to  the  anterior  capsule  of  the  lens,  producing 
under  dilatation  the  characteristic  irregularity  of  the  pupil. 

More  frequently,  however,  there  is  injection  of  the  conjunctival 
and  sclerotic  vessels,  giving  the  eye  a  red  appearance.  But  unnatural 
redness  is  observed  in  simple  conjunctivitis,  and  how  shall  the  two  be 
distinguished  ?  In  the  first  place,  by  depressing  the  lower  lid,  and  at 
the  same  time  telling  the  patient  to  look  upward,  whereby  the  inferior 
palpebral  fold  will  be  exposed.  In  most  cases  of  conjunctivitis  the 
greatest  amount  of  injection  will  be  found  remote  from  the  cornea, 
while  in  iritis  the  contrary  is  the  case ;  the  redness  is  almost  entirely 
confined  to  a  circle  around  the  cornea  called  the  "sclerotic  zone,"  and 
the  more  distant  portions  of  the  white  of  the  eye  remain  clear.  If  the 
eye  has  been  congested  by  the  injudicious  application  of  poultices,  alum, 
curds,  etc.,  this  difference  will  be  less  or  not  at  all  apparent.  Again, 
observe  the  character  of  the  injection:  some  of  the  conjunctival  vessels 
are  distended,  and  may  be  recognized  by  their  brick-red  color,  large 
size,  tortuous  course  (chiefly  over  the  recti  muscles),  and  their  mobility 
if  the  conjunctiva,  by  means  of  slight  pressure  with  the  finger  external 
to  the  lid,  be  made  to  slide  over  the  sclerotica ;  but  beneath  these  brick- 
red  vessels  a  second  layer  is  discovered  on  close  examination,  composed 
of  others  radiating  from  the  margin  of  the  cornea,  much  finer  than  the 


692  SYPHILIS. 

preceding,  straight  and  of  a  pinkish  hue,  and  which  are  seen  to  remain 
stationary  through  the  meshes  of  the  sliding  network  of  conjunctival 
vessels.  It  is  these  vessels  which  constitute  the  sclerotic  zone,  met 
with  not  only  in  iritis,  but  in  other  internal  inflammations  of  the  eye. 

Next  observe  the  condition  of  the  iris  and  pupil  and  compare  them 
[with  those  of  the  opposite  and  sound  eye.  The  affected  iris  is  seen  to 
have  lost  its  natural  brilliancy ;  its  minute  texture  is  less  apparent ;  its 
surface  covered  over  with  a  thin  layer  of  fibrin  ;  and  its  color  changed. 
In  persons  with  blue  eyes  it  assumes  a  yellowish-green  hue ;  in  others 
the  change  is  less  marked,  but  may  generally  be  detected.  Close  the 
two  eyes  with  the  thumb  of  each  hand,  the  fingers  resting  for  support 
upon  the  temples,  and  alternately  open  one  and  then  the  other,  and  the 
iris  of  the  affected  eye  will  be  found  to  be  sluggish  in  its  motions  or 
quite  immovable. 

At  an  early  stage  of  the  disease  the  pupil  assumes  a  dull  appearance, 
and  is  less  clear  and  bright  than  in  the  normal  condition,  owing  some- 
times to  a  slight  turbidity  in  the  aqueous,  and  sometimes  to  a  delicate 
film  of  exudation  from  the  margin  of  the  iris  over  the  anterior  capsule. 
I  have,  moreover,  sometimes  thought  that  the  capsule  itself  or  the  un- 
derlying epithelial-cell  layer  becomes  implicated,  though  of  this,  so  far, 
I  have  had  no  anatomical  proof.  The  pupil  may  also  become  irregular 
in  shape.  This  irregularity  of  outline,  due  to  adhesions  between  its 
margin  and  the  capsule  of  the  lens  or  to  exudation  into  its  substance, 
becomes  more  marked  as  the  disease  progresses,  and  is  especially  evi- 
dent if  the  pupil  be  dilated  by  belladonna  or  atropine,  when  its  margin 
is  found  to  be  scalloped,  owing  to  its  being  attached  at  some  points  and 
drawn  out  in  others.  In  some  cases  the  adhesions  become  continuous 
around  the  whole  circumference,  and  the  capsule  of  the  lens  is  covered 
with  a  layer  of  lymph  which  completely  blocks  up  the  pupil. 

Serous  Iritis. — This  is  distinguished  from  the  simple  variety  by  the 
fact  that  the  exudation  is  of  a  serous  instead  of  a  plastic  nature,  and  is 
due  to  a  hypersecretion  of  slightly  turbid  aqueous  humor,  which  pro- 
duces,  as  a  rule,   an  increase  in  the  intraocular  tension. 

On  this  account  the  anterior  chamber  becomes  deepened,  and  the 
pupil,  instead  of  being  contracted,  moderately  dilated,  sometimes  mark- 
edly so.  This  is  probably  due  to  direct  pressure  by  the  contents  of  the 
globe  upon  the  nerves  of  the  iris. 

The  circumcorneal  injection  is  here  much  less  than  in  the  plastic 
form,  or  it  may  be  entirely  Avanting.  Besides  the  aqueous  humor 
becoming  slightly  cloudy,  the  entire  posterior  surface  of  the  cornea 
appears  oftentimes  as  if  covered  with  a  delicate  film,  and  minute  punc- 
tated opacities  make  their  appearance  upon,  the  internal  lining  mem- 
brane (membrane  of  Descemet).  These  spots  owe  their  existence,  at 
least  in  the  beginning  of  the  disease,  to  the  precipitation  upon  the 
membrane  of  minute  particles,  which  are  held  in  suspension  in  the 
troubled  aqueous  humor,  and  which  often  disappear  when  the  anterior 
chamber  is  evacuated  by  paracentesis  cornete.  Later  in  the  disease, 
however,  they  assume  a  somewhat  larger  size,  and  are  then  permanent, 
being  due  to  a  morbid  change  in  the  epithelium  of  the  membrane  itself. 

Sometimes  these  punctated  spots  are  either  entirely  absent  or  are 
so  slight  as  to   escape  any  but  a  most  careful  examination.     In  this 


AFFECTIONS  OF  THE  EYE.  693 

case  the  predominant  symptoms — viz.  slight  discoloration  and  dila- 
tation of  the  iris,  and  trifling  cloudiness  of  the  aqueous  humor — are 
very  easily  overlooked  by  an  inattentive  observer,  and  the  disease  is 
allowed  to  progress  until  it  extends  itself  to  the  ciliary  bod}^  and  cho- 
roid, gradually  involving  the  deeper  structures,  and  the  eye  falls,  step 
by  step,  into  a  state  of  low   chronic  glaucoma. 

In  this  form  of  iritis  it  seldom  happens  that  there  are  any  adhesions 
of  the  iris  to  the  capsule  of  the  lens. 

I  have  been  particular  in  giving  the  principal  symptoms  of  this  pecu- 
liar form  of  iritis,  both  on  account  of  its  insidious  nature,  which  renders 
it  so  liable  to  escape  detection,  and  from  the  fact  that  it  has  been  alleged 
to  be  oftentimes  the  product  of  hereditary  syphilis. 

Parenchymatous  or  Suppurative  Iritis. — This  form  of  iritis  is  cha- 
racterized by  a  deep-seated  inflammation  affecting  the  stroma  of  the  iris, 
and  giving  rise  to  a  considerable  swelling  of  the  membrane,  and  causing 
an  increase  in  its  cellular  tissue-elements.  Owing  to  this  fact,  the  sur- 
face of  the  iris  becomes  elevated  in  different  parts,  and  vessels,  sometimes 
of  considerable  size  from  arrest  in  their  circulation,  make  their  appear- 
ance on  the  surface  of  the  membrane.  These  elevations  are  almost 
entirely  composed  of  cellular  tissue,  and  usually  contain  a  number  of 
vessels  of  new  formation. 

It  is  in  this  form  of  iritis  that  we  meet  most  frequently  with  extensive 
adhesions  between  the  margin  of  the  pupil  and  the  lens,  together  with  a 
complete  loss  of  contractility  of  the  iris,  and  when  these  adhesions  once 
take  place  they  are  far  more  obstinate  in  resisting  the  effect  of  atropine 
than  those  of  simple  idiopathic  iritis.  Here,  too,  the  production  of  pus 
in  the  anterior  chamber  is  much  more  rapid  and  abundant. 

The  so-called  syphilitic  iritis  of  various  authors  is,  strictly  speaking,, 
only  a  variety  of  parenchymatous  iritis,  its  distinguishing  characteristic 
being  that  the  inflammatory  action  is  more  circumscribed,  confining  itself 
usually  to  one  part  of  the  iris,  while  the  neighboring  portions  preserve, 
for  a  considerable  time  at  least,  a  nearly  perfectly  normal  condition.  In 
the  same  way  it  is  less  apt  to  propagate  itself  in  the  deeper-lying  mem- 
branes. It  is  here  that  we  find  those  peculiar  brownish  or  yellowish 
elevations  upon  the  surface  of  the  iris  which  generally,  though  not 
always,  occur  on  its  inner  ring  near  the  margin  of  the  pupil. 

These  "  tubercles" — or  "  condylomata,"  as  they  are  called — gradually 
increase  in  size,  and  sometimes  become  organized  and  covered  wnth  a 
network  of  small  vessels.  They  vary  exceedingly  in  their  dimensions, 
sometimes  acquiring  a  growth  sufiicient  to  occupy  the  quarter  or  even 
one-half  or  more  of  the  entire  iris,  and,  if  then  situated  near  the  exter- 
nal border  of  the  membrane,  may  cause  projection  of  the  cornea  or 
sclerotic. 

It  has  been  demonstrated  by  Colberg  ^  that  the  composition  of 
"tubercles"  is  identical  Avith  that  of  gummy  tumors  as  described  by 
Virchow.^ 

The  presence  of  these  tubercles  affords  a  very  strong  probability,  if 
not  an  absolute  certainty,  of  syphilitic  taint.  Of  sixty  cases  of  iritic 
tubercle  collected  by  Graefe,  in  only  two  was  there  no  proof  of  syphilitic 
infection. 

1  Archiv  far  Ophth.,  t.  viii.  p.  2S8.  ^  Archiv  fur  Path.  Anat.,  No.  15,  p.  265. 


694  SYPHILIS. 

Such  evidence  as  this,  from  such  a  source,  must  be  considered  almost 
conclusive  that  there  is  a  specific  form  of  iritis  differing  from  that  of  the 
idiopathic  form,  although  such  has  been  denied.  So  far  as  my  own  per- 
sonal experience  goes,  I  have  never  seen  a  case  of  "  condyloma  "  of  the 
iris  "which  could  not  be  traced  to  a  syphilitic  source.  I  have,  however, 
seen  one  case  in  a  non-syphilitic  subject  which  might  have  been,  and 
indeed  was,  taken  for  a  "tubercle."  The  trouble  began  and  continued 
in  its  course  precisely  like  a  "tubercle,"  with  all  the  signs  and  symptoms 
of  iritis,  until  it  had  reached  a  certain  stage,  when  it  ruptured,  sending 
out  into  the  anterior  chamber  a  feathery,  purulent  exudation  like  the  tail 
of  a  comet.  After  a  careful  consideration  and  observation  of  the  case,  I 
could  attribute  the  appearance  only  to  a  papule  in  the  tissues  of  the  iris. 
Dr.  Kipp  has  also  reported  a  similar  case  in  a  syphilitic  person. 

When  syphilitic  iritis  is  early  and  successfully  treated,  the  iris  re- 
sumes its  normal  mobility  and  color  and  the  eye  is  restored  to  its  original 
integrity.  But  in  weak  and  cachectic  subjects,  and  in  the  absence  of 
appropriate  treatment,  the  changes  which  take  place  are  more  or  less  per- 
manent. The  tubercles  are  absorbed,  but  the  iris  never  regains  its 
original  color  and  consistency  ;  it  is  thinned  and  friable,  and  its  adhesions 
to  the  capsule,  unless  stretched  or  broken  by  the  persevering  use  of 
mydriatics,  permanently  impede  the  motions  of  the  pupil.  As  a  general 
rule,  the  pain  and  photophobia  in  syphilitic  iritis  are  much  less  than  in 
the  other  forms  of  the  disease.  The  patient  may  merely  complain  of  a 
sense  of  fulness  and  uneasiness  in  the  globe,  and  shrink  from  exposure  to 
a  strong  light  only.  In  other  cases  severe  pain  is  felt  in  the  ball  of  the 
eye  and  in  the  temporal  and  supraorbital  regions,  when  the  least  ray  of 
light  causes  the  most  intense  suffering ;  the  variations  between  these  two 
extremes  are  numerous.  There  is  almost  invariably  some  dimness  of 
vision,  which  is  due  not  only  to  the  changes  in  the  capsule  of  the  lens, 
but  also  to  those  in  the  deeper  structures  of  the  eye,  which  are  always 
involved  to  a  greater  or  less  extent. 

Iritis,  as  a  rule,  presents  such  marked  symptoms  that  it  is  usually  rec- 
ognized by  any  competent  person,  and  yet  every  ophthalmic  surgeon  must 
have  met  with  not  unfrequent  instances  in  which  through  carelessness  or 
ignorance  it  has  been  mistaken  for  simple  conjunctivitis,  and  treated 
solely  with  collyria  of  nitrate  of  silver,  sulphate  of  zinc,  etc.  A  few 
cases,  however,  iare  met  with  in  which  the  most  experienced  sur- 
geon may  for  a  day  or  two  fail  to  make  a  diagnosis.  This  generally 
occurs  at  the  commencement  of  the  disease,  before  any  marked  changes 
have  taken  place  in  the  iris,  and  especially  when  the  conjunctival  vessels 
have  been  congested  by  the  application  of  poultices.  Impairment  of 
vision  will  afford  valuable  aid  to  the  diagnosis,  and  the  instillation  of  a 
drop  of  a  solution  of  atropine  will  soon  decide  the  question  by  showing 
irregularity  of  the  pupil  if  the  case  be  one  of  iritis. 

It  is  well  in  these  doubtful  cases  to  use  a  very  weak  solution,  as  then 
the  inconvenience  of  a  lengthy  mydriasis  is  avoided  in  case  the  trouble 
should  prove  to  be  conjunctivitis  and  not  iritis.  One  of  Moore  and 
Savory's  atropine  wafers,  divided  into  two  or  even  four  pieces,  each  piece 
then  equalling  only  ^q]^ ,, „  of  a  grain,  is  sufficient.  If  the  iris  is  not  the 
seat  of  the  trouble,  it  will  dilate  in  less  than  an  hour,  and  the  next  day 
the  dilatation  will  have  passed  off.     In  place  of  a  wafer,  a  solution  may 


AFFECTIONS  OF  THE  EYE.  695 

be  used  which  can  be  readily  made  by  putting  one  drop  of  the  ordinary 
solution  (gr.  ij  to  5J)  into  half  an  ounce  of  water.  One  drop  of  this 
equals  ^^^  of  a  grain. 

I  have  already  remarked  that  the  diagnosis  of  syphilitic  iritis,  although 
rendered  highly  probable  by  the  absence  of  severe  pain  and  photophobia 
and  the  presence  of  tubercles  upon  the  iris,  can  only  be  satisfactorily 
established  by  the  history  of  the  case  or  the  coexistence  of  undoubted 
syphilitic  symptoms.  I  would  also  add  that  the  presence  of  any  general 
eruption  upon  the  body  leaves  scarcely  room  to  doubt  that  a  coexisting 
iritis  is  of  specific  origin,  since  this  disease,  when  due  to  other  causes,  is 
very  rarely  accompanied  by  affections  of  the  skin.  The  practical  surgeon, 
when  called  to  treat  a  case  of  iritis,  almost  instinctively  turns  to  the  arms, 
chest,  and  abdomen  to  look  for  traces  of  one  of  the  syphilides,  to  the 
throat  for  mucous  patches,  and  to  the  neck  for  engorged  ganglia.  As 
noticed  by  Carmichael,  the  accompanying  eruption  is  in  most  cases 
papular. 

In  regard  to  the  particular  period  of  the  general  trouble  in  which 
specific  iritis  makes  its  appearance  no  precise  rule  can  be  laid  down ; 
still,  the  form  which  is  most  common  and  most  worthy  of  our  attention  is 
to  be  ranked  among  the  secondary  symptoms  of  syphilis.  Without  being 
able  to  furnish  any  statistics  from  which  the  exact  time  of  its  development 
may  be  determined,  yet  I  have  often  been  struck  with  the  fact  that  when 
no  mercury  had  been  administered  this  occurred  from  four  to  six  months 
after  contagion.  In  a  number  of  instances  iritis  has  been  the  first  general 
symptom  which  has  induced  patients  to  seek  surgical  advice,  but  careful 
inquiry  has  never  failed  to  show  that  other  symptoms,  as  alopecia,  engorge- 
ment of  the  cervical  ganglia,  mucous  patches,  erythema,  or  papules,  had 
preceded  it,  although  regarded  at  the  time  as  of  no  importance. 

Wecker  observes  ^  that  the  specific  form  of  iritis  occurs  more  frequently 
when  the  disease  has  been  a  long  time  in  developing  itself  than  when  it 
has  pursued  a  rapid  course. 

There  is,  however,  another  form  of  iritis  which  is  met  with  chiefly  as 
a  symptom  of  tertiary  syphilis,  and  differs  from  the  preceding  mostly 
by  the  insidious  manner  in  which  it  attacks  the  eye  and  by  its  greater 
persistency.  There  is  almost  a  complete  absence  of  pain  and  photo- 
phobia ;  the  iris  becomes  infiltrated  and  covered  with  exudation,  having 
a  peculiar  swollen  and  velvety  appearance ;  numerous  adhesions  take 
place  between  its  pupillary  margin  and  the  capsule  of  the  lens ;  and  the 
irregular  pupil  is  blocked  up  with  an  eff"usion  of  lymph,  upon  which  small, 
black,  uveal  deposits  may  often  be  detected.  The  eyes  are  generally 
attacked  in  succession ;  the  disease  is  exceedingly  persistent,  and  with 
difficulty  controlled  by  treatment,  the  danger  of  complete  loss  of  sight 
from  obstruction  of  the  pupil  being  very  great.  The  deeper  structures 
of  the  eye  appear  to  be  implicated  to  a  less  extent  than  in  the  acute 
form. 

Among  the  absurdities  of  medical  belief  that  have  had  their  day  is  to 
be  reckoned  the  idea  that  mercury  may  give  rise  to  iritis — a  disease  which 
is  often  met  with  when  no  specific  remedy  has  been  employed,  and  which 
can  in  no  way  be  better  controlled  than  by  the  judicious  use  of  mercurials  ; 
indeed,  the  surgeon  rarely  has  an  opportunity  of  witnessing  a  more  remark- 

'  Eludes  ophth.,  t.  i.  p.  396. 


696  SYPHILIS. 

able  effect  of  treatment  than  is  seen  in  the  absorption  of  lymph,  the  dis- 
appearance of  the  abnormal  injection,  and  the  restoration  of  the  iris  to  its 
original  condition,  which  takes  place  under  the  administration  of  mercury 
in  acute  syphilitic  iritis.  It  is  hardly  necessary  to  say  that  an  agent  of  so 
much  good  is  capable  of  doing  a  great  amount  of  harm,  and  that  I  am 
here  speaking  of  its  use  and  not  of  its  abuse. 

The  plan  of  treatment  of  the  acute  form  of  iritis  which  I  have  found 
almost  uniformly  successful  has  for  its  objects — 

1.  To  bring  the  system  under  the  influence  of  mercurials  as  speedily 
as  possible  without  injury  to  the  general  health  and  without  inducing 
salivation. 

2.  In  a  depressed  state  of  the  system  to  combine  tonics  with  mer- 
curials, or  to  employ  the  former  in  connection  with  iodide  of  potassium 
instead  of  the  latter. 

3.  To  keep  the  pupil  constantly  dilated  by  means  of  atropine,  and  thus 
prevent  adhesions  between  the  iris  and  capsule  of  the  lens. 

4.  To  relieve  pain  and  regulate  the  general  hygienic  management  of 
the  case. 

The  subjects  of  these  different  heads  will  be  somewhat  briefly  con- 
sidered, in  view  of  the  fact  that  most  of  them  have  been  included  in  what 
has  been  said  of  the  general  treatment  of  syphilis. 

It  is  of  the  first  importance  in  the  treatment  of  iritis  to  maintain  the 
pupil  in  a  constant  state  of  dilatation,  so  as  to  remove  the  iris  as  far  as 
possible  from  the  convex  surface  of  the  lens  and  prevent  adhesions  or 
closure  of  the  pupil  with  lymph.  For  this  purpose  instillations  of  a  solu- 
tion of  atropine  are  far  preferable  to  extract  of  belladonna  smeared  upon 
the  brow.  In  addition  to  its  power  of  dilating  the  pupil,  atropine  is  a  most 
valuable  sedative — a  rare  combination  in  the  same' remedy.  Two  grains 
of  the  neutral  sulphate  to  the  ounce  of  distilled  water  is  the  formula  which 
I  commonly  employ.  This  solution  is  best  applied  to  the  inner  canthus 
by  means  of  an  eye-pipette  or  a  camel's-hair  brush  ;  in  default  of  which 
the  patient's  head  may  be  thrown  back,  and  a  small  portion  of  the  fluid 
be  poured  upon  the  concavity  upon  the  side  of  the  nose,  when  some  of  it 
may  readily  be  made  to  flow  between  the  lids.  If  the  case  be  seen  at  the 
outset,  before  the  motions  of  the  iris  are  impeded  by  an  infiltration  of 
lymph,  two  or  three  times  a  day  will  be  sufiiciently  often  to  use  the  drops. 

In  the  acute  stage  of  iritis  some  authors  advise  us  entirely  to  abstain 
from  the  use  of  atropine  and  belladonna,  which  have  but  little  power  of 
influencing  the  pupil  after  effusion  has  taken  place,  and  which,  it  is  said, 
may  "irritate  and  tease  the  iris  and  cause  pain."^  My  own  experience 
leads  me  to  believe  that  these  fears  are  groundless.  Instead  of  aggra- 
vating, I  believe  that  atropine  greatly  relieves,  the  pain  and  irritation,  and 
although  its  immediate  action  upon  the  pupil  is  not  perceptible,  yet  it 
gradually  stretches  or  breaks  down  the  adhesions  already  formed,  and  thus 
assists  the  iris  in  recovering  its  dilatability ;  hence  I  am  in  the  habit  of 
increasing  the  frequency  of  the  instillations,  during  the  acute  stage,  to 
three  or  four  times  a  day,  and  in  case  the  iris  is  still  obstinate  in  yielding 
it  is  advisable  to  increase  the  strength  of  the  solution  to  four  or  f^ve  grains 
to  the  ounce  of  water,  and  to  instil  a  drop  into  the  eye  every  five  minutes 

^  Critchett,  "Lectures  on  Diseases  of  the  Eye,"  London  Lancet,  Am.  ed.,  Marcli,  1855, 
p.  216. 


AFFECTIONS  OF  THE  EYE.  697 

for  twenty  minutes  or  half  an  hour  at  a  time,  repeating  this  method  of 
application  three  or  four  times  a  clay.  Care  should  be  taken,  however, 
that  the  atropine,  some  of  which  gains  the  pharynx  through  the  lachry- 
mal and  nasal  passages,  does  not  produce  its  physiological  effects  upon  the 
general  system. 

Very  recently  a  new  mydriatic,  duboisine,  has  come  into  use.  It  has 
the  same  effect  as  atropine,  though  it  is  somewhat  more  powerful.  It  is 
claimed  that  it  is  less  apt  to  produce  the  poisoning  of  the  circumorbital 
skin,  and  that  it  may  be  used  when  this  has  been  occasioned  by  atropine. 
My  own  experience  with  it,  however,  does  not  support  this  claim,  for  in 
several  instances,  when  the  poisoning  had  been  once  produced,  it  was 
maintained  by  duboisine  just  as  it  is  by  atropine.  It  is  well,  however,  in 
those  cases  Avhich  promise  to  be  protracted  to  use  the  drugs  alternately. 

Should  the  iris  refuse  to  yield  even  after  this  vigorous  use  of  atropine, 
the  action  of  the  drug  can  often  be  induced  by  decreasing  the  tension  of 
the  eye  through  the  application  of  leeches  to  the  temple  or  by  the  evacu- 
ation of  the  anterior  chamber  by  paracentesis  corneas. 

Venesection  is  never  required  in  syphilitic  iritis,  though  local  depletion 
by  means  of  cups  and  leeches  is  often  advisable  in  those  cases  in  robust 
subjects  where  the  pain  is  very  severe ;  and  when  this  assumes  a  neuralgic 
■character  frequent  fomentation  of  the  eye  and  surrounding  parts  with 
water  as  hot  as  can  be  borne  often  gives  great  relief.  Here,  too,  a  sub- 
cutaneous injection  of  morphia  in  the  region  of  the  temple  often  stops  at 
once  a  paroxysm  of  pain,  which  then  does  not  show  itself  again,  or  at  least 
not  in  its  former  violence.  After  the  acute  stage  has  passed  counter- 
irritation  may  be  effected  by  painting  the  brow  with  the  strong  tincture  of 
iodine.     This  remedy  is,  however,  not  as  much  employed  as  formerly. 

It  is  highly  important  that  the  patient  should  obtain  sleep,  for  which 
purpose  ten  grains  of  Dover's  powder  may  be  given  at  bed-time,  and 
repeated  if  necessary.  In  many  cases,  however,  frictions  upon  the  brow 
and  temple  at  bed-time  of  mercurial  ointment,  with  the  addition  of  pow- 
dered opium  (ung.  hydrarg.  5J,  pulv.  opii  3j)  will  suffice  to  allay  pain  and 
procure  sleep. 

In  this  as  in  nearly  all  affections  of  the  eye  the  surgeon  has  to  con- 
tend Avith  the  deeply-rooted  prejudices  of  the  masses  in  favor  of  poultices 
of  bread  and  milk,  tea-leaves,  alum  curds,  raw  oysters,  pieces  of  pork,  et 
id  genus  omne.  Not  only  should  all  such  vile  applications  be  put  far 
away,  but  the  eye  should  not  be  tied  up  with  handkerchiefs  or  cloths  in 
any  manner.  In  women  the  best  protection  against  the  strong  light  is  a 
veil ;  in  men  a  pasteboard  shade  will  answer  the  same  purpose. 

In  unfavorable  weather  or  in  unusually  severe  cases  of  iritis  the  patient 
should  be  confined  to  the  house,  or  even  to  his  room,  which  should  be 
shaded,  but  not  darkened.  In  most  cases,  however,  when  the  weather  is 
feir,  it  is  desirable  that  the  patient  should  pass  a  portion  of  the  day  out 
of  doors,  in  the  early  morning  or  evening  if  the  intolerance  of  light  be 
excessive,  and  with  the  eye  protected  in  the  manner  above  directed,  or, 
better  still,  by  a  pair  of  tinted  glasses  of  the  kind  which  is  known  to  the 
opticians  as  "coquilles,"  the  color  of  which  should  be  some  shade  of  blue 
or  London  smoke,  never  green.  Photophobia  and  irritability  of  the  eye 
■will  be  aggravated  by  confinement  to  a  dark  room. 

The  diet  must  be  proportioned  to  the  general  condition  of  the  system. 


698  SYPHILIS. 

Robust  subjects  should  take  but  a  small  quantity  of  light  food,  while  the 
cachectic  require  an  abundant  supply  of  nourishment  and,  it  may  be,  stim- 
ulants. Proper  attention  should  also  be  paid  to  the  digestive  organs,  and 
a  daily  evacuation  of  the  bowels  secured. 

The  chronic  form  of  iritis,  met  with  in  tertiary  syphilis  most  frequently, 
occurs  in  persons  whose  constitution  is  enfeebled  and  by  whom  mercury  is 
poorly  tolerated  ;  but  when  properly  guided  by  tonics  this  mineral  may 
still,  in  many  cases,  be  used  with  marked  benefit ;  in  others  we  are  obliged 
to  resort  to  iodide  of  potassium  until  by  every  available  means  the  general 
health  is  restored.  Mercurial  inunction  or  fumigation  may  often  be  em- 
ployed when  mercury  by  the  mouth  cannot  be  borne.  In  these  cases  one- 
half  or  even  a  drachm  of  the  oleate  may  be  rubbed  into  the  soles  of  the- 
feet  alternately  or  under  the  armpits  each  night. 

Such  being  the  therapeutical  remedies  which  experience  thus  far  has 
shown  us  to  be  the  most  beneficial  in  the  treatment  of  syphilitic  iritis,  two 
others,  belonging  properly  to  the  domain  of  surgery,  ought  to  be  briefly 
considered,  or  at  least  mentioned,  here.  I  allude  to  paracentesis  corneae 
and  iridectomy. 

If,  in  spite  of  all  our  eiforts  at  medication,  the  aqueous  humor  becomes 
very  cloudy,  or  the  pain  increases,  or  the  tension  of  the  eyeball  becomes 
augmented,  with  a  corresponding  decrease  of  the  amount  of  vision  and 
contraction  of  the  visual  field,  or  if  a  considerable  collection  of  pus  takes 
place  into  the  anterior  chamber,  then  a  paracentesis  should  be  performed, 
and  repeated  several  times,  if  necessary  ;  and  especially  should  this  be 
done  in  the  last-mentioned  condition,  for,  of  all  the  remedies  Avhich  we 
possess  against  the  formation  and  increase  of  hypopyon,  none  is  more 
efiicacious  than  this. 

Should,  however,  the  disease  still  steadily  progress  and  the  above 
symptoms  increase  in  severity,  and  give  evidence  that  the  inflammatory 
action  runs  in  danger  of  seriously  involving  the  deeper  structures  of  the 
eye,  then  an  iridectomy  should  be  performed  at  once,  for  it  often  happens 
that  an  inflammation  which  has  resisted  all  other  agents  quickly  subsides 
after  this  operation.     The  above  is  applicable  to  all  forms  of  iritis. 

For  a  more  detailed  description  of  these  two  operations,  as  well  as  of 
those  intended  for  the  relief  of  closure  of  the  pupil  from  the  eff"ects  of 
iritis,  I  must  refer  the  reader  to  works  upon  ophthalmic  surgery,  merely 
remarking  that  these  operations  require  considerable  delicacy  of  manip- 
ulation, and  if  the  general  practitioner  feels  tha,t  he  does  not,  from  want 
of  practice,  possess  the  requisite  technical  skill,  then  it  is  his  duty  to  obtain 
the  services  of  some  one  who  has  made  these  matters  a  special  study. 

Infantile  Iritis. — An  extremely  interesting  form  of  iritis  is  met  with 
in  infants  aflected  with  hereditary  syphilis.  It. is  a  rare  disease,  but  prob- 
ably exists  in  many  instances  in  which  it  is  overlooked. 

Mr.  Hutchinson  deduces  the  following  conclusions  from  a  series  of 
twenty-one  cases :  ^ 

1.  That  the  subjects  of  infantile  iritis  are  much  more  frequently  of 
the  female  than  the  male  sex. 

2.  That  syphilitic  infants  are  most  liable  to  suff"er  from  iritis  at  about 
the  age  of  five  months. 

1  Med.  Times  and  Gaz.,  July  14,  1860 ;  also  Ophthalmic  Hospllal  Reports,  vol.  viii.  p. 
217,  1875. 


AFFECTIONS  OF  THE  EYE.  699 

3.  That  syphilitic  iritis  in  infants  is  often  symmetrical,  but  quite  as 
frequently  not  so. 

4.  That  iritis,  as  it  occurs  in  infants,  is  seldom  complicated,  and  is 
attended  by  but  few  of  the  more  severe  symptoms  which  characterize  the 
disease  in  the  adult.  Haziness  of  the  cornea  and  photophobia,  which  are 
common  in  adults,  are  rare  in  infants,  in  whom  there  is  also  but  little  pain 
and  sclerotic  injection. 

5.  Notwithstanding  the  ill-characterized  phenomena  of  acute  inflam- 
mation, the  effusion  of  lymph  is  usually  very  free  and  the  danger  of  occlu- 
sion of  the  pupil  great. 

6.  Mercurial  treatment  is  most  signally  efficacious  in  curing  the  disease, 
and,  if  recent,  in  procuring  the  complete  absorption  of  the  effused  lymph. 

7.  Mercurial  treatment  previously  adopted  does  not  prevent  the  occur- 
rence of  this  form  of  iritis. 

8.  The  subjects  of  infantile  iritis,  though  often  puny  and  cachectic,  are 
also  often  apparently  in  good  health. 

9.  Infants  suffering  from  iritis  almost  always  show  one  or  another  of 
the  well-recognized  symptoms  of  hereditary  taint. 

10.  Most  of  those  who  suffer  from  syphilitic  iritis  are  infants  born 
within  a  short  period  of  the  date  of  the  primary  disease  in  their  parents. 
This  accords  with  what  is  observed  in  the  iritis  of  adults,  which  in  a  great 
majority  of  instances  is  a  secondary  and  not  a  tertiary  symptom. 

I  have  seen  only  one  instance  of  this  affection  in  an  infant  at  the 
infirmary,  who  was  not  brought  a  second  time,  and  Avhose  case  I  was 
therefore  unable  to  follow  out.  I  once  had  under  my  charge  a  case  of 
double  chronic  iritis  in  a  boy  aged  ten,  affected  also  with  engorgement  of 
the  cervical  ganglia,  who,  as  reported  by  his  father,  was  said,  by  the 
attending  physician  (Dr.  G.  L.  Bedford),  to  have  contracted  syphilis  from 
his  wet-nurse.  I  may  mention  incidentally  that  his  teeth  were  generally 
misshapen,  and  that  one  of  his  upper  incisors  was  completely  perforated 
by  a  small  hole  about  one-third  of  its  length  from  the  lower  margin. 

Spongy  Iritis. — Under  this  title  some  ophthalmologists  have  of  late 
years  described  a  form  of  iritis  which  consists  of  a  gelatinous,  spongy 
exudation  into  the  anterior  chamber  from  the  surface  of  the  iris.  This 
has  been  claimed  to  be  due  to  syphilis.  It  has,  however,  no  pathogno- 
monic significance,  and  may  occur  in  the  idiopathic  form  or  from  simple 
traumatism.^  The  manner  in  which  it  is  formed  and  the  appearance 
which  it  presents  have  already  been  described  at  length  in  speaking  of 
Episcleritis. 

Affections  of  the  Lens. 

So  far,  the  lens  has  never  been  observed  to  be  primarily  the  seat  of 
any  syphilitic  inflammation  or  product.  Secondary  changes  in  the  cap- 
sule and  lenticular  substance,  in  which  the  lens  become  either  partially 
or  wholly  cataractous,  are  common  enough.  The  only  relief  from  these 
is  surgical,  and  may  consist  either  in  the  formation  of  a  new  pupil  or 
extraction,  and  I  am  inclined  to  believe,  from  my  own  experience,  that 
these  cases  of  cataract  with  numerous  adhesions,  even  to  the  extent  of 
total  synechia,  do  not  offer  so  bad  a  prognosis  as  is  commonly  sup- 
posed. 

'  Dr.  Gruening,  Archiv.  Ophlh.  and  OloL,  vol.  iii.  p.  1,  1873. 


700  SYPHILIS. 

Affections  of  the  Ciliary  Body. 

Inflammations  of  the  ciliary  body  (or  cyclitis)  which  are  not  due  to 
extension  of  the  morbid  process  from  the  iris  on  the  one  hand,  and  the 
choroid  on  the  other,  are  extremely  rare.  Syphilitic  cyclitis,  like  the 
non-specific,  shows  itself  by  a  deep-lying,  partial  or  total  pericorneal 
injection  of  a  livid  color,  which  is  usually  more  intense  in  one  particular 
spot,  and,  as  a  rule,  at  the  upper  portion,  though  it  may  be  in  any  part 
of  the  scleral  zone.  Sometimes  more  than  one  of  these  foci  exist  at  the 
same  time.  There  is  usually  a  peculiar  retraction  of  the  iris  opposite  the 
inflammatory  centre  or  centres,  which  is  then  useful  as  a  diagnostic  mark 
of  the  trouble  being  limited  to  the  ciliary  body,  for  if  the  iris  is  impli- 
cated the  contraction  of  the  pupil  conceals  this  peculiarity  in  the  shape 
of  the  iris.  Here,  as  elsewhere  in  the  uveal  tract,  the  only  distinctive 
mark  of  the  syphilitic  taint  is  the  characteristic  gummata. 

The  diagnosis  of  these  troubles  is  oftentimes  somewhat  speculative,  as, 
from  the  position  of  the  ciliary  body,  these  affections  do  not  lie  open  to 
either  direct  inspection  or  that  of  the  ophthalmoscope.  Yirchow^  was, 
however,  fortunate  enough  to  see  a  gummy  tumor  of  the  ciliary  body 
which,  ophthalmoscopically  and  by  oblique  light,  was  seen  and  taken  by 
others  for  a  sarcoma.  That  syphilis  was  the  cause  of  the  tumor  was 
demonstrated  by  the  fact  that  it  disappeared  under  specific  treatment. 

Choroiditis. 

Choroidal  affections,  like  those  of  the  iris,  have  been  divided  into 
three  principal  classes:  Plastic  (exudativa,  disseminata)  choroiditis; 
Serous  clioroiditis ;   Parenchymatous  (suppurative)  choroiditis. 

It  must  be  admitted  that  the  distinctions  between  these  various  forms 
cannot  be  drawn,  either  pathologically  or  clinically,  so  closely  as  those 
of  iritis ;  still,  as  they  are  based  on  anatomical  research,  however 
meagre,  they  are  preferable  to  any  classification  of  a  merely  arbitrary 
character,  and  will  therefore  be  retained  here.  Inasmuch  as  they  may 
all  be  the  product  of  syphilitic. infection,  a  short  description  of  each  will 
be  given. 

Plastic  Choroiditis — or,  more  properly  speaking,  choroiditis  exudativa 
— is  characterized  by  the  production  of  an  exudation  upon  the  surface  or 
in  the  substance  of  the  choroid.  This  exudation  manifests  itself,  when 
seen  by  the  ophthalmoscope,  by  the  presence  at  the  bottom  of  the  eye  of 
certain  circumscribed  spots  or  patches,  varying  greatly  as  to  number, 
shape,  and  size.  When  freshly  deposited  they  are  of  a  yellowish-white  or 
pale-straw  color,  and  give  the  appearance  of  having  been  flecked  on  to 
the  membrane,  the  pigment  epithelium  preserving,  as  a  general  rule,  a 
perfectly  normal  aspect.  These  spots  entirely  conceal  from  view  the 
subjacent  choroid,  so  that  the  epithelial  layer,  together  with  the  deeper- 
lying  vascular  tonics,  are  completely  hidden  from  sight;  while,  on  the 
contrary,  the  retinal  vessels,  which,  as  a  rule,  run  over  the  patches  unim- 
peded in  their  course,  are  brought  strongly  in  view  through  contrast,  and 
clearly  prove  the  trouble  to  be  in  the  deeper-seated  membrane. 

These  spots  of  exudation  may  be  entirely  absorbed,  and  leave  but 
^  Jahresberickt  der  Ophth.,  1872,  p.  307. 


AFFECTIONS  OF  THE  EYE.  701 

little  or  no  trace  of  their  former  existence ;  but  usually  they  pass  to  a 
secondary  or  atrophic  stage,  in  which,  although  the  exudation  itself  dis- 
appears, the  underlying  and  surrounding  tissue  becomes  implicated.  On 
this  account  the  substance  of  the  choroid  itself  undergoes  atrophic 
changes,  permitting  the  sclera,  on  account  of  the  former  becoming 
thinned,  to  show  through,  thus  giving  to  what  were  formerly  straw- 
colored  spots  a  glistening  white  appearance.  These  atrophic  spots  may 
be  further  distinguished  from  those  due  to  simple  exudation  by  the  fact 
that  single  choroidal  vessels  or  their  remains  may  be  detected  on  their 
surface,  while  their  border,  instead  of  being  sharply  defined  and  sur- 
rounded by  normal-looking  tissue,  is  irregular,  and  marked  by  collections 
of  dark  pigment-cells,  which,  from  proliferation,  may  combine  together 
so  as  to  form  a  black  zone,  which  then  surrounds  in  part  or  in  whole  the 
denuded  spots,  or  the  pigment  may  lie  irregularly  scattered  over  its  sur- 
face. This  latter  takes  place,  especially  in  the  early  stage  of  the  dis- 
ease, when  the  trouble  is  confined  to  the  internal  and  pigmentary  layers, 
producing  a  condition  known  as  "  maceration  of  the  pigment  of  the 
choroid,"  in  which  the  coloring  matter  is  distributed  irregularly,  thinned 
in  some  places  and  aggregated  in  others,  thus  giving  to  the  fundus  of  the 
eye  a  mottled  or  watery  appearance,  as  if  sprinkled  with  ink. 

Serous  Choroiditis. — This  is  characterized  by  the  exudation  from 
the  choroidal  membrane  being  of  a  serous  instead  of  a  plastic  nature, 
and  presents  externally  oftentimes  the  same  appearance,  both  as  to  the 
dilatation  of  the  pupil  and  spots  upon  the  inner  surface  of  the  cornea, 
as  serous  iritis. 

The  ophthalmoscopic  appearances  are  not  well  marked,  and  are 
sometimes  entirely  wanting.  When  present,  however,  they  are  such 
as  are  produced  by  increased  intraocular  pressure,  and  are  chiefly  con- 
fined to  the  pigment  epithelium,  the  whole  surface  of  which  may  be 
affected,  exhibiting  the  changes  peculiar  to  the  condition  of  "  macera- 
tion." Sometimes  this  form  is  also  accompanied  by  extensive  changes 
in  the  fundus,  similar  to  those  just  detailed  under  the  plastic  form. 
This  variety  is  exceedingly  prone  to  fall  into  a  glaucomatous  condition, 
and  is  then  accompanied  by  excavation  of  the  optic  nerve  and  the  other 
ophthalmoscopic  signs  common  to  that  disease. 

Parenchymatous  Choroiditis. — This  is  a  deep-seated  inflammation, 
with  a  marked  tendency  toward  an  increase  in  the  cellular  tissue- 
elements,  especially  in  the  neighborhood  of  the  larger  choroidal  vessels. 
This  hypertrophy  of  the  cellular  tissue,  as  in  this  form  of  iritis,  some- 
times forms  masses  which  are  elevated  considerably  above  the  surround- 
ing level  of  the  choroid,  and  may  attain  the  size  and  appearance  of  a 
veritable  tumor,  most  probably  of  gummy  origin,  and  as  such  project 
into  the  vitreous  humor,  its  surface  being  covered  by  the  retina,  which 
ordinarily  undergoes  fatty  degeneration. 

It  is  this  variety  of  the  affection  which  has  been  described  by  various 
authors  as  "  choroiditis  circumscripta,"  and  attributed  by  them  particu- 
larly to  a  syphilitic  origin. 

The  fact  is,  however,  that  the  predominant  cause  of  all  choroidal 
affections  is  the  specific  virus,  and  the  particular  form  under  which 
it  shows  itself  most  frequently  is  certainly  the  plastic  form  (choroiditis 
exudativa).     There  are,  however,  even  in  this  latter  form  certain  pecu- 


702  SYPHILIS. 

liarities,  which  have  been  thought  by  some  of  the  leading  authorities 
(Graefe,  Liebreich,  Schweigger,  and  others)  to  be  characteristic  of  the 
specific  origin  of  the  disease.     The  chief  of  these  are — 

(1)  The  spots  of  exudation  and  atrophy  are,  as  a  rule,  situated  at 
the  posterior  pole  of  the  eye  and  in  the  neighborhood  of  the  macula, 
instead  of,  as  in  the  idiopathic  variety,  at  the  periphery.  They  also 
have  a  tendency  to  arrange  themselves  in  groups,  and  are  less  apt 
to  coalesce  with  each  other,  while  at  the  same  time  they  penetrate 
deeper. 

(2)  The  retina  and  optic  nerve  are  more  apt  to  be  involved,  and 
sometimes  to  such  a  degree  as  to  undergo  subsequently  partial  or  com- 
plete atrophy. 

(3)  The  choroidal  affection  is  very  liable  to  be  complicated  with  a 
characteristic  disturbance  of  the  vitreous,  which  often  appears  and  dis- 
appears with  great  rapidity.  Oftentimes  this  opacity  is  so  delicate  as 
to  give  the  idea  of  a  slight  want  of  transparency  of  the  retina. 

1  must,  however,  guard  the  reader  against  placing  too  much  depend- 
ence on  the  above  statements  as  to  the  specific  origin  of  the  disease, 
especially  in  regard  to  the  situation  and  general  contour  of  the  patches, 
as  these  are  often  situated,  even  in  undoubted  cases  of  specific  infection, 
at  the  very  periphery,  instead  of  the  posterior  pole,  of  the  eye,  and  may 
assume,  whatever  their  seat,  any  and  all  shapes.  So,  too,  disturbance 
of  the  vitreous  humor  is  one  of  the  commonest  complications  of  all  cho- 
roidal affections. 

It  would  be  out  of  place  in  a  work  of  this  kind  to  give  a  detailed 
description  of  all  the  ophthalmoscopic  appearances  which  this  protean 
disease  may  assume.  I  would,  therefore,  since  the  use  of  the  ophthal- 
moscope has  now  become  so  prevalent  and  opportunities  for  its  study  so 
attainable,  strongly  advise  the  student  of  venereal  diseases  to  make 
himself  acquainted  at  least  with  the  general  outlines  of  ophthal- 
moscopy. 

It  is  only  in  this  way  that  he  can  get  at  all  an  adequate  idea  of  a 
large  class  of  diseases  which  are  intimately  connected  with  syphilis, 
and  in  this  connection  I  would  refer  the  reader  to  the  magnificent 
plates  of  Jaeger,^  Liebreich,^  and  Stellwag  von  Carion.^ 

If  the  connection  between  the  iris  and  choroid,  anatomically  speak- 
ing, is  an  intimate  one,  clinically  speaking  it  is  even  more  so,  and  the 
diseases  of  the  one  may  be  considered  as  the  analogue  of  the  other :  for 
this  reason  the  indications  for  treatment  and  the  remedies  to  be  em- 
ployed are,  as  a  rule,  precisely  the  same  as  those  laid  down  under  Iritis, 
only  greater  care  and  attention  are,  if  possible,  required  of  the  physi- 
cian, as  the  part  concerned  is  hidden  from  ordinary  inspection. 

Choroiditis  syphilitica,  as  a  rule,  belongs  to  the  later  stages  of  life, 
in  which  the  disposition  to  all  choroidal  troubles  is  particularly  marked. 
Out  of  fifty-five  cases,  forty  were  above  thirty  years,  and  of  these  forty, 
fourteen  were  over  fifty  years  of  age.     The  appearance  of  the  disease 

^Jaeger,  Opldhalmmkophcher  /7«?ic?a</fl.s,  1868,  "  Choroiditis  Exudativa,"  Tafel  xxii., 
Figs.  99,  100;  Taf.  xxiii.,  Figs.  101,  102,  104;  Taf.  xxiv.,  xxviii.,  xxix. 

2  Liebreich,  ^^ks  d' Ophf.lmlmoscopic,  "Choroiditis  Syphilitica,"  Table  iv.,  Fig.  2. 
(See  also  Soelberg  Wells,  for  copy  of  the  same.) 

^  Stellwag  von  Carion,  Am.  ed. 


AFFECTIONS  OF  THE  EYE.  703 

usually  coincides  with  the  late  secondary  and  the  early  tertiary  symp- 
toms.^ 

Sufficient  has  been  said  under  Iritis  of  the  necessity  for,  and  the 
efficacy  of,  the  operations  of  iridectomy  and  paracentesis,  and  of  those 
for  the  removal  of  the  eye  when  the  other  is  threatened  by  what  is 
known  as  sympathetic  ophthalmia  (a  contingency  which  should  never 
be  lost  sight  of),  but  I  must  refer  the  reader  to  the  various  text-books 
on  ophthalmic  surgery  for  their  minute  description. 

The  complications  which  are  to  be  feared  in  choroiditis  are  extension 
of  the  inflammatory  action  to  the  neighboring  tissues,  to  the  iris  (pro- 
ducing irido-choroiditis),  to  the  retina  and  optic  nerve.  There  is  danger 
also  of  exudation  from  the  choroidal  vessels  producing  subretinal  effu- 
sion, with  subsequent  separation  of  a  part  or  the  whole  of  the  membrane. 

Retinitis. 

The  natural  effect  of  inflammation  upon  the  transparent  retina 
is  to  give  it  increased  vascularity  and  cause  effusion  into  its  substance 
and  render  it  opaque.  Hence  one  of  the  earliest  signs  of  retinitis  is 
increased  redness  of  the  optic-nerve  entrance,  imparting  to  it  a  pinkish 
hue,  or  the  trouble  may  show  itself  simply  by  a  slight  oedema,  which 
obscures  the  contour  of  the  nerve,  or  the  vessels  which  emerge  from  the 
optic  disk  to  be  distributed  to  the  retina  may  be  abnormally  enlarged, 
injected,  and  tortuous,  and  at  certain  points  of  their  course  lost  to  view, 
owing  to  the  opacity  of  the  retinal  tissue  which  covers  them.  Their 
rupture  may  also  give  rise  to  small  patches  of  ecchymosis.  Again,  effu- 
sion into  the  substance  of  the  retina  first  impairs  its  transparency,  and 
produces  the  appearance  of  a  fog  or  haze  in  the  fundus  of  the  e^^e,  and 
finally  entirely  conceals  the  entrance  of  the  optic  nerve,  the  site  of 
which  can  only  be  determined  by  the  convergence  of  the  dilated  veins. 
The  obscurity  of  the  deeper  structures  may  also  be  increased  by  transu- 
dation into  the  vitreous  humor.  Deposits  of  lymph  in  the  retina  may 
also  give  rise  to  light-colored  patches  similar  to  those  produced  in  the 
choroid ;  but  the  former  may  be  recognized  from  the  fact  that  they  con- 
ceal the  choroidal  and  retinal  vessels,  which  in  the  latter  may  be  seen  to 
cross  the  patch. 

Although  the  ophthalmoscopic  appearances  of  specific  retinitis  do 
not  differ,  as  a  whole,  from  the  non-specific  form,  still  there  are  certain 
peculiarities  attending  it  which  are  supposed  to  be  characteristic  of  its 
syphilitic  origin. 

Thus,  it  has  been  observed  that  the  inflammatory  changes  do  not, 
as  a  rule,  either  in  the  vascular  system  or  in  the  substance  of  the  retina, 
reach  the  same  intensity  as  in  the  idiopathic  form.  Sometimes,  indeed, 
these  are  so  slight  as  only  to  give  the  idea  of  a  normal  retina  seen 
through  a  delicate  gauze,  which,  however,  has  been  proved  by  the  micro- 
scope to  be  due,  not  to  any  disturbance  in  the  vitreous,  but  to  changes 
in  the  retina  itself.  The  alteration  in  the  tissue  does  not,  as  a  rule, 
extend  equally  in  all  directions  from  the  optic  nerve,  but  is  usually 
more  developed  on  one  side  than  the  other,  and  the  border  of  the  dis- 
turbance is  more  sharply  defined  than  in  the  simple  form,  while  the 

^  Forster,  Handbuch  der  gesammien  Augenheilkunde,  1876,  vol.  vii.,  Part  1st,  p.  191. 


704  SYPHILIS. 

exudations  into  the  substance  of  the  retina  have  a  tendency  to  extend 
along  the  vessels.^  Schweigger,^  Von  Graefe,^  Classen,*  and  others 
have  also  described  some  peculiar  forms  of  syphilitic  retinitis,  which, 
with  their  fine-drawn  distinctions,  are,  however,  of  interest  rather  to 
the  ophthalmologist  than  to  the  general  physician,  and  I  would  there- 
fore refer  the  reader  who  is  curious  about  these  matters  to  the  articles 
themselves. 

Retinitis  is  by  no  means  as  frequent  a  symptom  of  secondary  syph- 
ilis as  iritis  ;  it  is,  in  fact,  rather  a  rare  occurrence,  and  when  it  does 
take  place  it  is  usually  with  the  later  series  of  symptoms ;  thus,  in  one 
instance  which  came  under  my  observation  the  patient  suffered  from 
this  disease  fifteen  months  after  an  attack  of  iritis,  and  at  a  time  when 
no  other  syphilitic  symptoms  were  present. 

It  is  certainly  an  interesting  fact  in  this  connection  that  Mooren^ 
says  that  he  has  never  seen  specific  retinitis  accompanied  at  the  same 
time  by  any  other  syphilitic  symptoms.  The  same  author  mentions 
that  he  has  often  observed  that  the  subjective  phenomena  of  light  are 
more  marked  in  syphilitic  than  in  the  simple  form  of  retinitis,  and  that 
these  are  often  accompanied  by  zone-like  limitations  in  the  field  of 
vision,  and  hemeralopia.  These  latter  may  also  occur  in  that  form  of 
specific  choroiditis  which  is  attended  with  infiltration  of  pigment  into 
the  retina.  When  both  the  choroid  and  retina  are  affected  we  have 
a  combination  of  the  symptoms  of  both  under  the  name  of  choroido- 
retinitis. 

Moreovef,  it  must  be  borne  in  mind  that  the  subjective  symptoms  of 
both  retinitis  and  choroiditis  are  often  so  slightly  marked  at  their  com- 
mencement as  to  attract  but  little  attention  from  the  patient,  and  irre- 
parable mischief  may  be  done  before  their  gravity  is  fully  appreciated. 
I  have  repeatedly  met  with  cases  of  syphilis  in  which  some  slight  com- 
plaint from  the  patient  has  led  to  an  ophthalmoscopic  examination  of 
the  eye,  disclosing  the  existence  of  a  disease  which  threatened  the  loss 
of  sight,  but  which  was  subsequently  arrested  by  appropriate  treatment. 
Consequently,  any  impairment  of  vision  in  syphilitic  subjects,  although 
unattended  by  symptoms  of  external  inflammation,  should  at  once  put 
the  surgeon  upon  his  guard  and  lead  him  to  resort  to  specific  remedies. 
Indeed,  the  latter  are  usually  the  only  resource,  as  operative  interference 
is  very  rarely,  if  ever,  called  for. 

The  prognosis  is  generally  favorable  when  appropriate  treatment  is 
employed  at  an  early  stage  of  the  disease,  and  in  this  respect  syphilitic 
choroiditis  and  retinitis  resemble  syphilitic  iritis. 

Affections  of  the  Optic  Nerve. 

Inflammation  of  the  optic  nerve,  or  neuritis,  which  is  not  an  extension 
of  the  process  from  the  retina  or  choroid,  is  an  extremely  rare  result  of 
the  syphilitic  infection — so  rare,  indeed,  that  it  has  been  doubted  by  com- 
petent authorities  whether  the  optic  nerve  was  ever  primarily  affected. 

1  For  more  minute  distinctions  see  Lehrhnch  der  Ophthalmoscopie,  Manthner,  Abth.  ii. 

p.  368.  For  ophthalmoscopic  plates  of  syphilitic  retinitis  see  Liebreich's  Atlas,  Tab.  x., 
Figs.  1  and  2. 

■^  Augenspiegel,  p.  110.  ^  Archlvfiir  Ophth.,  vii.  2,  p.  211. 

*  Archiv,  x.  2,  p.  157.  ^  Ophthalmologische  Beobachtungen,  p.  287. 


AFFECTIONS  OF  THE  EYE.  705 

Thus,  Hughlings  Jackson  says :  "  Optic  neuritis  from  syphilis  is  not 
syphilitic  optic  neuritis.  The  optic  neuritis  produced  by  a  syphilitic 
tumor  is  just  like  that  produced  by  a  glioma  or  by  any  other  adventitious 
product  in  the  cerebrum  or  cerebellum."  ^ 

Forster,  on  the  other  hand,  is  of  the  opinion  that  choked  disk, 
dependent  on  syphilis,  may  occur,  not  as  a  symptom  of  an  intracranial 
trouble,  but  as  the  result  of  gummy  infiltration  of  tissue  betAveen  the 
sheaths  of  the  nerve,  rather  than  of  the  nerve-stem  itself.  He  also  calls 
attention  to  the  fact  that  by  fir  the  greater  number  of  cases  of  neuritis 
with  syphilis  are  unaccompanied  by  any  brain-symptom  whatever,  and 
moreover  that  it  is  only  when  the  trouble  is  due  to  syphilis  that  the  most 
pronounced  cases  of  choked  disk  run  their  course  within  a  few  weeks, 
with  rapid  return  to  the  normal  condition  under  the  employment  of 
specific  remedies.  There  have  been,  moreover,  a  few  cases  reported  of 
gummy  infiltration  of  the  optic  nerve  itself  by  Graefe,  Hulke,  and 
Barber.^ 

Westphal  has  also  reported,  as  an  example  of  gummy  infiltration  of  an 
individual  cranial  nerve,  a  case  in  which  the  oculo-motorius  had  been 
changed  into  a  gummy  mass.^ 

I  think,  therefore,  there  is  no  doubt  that  the  optic  nerve  may  be 
affected  primarily  by  the  syphilitic  taint,  which  may  produce  the  symp- 
toms of  both  kinds  of  neuritis ;  that  is,  the  simple  form  already  described 
in  connection  with  retinitis,  and  the  form  known  as  choked  disk,  in  which 
the  predominant  features  are  venous  stasis  with  enlarged  and  tortuous 
vessels,  protrusion  of  the  papilla,  oedema,  and  hemorrhage.  That  these 
affections,  especially  the  latter,  are  more  commonly  the  result  of  an  intra- 
cranial trouble,  such  as  diffused  meningitis  or  concrete  masses  (gummata), 
is  of  course  incontestable,  but  that  they  may  be  purely  intraocular  I  have 
from  my  own  experience  no  reason  to  doubt. 

There  is  nothing  distinctive  between  the  ophthalmoscopic  appearances 
of  syphilitic  and  non-syphilitic  neuritis.  The  origin,  progress,  and  retro- 
gression are  also  the  same,  with  the  exception  that  the  course  of  the  dis- 
ease is  shorter,  and  the  prognosis  is,  as  a  rule,  more  favorable  in  the  specific 
than  in  the  non-specific  form. 

It  should  be  constantly  kept  in  mind  that  the  amount  of  sight  and  the 
field  of  vision  may  be,  and  often  is,  perfectly  normal  in  the  most  pro- 
nounced cases  of  choked  disk,  and  that  for  this  reason  the  practitioner 
must  be  doubly  on  his  guard,  so  as  to  detect  the  trouble  at  the  outset. 
Any  complaint  whatever  in  regard  to  the  eye  should  at  once  demand  a 
careful  examination  into  all  its  parts  and  functions. 

Affections  of  the  Vitreous. 

It  has  already  been  pointed  out,  in  the  section  on  Choroiditis,  that 
turbidity  of  the  vitreous  is  a  common  accompaniment  of  inflammation  of 
the  choroid,  but  whether  the  vitreous  is  ever,  under  any  circumstances, 
the  seat  of  a  primary  inflammation  is  still  a  matter  of  discussion  among 
ophthalmologists,  and  one  which  is  hardly  suitable  to  the  character  of  the 
present  work.     I  will  say,  hoAvever,  that  I  have  occasionally  noticed  in 

'  Ophthalmic  Hospital  Reports,  vol.  viii.  pt.  ii.  p.  322. 

^  Inawj.  Diss.,  Zurich,  1873.  *  Jahresbericht  Ophthal,  1873,  p.  436. 

45 


706  SYPHILIS. 

young  adults  and  those  in  middle  life  who  have  had  syphilis  a  tendency 
toward  troubles  in  the  vitreous  apparently  unconnected,  so  far  as  the  oph- 
thalmoscope showed,  with  any  trouble  in  the  uveal  tract.  That  such 
existed,  but  of  too  low  a  grade  to  be  detected,  is  of  course  possible,  and 
the  disease  in  these  cases  would  then  be,  as  it  is  in  the  vast  majorty,  a 
secondary,  and  not  a  primary,  affection. 

Paralysis  of  the  Nerves  of  the  Eye. 

A  large  proportion  of  the  cases  of  paralysis  of  these  nerves  is  due  to 
syphilis.  Graefe  ^  attributes  fifty  in  a  hundred  of  all  the  cases  met  with 
to  this  cause,  while  others  have  placed  it  as  high  as  60  or  65  per  cent. 
And  it  is  this  predominating  frequency,  and  especially  the  marked  and 
very  curious  predilection  which  the  virus  would  appear  to  have  in  regard 
to  certain  particular  nerves  of  the  ocular  group,  which  must  be  looked 
upon  as  the  essential  character  of  the  disease.  Thus,  in  most  instances 
it  is  the  third  pair,  or  motor  oculi,  that  is  affected ;  next  in  order  comes 
the  sixth  pair,^  or  abducens  ;  and  finally  the  fourth  pair,  or  patheticus. 

My  limited  space  compels  me  to  refer  the  reader  to  special  treatises 
upon  diseases  of  the  eye  for  a  detailed  description  of  the  symptoms  and 
for  the  methods  employed  by  ophthalmologists  in  diagnosis  of  these  affec- 
tions.^ These  are  much  too  technical  and  intricate  for  the  present  work  ; 
still,  the  general  practitioner  should  be  aware  of  the  most  prominent 
symptoms  as  disturbances  in  vision,  due  to  a  want  of  co-ordination  of  the 
eyes,  are  often  the  initial,  if  not  the  sole,  symptoms  of  commencing  cere- 
bral syphilis — a  warning  which,  if  neglected,  often  leads  to  a  disastrous 
result,  but  which,  if  seized  upon  at  the  moment,  allows  the  application 
of  remedies  with  the  most  beneficial  effect. 

The  principal  symptoms  of  all  these  affections  are  loss  of  power  in 
a  muscle  or  muscles,  and  consequent  limitation  in  the  motion  of  the  eye, 
shown  by  double  images  and  strabismus.  The  individual  characteristics 
are  as  follows : 

Third  Pair. — Falling  of  the  lid,  or  ptosis  ;  deviation  outward  of  the 
eye,  with  loss  of  power  upward,  inward,  or  downward.  Dilatation  of 
the  pupil,  with  loss  or  limitation  of  the  accommodation. 

Sixth  Pair. — Deviation  inward,  with  loss  of  power  outward,  and 
double  vision  on  the  temporal  side  of  the  median  line  of  the  affected 
eye. 

Fourth  Pair. — Double  vision  when  looking  at  objects  below  the  hori- 
zontal plane,  and  a  peculiar  inclination  of  the  ground  or  floor,  with  an 
opposing  inclination  of  the  head  of  the  patient  to  counterbalance  the 
disturbance. 

The  paralysis,  instead  of  being  complete,  may  be  limited  to  single 
muscles,  from  which  it  would  appear  that  different  branches  of  the 
nerve  only  were  affected,  or,  instead  of  being  an  actual  paralysis,  it 
may  be  only  a  paresis.     This  "incompleteness"  has  been  looked  upon 

1  "Syphilitic  Affections  of  the  Eye,"  Deufsch.  Klinik,  1858,  No.  21. 

^  Dr!  Beyram  has  related  three  interesting  cases  of  paralysis  of  the  sixth  pair  due  to 
svphilis  (V  Union  viedicale,  February  23,  1860). 

^  See  an  able  article  by  Dr.  Wells,  giving  an  account  of  Graefe's  researches  upon  para- 
lytic affections  of  the  eye,  Ophthalmic  Hospital  Reports,  vol.  ii.  p.  44.  Also,  Diseases  of  the 
Eye,  same  author. 


AFFECTIONS  OF  THE  EYE.  707 

by  some  as  characteristic  of  syphilitic  paralysis,  and  it  is  this  condition 
which  has  led  to  the  supposition  that  there  Avas  a  "syphilitic  vertio-o." 
There  is,  however,  nothing  sui  generis  in  this  vertigo,  which  may  occur 
from  any  cause,  as  it  is  usually  only  the  expression  of  a  want  of  co-or- 
dination of  the  muscles.  The  latter  may  be  so  slight  as  not  to  produce 
any  deviation  of  the  axes,  but  be  just  sufficient  to  interrupt  transiently 
the  perfect  co-ordination  of  the  muscles  and  produce  a  dizzy  sensation, 
but  it  may  on  some  occasions  produce  for  a  moment  actual  double  vision, 
especially  when  the  gaze  is  turned  in  a  particular  direction.  Still,  it 
must  be  borne  in  mind  that  this  want  of  co-ordination  is  not,  as  asserted 
by  some,  the  only  cause  of  vertigo  in  syphilitic  patients,  as  it  may  exist 
and  be  exceedingly  annoying  even  when  the  ocular  muscles  are  not 
affected  in  the  slightest  degree.  It  must  then  be  referred  to  an  intra- 
cranial cause  not  connected  with  the  organs  of  vision,  but  probably  due 
to  a  morbid  influence  upon  the  semicircular  canals.  Among  these  lim- 
ited paralyses,  one  of  the  most  striking  is  that  of  monocular  mydriasis, 
which  may  occur  even  without  any  implication  of  the  accommodation 
of  the  same  eye.  It  has  sometimes  been  looked  upon  as  a  precursor 
of  severe  brain-trouble,  but  that  it  is  often  not  so  is  proved  by  a  number 
of  syphilitic  cases  in  which  it  has  appeared  and  then  disappeared  with 
no  intracranial  Symptom. 

Besides  these  simple  paralyses  affecting  a  single  nerve  or  some  of  its 
branches,  there  may  be  a  coincident  paralysis  of  the  other  nerves ;  thus 
the  third  and  sixth  pair,  or  the  sixth  and  fourth  pair,  and  so  on,  either 
in  one  or  both  eyes,  may  be  affected,  or  there  may  be  a  triple  paralysis, 
when,  between  the  two  eyes,  the  third,  fourth,  and  sixth  are  all  affected. 
The  paralysis  of  the  ocular  nerves  may  be  also  associated  with  that  of 
other  nerves,  notably  the  facial. 

Owing  to  the  great  importance  of  these  ocular  troubles  and  their 
symptoms  in  regard  to  the  early  diagnosis  of  cerebral  syphilis,  praise- 
worthy attempts  have  been  made  to  put  the  cause  of  their  greater 
frequency  in  syphilitic  affections  upon  an  anatomical  basis,  the  prin- 
cipal reasons  for  which  are  as  follows :  In  the  first  place,  the  ocular 
nerves,  before  entering  the  orbit,  run  for  a  great  distance  along  the 
base  of  the  brain  in  contact  with  the  investing  membranes  and  bony 
surfaces,  in  a  region  Avhich  is  the  place  of  selection  of  all  others  for 
syphilitic  inflammations  and  their  products,  such  as  neoplasms,  gum- 
mata,  and  sclerosis,  by  which  these  delicate  nerves  may  be  surrounded 
and  compressed ;  and  especially  does  this  refer  to  the  third  pair,  Avhich 
is  even  more  apt  to  suffer  than  the  rest  from  its  relation  to  the  inter- 
peduncular space,  which  has  been  shown  to  be  the  seat  of  predilection, 
of  intracranial  syphilitic  hyperplasia.^  But  besides  these  changes, 
Avhich  lie  at  the  base  of  the  brain,  modern  investigation  has  shown,  by 
clinical  observation  and  by  autopsies,  that  Avhat  have  been  called  nerve- 
centres  exist  in  the  cortical  substance  of  the  brain,  so  that  localized 
lesions  in  the  gray  matter  may  produce  a  paralysis  of  a  nerve  or  its 
branches  over  which  the  ])urticular  centre  presides.  And,  as  disease  of 
the  cortex  is  fre{|uently  the  result  of  syphilis,  the  connection  between 
the  lesion  and  the  paralA^sis  is  a  very  probable  one.  This  mode  of 
origin  would  also  explain  the  curious  limitation  of  the  paralysis  to  a 
'  La  Syphilis  du  Cerveaii,  p.  372  et  passim,  1879,  par  A.  Fournier. 


708  SYPHILIS. 

single  muscle,  instead  of  the  entire  group  over  which  the  nerve  pre- 
sides. 

The  surgeon  should  carefully  avoid  confounding  paralysis  of  the 
sixth  pair  with  converging  strabismus.  The  two  may  readily  be  dis- 
tinguished by  the  fact  that,  in  the  former,  the  patient  is  unable,  under 
any  circumstances,  to  turn  the  eye  outward ;  while  in  the  latter,  if  the 
straight  eye  be  covered,  the  squinting  eye  resumes  its  normal  direction. 

The  treatment  of  paralytic  strabismus,  resulting  as  it  so  often  does 
from  syphilis,  is  one  of  the  most  difficult  problems  offered  to  the  oph- 
thalmic surgeon,  not  only  in  regard  to  the  fact  whether,  after  all  other 
remedies  have  failed,  an  operation  should  be  done,  but  also  as  to  the 
choice  of  the  operation — Avhether,  in  fact,  advancement  of  the  paralyzed 
muscle  with  a  tenotomy  of  the  antagonist  should  be  done,  or  a  simple 
tenotomy  of  the  opposing  muscle,  with  the  use  of  the  suture,  as  pro- 
posed by  Knapp,  to  increase  the  effect.  I  must  again  refer  the  general 
reader  to  special  treatises  on  the  subject,^  merely  remarking  here  that 
the  effect  of  a  tenotomy  is  often  surprising,  and  that  I  have  known  a 
paralytic  squint  from  syphilitic  causes,  which  had  resisted  all  the  thera- 
peutical means  known  to  modern  syphilographers,  cured  at  once  by  a 
simple  tenotomy. 

Dixon  ^  relates  two  highly  interesting  cases  in  which  examination  after 
death  revealed  the  existence  of  tumors  in  the  substance  of  the  nerve. 
The  paralysis  is  sometimes,  though  rarely,  due  to  disease  of  the  bony 
passages  or  their  lining  membrane  traversed  by  the  nerve,  and  has  also 
been  traced,  upon  post-mortem  examination,  to  softening  of  the  nervous 
or  cerebral  tissue.  Virchow  ^  quotes  a  number  of  cases  dependent  upon 
the  last-mentioned  cause. 


Hereditary  Syphilis  of  the  Eye. 

That  the  effects  of  acquired  syphilis  in  one  generation  may  be  trans- 
mitted to  the  following,  and  there  manifest  themselves  in  symptoms 
analogous  to,  though  perhaps  not  exactly  identical  with,  those  of  the 
acquired  form,  there  can  be  little  or  no  doubt.  Thus  the  skin  of  the 
eyelids  may  be  the  seat  of  eruptive  diseases,  and  the  deeper-lying  tissue 
the  site  of  infiltrations  or  destructive  secondary  ulcerations,  Avith  or  with- 
out a  coexisting  adenitis  of  the  pre-auricular  and  submaxillary  glands. 
Moreover,  the  hereditary  syphilitic  taint  may  manifest  itself,  so  far  as  the 
eyeball  itself  is  concerned,  in  every  form  of  inflammatory  action,  from  a 
muco-purulent  conjunctivitis  to  keratitis,  iritis,  choroiditis,  and  even 
retinitis  and  neuritis,  all  of  which  have  been  described  already  under 
their  appropriate  headings.  Indeed,  so  general  and  numerous  are  the 
varieties  of  ocular  disease  which  the  poison  produces  that  it  has  been 
claimed  that  where  the  result  was  so  general  the  cause  could  not  be  indi- 
vidual and  specific  ;  and  it  was  consequently  argued  that  when  these 
various  manifestations  occurred  in  broken-down  and  debilitated  constitu- 
tions they  Avere  due  to   the   depraved   condition  of  the    general  system, 

^  Among  others,  see  a  paper  entitled  "  The  iModern  Operation  for  Strabismus,"  E.  G. 
Loring,  Transactions  of  the  New  York  Academy  of  Medicine,  1874,  p.  161. 
2  Medical  Times  and  Gaz.,  Lond.,  Oct.  23,  1858. 
^  Syphilis  constitutionelle,  p.  129  et  seq. 


AFFECTIONS  OF  THE  EAR.  709 

rather  than  the  result  of  a  particular  morbific  infection.  Also,  it  was 
brought  forward  as  a  proof  of  this  that  in  the  vast  number  of  troubles  of 
the  eye  there  were  but  two  that  had  any  claim  to  having  any  individual 
and  characteristic  features — specific  iritis  and  keratitis  ;  and  that  even 
these  two  forms  of  disease  might  occur,  with  all  their  so-called  distinctive 
features,  in  cases  in  which  there  was  not  a  trace  of  any  hereditary  taint 
whatever.  The  weight  of  evidence  is,  however,  against  such  a  reason- 
ing and  in  favor  of  a  definite  and  distinctive  cause. 

In  the  first  place,  these  troubles  occur  in  the  hereditary  varieties  at  a 
very  early  age,  which  in  the  non-hereditary  forms  only  do  so  at  a  period 
very  much  later.  And  especially  true  is  this  with  infantile  iritis  and 
other  troubles  of  the  uveal  tract ;  and  it  may  be  laid  down  as  a  rule  that 
the  earlier  a  disease  common  to  adult  life  makes  its  appearance,  the  more 
likely  it  is  to  be  hereditary.  Moreover,  in  fiivor  of  its  hereditary  nature 
is  the  frequency  in  which  pre-existing  disease  of  a  syphilitic  nature  is 
shown  to  have  occurred  in  one  or  both  of  the  parents,  as  indeed  is  also 
the  fact  of  coexisting  manifestations  in  other  parts  of  the  body  of  the 
parents  or  child — manifestations  which  are  peculiar  to  syphilis  and  not  to 
struma  or  other  diatheses,  such  as  peculiar  eruptions,  erosive  ulcerations, 
nodes,  and  fissures.  To  which  may  be  added  also  the  fact  that  it  is  the 
eldest  child  or  the  one  born  next  subsequent  to  the  infection  of  the 
parents  which  is  markedly  predisposed  to  be  affected,  the  frequency  of 
the  attack  and  the  force  of  the  symptoms  decreasing  in  the  later-born 
children  ;  and,  finally,  the  peculiar  physiognomy. 

Such  evidence  as  this,  and  much  more  of  a  similar  character,  has  led 
syphilographers,  notably  Mr.  Hutchinson,  to  believe  and  to  declare  that 
these  ocular  troubles,  when  occurring  in  young  persons,  are  almost  always 
the  result  of  an  hereditary  taint  due  to  a  specific  virus — a  conclusion 
most  important  in  a  clinical  point  of  view,  as  upon  it  the  proper  treat- 
ment depends. 


CHAPTER    LXVIII. 

AFFECTIONS    OF   THE   EAR. 

Secondary  Affections  of  the  Ear. 

Auricle. — All  of  the  cutaneous  eruptions  of  syphilis  are  very  rarely 
seen  on  the  auricle.  Rupp  ^  saw  the  erythematous  syphilide  on  both 
auricles,  the  eruption  having  been  at  the  same  time  very  marked  all 
over  the  body,  face,  and  forehead.  Syenis^  and  Despres  saw  a  papular 
syphilide  upon  the  lobule  of  the  ear,  the  immediate  exciting  cause 
having  been  the  opening  made  for  an  ear-ring. 

Crummata  of  the  auricle  are  exceedingly   rare,  and  are  generally 

^  Journal  of  Cukmeous  and  Geniio-urinary  Diseases,  1891,  p.  367. 
^  Arch,  far  Ohrenheillc,  xxvi.  p.  140. 


710  SYPHILIS. 

accompanied  by  a  simultaneous  affection  of  the  middle  ear.  Hessler,^ 
Burnett,^  Pollak,^  Baratoux  and  Politzer*  have  recorded  instances  of 
gummata  of  the  auricle.  Gruber^  says  that  gummata  occurring  in  this 
region  are  seen  most  often  on  the  mastoid  process.  In  Burnett's  case 
the  gummata  spread  over  the  entire  auricle,  and  formed  deep-seated 
ulcers  and  partially  destroyed  the  auricle.  There  generally  is  a  simul- 
taneous affection  of  the  middle  ear. 

External  Auditory  Canal. — Ravogli  and  Buck  say  that  the 
syphilitic  affections  which  have  been  most  frequently  observed  in  the 
external  auditory  canal  are  condylomata  and  ulcers.  But  these  also 
are  very  rare.  Thus,  Kipp  ^  saw  condylomata  affecting  the  external  ear 
on  2  in  16,000  ear-patients.  Among  3976  ear-patients  Buck^  observed 
only  3  with  condylomata  in  the  external  auditory  canal.  Despres  met 
with  condylomata  and  ulcers  in  this  situation  4  times  among  1200  syph- 
ilitic subjects,  980  of  Avhom  had  condylomata  in  other  parts  of  the  body. 
Rupp  saw  condylomata  in  the  external  auditory  canal  3  times  only  in 
4000  ear-patients.  Troltsch  *  speaks  of  broad  moist  condylomata  of 
the  external  auditory  canal.  Stohr^  saw  14  cases  of  condylomata  of 
the  external  auditory  canal  in  three  years.  Zucker^'^  saw  only  1  case 
of  condylomata  of  the  external  auditory  canal  among  2000  ear-patients. 
Despres's  ^^  observations  are  instructive  in  this  connection.  He  saw 
among  2000  syphilitics,  980  of  whom  had  mucous. patches  in  other  parts 
of  the  body,  only  5  with  mucous  patches  of  the  external  auditory  canal. 
The  disease  appears  to  be  more  common  among  females.  In  the  major- 
ity of  instances  one  ear  only  is  affected ;  however,  as  Knapp's  ^^  case 
shows,  both  canals  may  be  involved.  It  is  almost  the  rule  for  condy- 
lomata of  the  external  auditory  canal  to  be  complicated  with  purulent 
inflammation  of  the  middle  ear,  and  this  affection  of  the  middle  ear 
generally  precedes  the  condylomata  of  the  external  auditory  canal. 

The  diagnosis  of  condyloma  of  the  external  auditory  canal  may  at 
first  be  attended  with  some  difficulty,  as  gradually  increasing  redness, 
followed  by  swelling,  which  is  seen  in  the  beginning  of  condyloma  may 
be  due  to  a  furuncular  affection  of  the  canal. 

Diffuse  inflammation  of  the  external  auditory  canal  has  been  ob- 
served by  McBride.^^  Ladreit  de  Lacherriere  states  that  he  has  seen  it 
often,  and  that  it  occurs  frequently  with  the  secondary  stage,  and 
usually  attacks  simultaneously  both  canals.  There  is  only  moderate 
swelling,  the  skin  is  red  and  cracked,  and  the  discharge  very  offensive. 
McBride,  on  the  other  hand,  states  that  in  his  case  there  was  no  dis- 
agreeable discharge  or  odor.     Kipp  has  also  seen  such  a  case,  and  it 

^  Arch,  fixr  Ohrenheilk.,  xx.  p.  242. 

2  Treatise  on  the  Ear,  2d  ed.,  1884,  p.  222. 

•'  Allgem.  Wiener  vied.  Zeitunq,  1881,  No.  20. 

*  Treatise  on  the  Ear,  1894,  p!  201. 

^  Treatise  on  the  Ear,  2d  ed.,  p.  374. 

®  Reference  Handbook  of  Med.  Sciences,  vol.  v.  p.  276. 

^  American  Journal  of  Otology,  1879,  p.  25. 

^  Lehrbiich,  4th  ed.,  p.  93. 

^  Arch.  f.  Ohrenheilk.,  vol.  v.  p.  131. 

10  Arch.  f.  OtoL,  vol.  xiii.  p.  243. 

11  Annates  des  Maladies  de  I' Oreille,  etc.,  vol.  iv.  p.  311. 
1^  Arch,  of  Otology,  vol.  viii.  p.  165. 

1^  Glasgow  Med.  Journal,  Sept.,  1885. 


AFFECTIONS  OF  THE  EAR.  711 

occurred  many  years  after  infection,  and  was  associated  with  non-puru- 
lent inflammation  of  the  middle  ear,  with  caries  of  the  superior  maxil- 
lary and  palatine  bones  of  the  same  side.  The  pain  was  very  great, 
and  not  relieved  by  deep  and  long  incisions,  which  at  no  time  liberated 
pus.  The  Eustachian  tube  was  almost  impermeable.  After  much  and 
long-continued  suiFering  the  pain  subsided  eventually  while  the  patient 
was  taking  potassium  iodide,  but  complete  deafness  remained. 

Exostosis  of  External  Auditory  Canal. — We  have  no  convin- 
cing proof  that  syphilis  ever  causes  exostosis  of  the  external  auditory 
canal.  Gruber  is  the  only  author  who  believes  that  syphilis  has  any- 
thing to  do  with  the  formation  of  these  growths. 

Membrana  Tympani. — Lang  ^  has  seen  a  syphilitic  papule  on  the 
drum-membrane. 

Middle  Ear. — Any  affection  of  the  throat  may  spread  to  the  middle 
ear ;  therefore  extension  of  a  syphilitic  inflammation  to  the  throat  is  not 
uncommon.  The  result  of  extension  of  an  inflammation  of  the  throat 
to  the  middle  ear  may  be  a  catarrh,  with  swelling  of  the  mucous  mem- 
brane of  the  Eustachian  tube,  a  collection  of  serum  or  mucus  in  the 
drum-cavity,  or  a  purulent  inflammation  resulting  in  perforation  of  the 
drum-membrane.  There  is,  however,  in  this  condition  nothing  charac- 
teristic of  syphilis.  In  syphilitic  aff"ections  of  the  throat  it  is  not  un- 
common for  the  ulceration  to  extend  to  the  cartilage  of  the  Eustachian 
tube,  destroy  some  portion  of  it,  and  cause  contraction  or  closure  of  the 
tube.  It  has  been  shown  that  primary  chancroidal  ulcers  occur  at  the 
pharyngeal  opening  of  the  Eustachian  tube,  and  that  this  process  gives 
rise  to  a  catarrhal  inflammation  in  the  middle  ear,  resulting  in  thicken- 
ing and  sclerosis  of  the  mucous  membrane  or  hyperostosis  of  the  bony 
wall  and  ossicles,  or  in  suppuration.  The  labyrinth  is  frequently  in- 
volved in  these  cases. 

Symptoms. — Although  there  is  nothing  characteristic  in  the  subjec- 
tive and  objective  symptoms  of  the  diseases  of  the  middle  ear  which 
occur  in  syphilis,  it  has  been  thought  that  the  symptoms  were  those  to 
which  Schwartze  called  attention  many  years  ago  (1869) — i.  e.  that  in 
syphilitic  acute  catarrhal  inflammation  an  impairment  in  the  conduction 
of  sound  through  the  bones  of  the  skull  occurs  regularly  at  an  early 
period  of  the  disease — but  he  gives  no  explanation  for  the  cause.  This 
symptom,  however,  is  often  absent,  and  the  bone-conduction  may  remain 
unimpaired  throughout.  The  acute  form  of  catarrhal  inflammation  of 
the  middle  ear  associated  with  syphilis  is  only  rarely  independent  of 
any  disease  of  the  nasopharynx;  therefore  careful  search  should  be 
made  with  the  rhinoscopic  mirror  for  some  form  of  ulceration  of  the 
pharynx.  Nor  has  chronic  aural  catarrh  occurring  in  a  syphilitic  any 
sign  by  which  it  can  be  distinguished  from  non-syphilitic  catarrh. 
Pain  may  be  absent  throughout  its  course.  Tinnitus  is  a  pretty  con- 
stant symptom.  The  hearing  is  variously  affected.  In  some  instances 
the  middle  ear  is  profoundly  affected  early  in  the  disease,  so  that  after 
a  few  months  only  loud  speech  is  heard.  In  another  class  of  cases  years 
may  elapse  before  the  hearing  is  seriously  affected. 

Pathological  Anatomy. — Moos  ^  has  described  the  pathological  changes 

'  Vorlesungen  iiber  Path,  und  Therap.  der  Syphilis,  1885,  p.  431. 
^  Archives  of  Otology,  vol.  iii.  pp.  107  et  seq. 


712  SYPHILIS. 

found  in  a  case  of  deafness  believed  to  be  due  to  syphilis,  but  the  same 
changes  have  been  observed  in  non-syphilitic  diseases ;  there  is,  there- 
fore, so  far  as  we  know,  nothing  characteristic  in  the  pathological 
anatomy  in  this  connection. 

Purulent  Inflammation  of  the  Middle  Ear. — Ulceration  of  the 
mucous  membrane,  with  caries  and  necrosis  of  the  walls  of  the  tympanic 
cavity,  the  mastoid  process,  and  petrous  portion  of  the  temporal  bone, 
and  facial  paralysis,  have  been  frequently  observed,  and  many  such 
cases  have  terminated  fatally  through  intracranial  complications ;  but 
the  same  conditions  exist  with  non-syphilitic  suppuration  in  the  middle 
ear.  If  pain  in  the  ear  is  complained  of  in  constitutional  syphilis,  we 
will  generally  find  that  it  is  caused  by  disease  in  this  part.  However, 
pain  in  the  ear  may  be  independent  of  inflammation.  Under  such  cir- 
cumstances the  absence  of  all  objective  signs  of  middle-ear  diseases  will 
enable  us  to  reach  a  correct  diagnosis. 

Eustachian  Tube. — Mucous  patches  may  occur  in  any  part  of  the 
nasopharynx,  and  this  condition  not  infrequently  extends  to  the  tubal 
prominence. 

Mastoid  Process. — Schwartze  believes  that  osteosclerosis  and  hyper- 
ostosis of  the  mastoid  process  may  sometimes  be  caused  by  syphilis.  The 
same  writer  declares  that  superficial  and  extensive  caries  of  the  outer 
cortex  of  the  mastoid  process,  without  disease  of  the  middle  ear,  is  met 
with  only  as  the  result  of  syphilitic  or  scrofulous  periostitis.  There  are 
no  signs  by  which  we  can  differentiate  between  syphilitic  and  non- 
syphilitic  forms  of  disease  in  this  part.  Thus,  gumma  of  this  region  may 
present  the  clinical  picture  of  periostitis  of  the  mastoid  process. 

Internal  Ear. — Syphilitic  aff"ections  of  the  internal  ear  are  much 
less  common  than  those  of  the  external  ear.  Politzer^  has  seen 
syphilitic  disease  of  the  labyrinth  develop  on  the  seventh  day  after  the 
primary  infection.  This  experience  is  very  rare,  because  the  disease 
occurs  more  frequently  toward  the  end  of  the  secondary  stage.  In  one 
of  Politzer's  cases  the  disease  in  the  middle  ear  occurred  simultaneously 
"with  gumma  on  the  head  twenty-one  years  after  the  primary  aifection. 
Kipp  has  seen  a  case  in  which  sudden  and  absolute  deafness  of  one  ear 
occurred  in  connection  with  nasocranial  osteitis  twenty-six  years  after 
infection,  and  after  an  interval  of  more  than  twenty-five  years  of  com- 
plete freedom  from  all  symptoms  of  constitutional  syphilis.  The  disease 
of  the  labyrinth  may  also  accompany  a  catarrhal  or  purulent  inflam- 
mation of  the  middle  ear  which  has  preceded  the  syphilitic  aifection. 
There  can  be  no  doubt  that  the  disease  of  the  labyrinth  sometimes  occurs 
independently  of  extension  of  the  middle-ear  aifection,  but  this  is  unques- 
tionably less  frequently  the  case  than  that  the  labyrinth  is  secondarily 
aifected. 

Pathological  Anatomy. — Schwartze,  who  is  the  most  distinguished 
authority  in  this  particular  field  of  inquiry,  declares  that  we  have  no 
anatomical  knowledge  whatever  on  this  subject,  and  that  the  pathological 
changes  found  by  Toynbee,  Gruber,  Moos,  and  others  cannot  be  regarded 
as  characteristic,  since  the  same  changes  occur  in  non-syphilitic  cases. 
Moreover,  there  has  generally  been,  in  the  cases  reported,  some  other 
general  systemic  disease  present  which  may  be  responsible  for  the  ana- 

^  Text-hook  on  Diseases  of  the  Ear,  edited  by  Dalby,  1894,  p.   645. 


AFFECTIONS  OF  THE  EAR.  713 

tomical  changes  found  in  the  labyrinth.  Thus,  in  Gruber's^  case  in  a 
syphilitic  subject  who  had  become  suddenly  deaf,  and  who  died  from 
typhus  fever,  there  was  found  considerable  hyperosmia  of  the  lining  mem- 
brane of  the  tympanic  cavity  and  of  the  membranous  labyrinth,  Avhich 
appeared  much  thickened.  The  fluid  in  the  labyrinth  was  abundant  in 
quantity  and  of  a  blood  color.  In  a  syphilitic  subject  in  whom  intense 
subjective  noises,  attacks  of  vertigo,  and  headache  suddenly  commenced, 
without  much  disturbance  of  the  hearing,  marked  deafness  having  set  in 
only  shortly  before  death,  Moos^  found  at  the  autopsy  condensation  of 
the  periosteum  of  the  vestibule,  the  foot-plate  of  the  stapes  raised  and 
immovable,  the  connective  tissue  between  the  membranous  and  osseous 
labyrinth  infiltrated  with  small  cells,  Corti's  arch  and  cells  especially 
considerably  infiltrated,  the  zona  pectinatse  and  the  periosteum  of  the 
lamina  spiralis  ossea  less  strongly  infiltrated  ;  the  ampullae  and  mem- 
branous semicircular  canals  were  alike  greatly  infiltrated ;  the  auditory 
nerve  was  normal.  Huebner,  Baratoux,  and  Kirchner  have  found  a  typi- 
cal endarteritis  luetica  in  the  blood-vessels  of  the  tympanic  mucous  mem- 
brane, lens-shaped  osseous  accretion  from  the  periosteum  on  the  promon- 
tory, and  the  formation  of  cavities  in  the  walls  of  the  labyrinth,  which 
were  due  to  obliteration  of  the  vessels. 

Symptoms. — Objective  examination  of  the  drum-membrane  often 
gives  a  negative  result,  but  should  middle-ear  disease  be  present  the 
symptoms  indicating  this  condition  will  be  observed.  The  subjective 
signs  wnll  show  marked  diminution  or  total  loss  of  hearing  in  one  or  both 
ears,  occurring  more  or  less  suddenly.  Subjective  noises  are  generally 
present.  Double  hearing,  according  to  Roosa,  is  rarely  observed.  Pain 
is  an  uncommon  symptom.  Politzer  observed  in  only  one  case  pain  in 
the  interior  of  the  ear,  with  tinnitus  and  deafness,  and  without  any  ob- 
jective evidence  of  inflammation  on  the  membrana  tympani.  Attacks  of 
vertigo  and  unsteady  gait  more  frequently  follow  than  precede  the  deaf- 
ness. The  deafness  is,  in  most  cases,  bilateral,  and  one  ear  is  usually 
much  more  affected  than  the  other.  Inflation  of  the  middle  ear  has  little 
or  no  influence  on  the  hearing-distance.  Perception  of  sound  through 
the  bones  of  the  head  is  either  greatly   diminished  or  quite  wanting. 

Course  and  Termination. — The  impairment  of  the  hearing  may  progress 
slowly  in  some  cases,  but  generally  it  is  rapid.  The  deafness  may  some- 
times be  almost  complete  on  the  third  day  after  the  commencement  of  the 
trouble  (Politzer).  The  unsteady  gait  generally  disappears  after  a  few 
weeks  or  months,  but  the  impaired  hearing  continues.  When  improve- 
ment in  the  hearing  takes  place  it  is  gradual,  and  the  restoration  of  the 
hearing  is  never,  as  is  its  loss,  sudden. 

Diagnosis. — The  diagnosis  of  labyrinthine  syphilis  can  only  be  made 
through  the  history  or  the  presence  on  the  body  of  evidence  of  active 
syphilis.  Politzer  states  that  in  young  people  the  rapid  development  of 
the  disturbance  of  hearing,  with  the  absence  of  objective  symptoms  of  an 
aff"ection  of  the  middle  ear,  is  sufficient  to  raise  the  suspicion  of  labyrinth- 
ine syphilis. 

Disease  of  the   Cochlea. — Roosa  ^  believes  that  we  may  classify 

'  Lehrbuch  der  Ohrenheilkunde,  2d  ed.,  p.  202. 
^  Arch,  fur  Path.  Anal.,  etc.,  vol.  Ixix.  p.  313. 
^  Treatise  on  Diseases  of  the  Ear,  7th  ed.,  1891,  p.  633. 


714  SYPHILIS. 

disease  of  the  cochlea.  He  prefers  to  say  "disease  of  the  cochlea"  in- 
stead of  the  labyrinth  when  the  prominent  symptoms  are  great  impair- 
ment of  hearing,  inability  to  hear  certain  tones,  and  the  production  of 
false  ones.     These,  he  believes,  are  evidences  of  cochlear  disease. 

Auditory  Nerve. — We  have  no  knowledge  of  the  morbid  changes  in 
the  trunk  of  the  auditory  nerve  due  to  syphilis. 

Inherited  Syphilis. 

According  to  Hutchinson  and  Jackson,  the  ears  are  affected  in  10  per 
cent,  of  all  children  with  inherited  syphilis.  The  middle  ear,  as  in  the 
case  of  adults  suffering  from  syphilis,  is  affected  with  the  same  forms  of 
disease — i.  e.  catarrhal  and  purulent  inflammation.  Baratoux,^  who  made 
autopsies  in  43  still-born  or  new-born  infants  with  hereditary  syphilis, 
found  lesions  of  the  middle  ear  23  times,  lesions  of  labyrinth  4  times,  and 
lesions  of  both  parts  12  times.  According  to  Politzer,  those  forms  of 
syphilitic  affections  of  the  labyrinth  are  to  be  regarded  as  hereditary 
which  develop  in  children  with  great  or  total  deafness.  Kipp  has  pub- 
lished a  series  of  cases  in  which  the  disturbances  of  hearing  caused  by 
hereditary  syphilis  were  combined  with  parenchymatous  keratitis.  The 
writer  has  treated  a  case  of  inherited  syphilis  in  which  the  ear-affection 
developed  three  years  after  recovery  from  the  parenchymatous  keratitis. 

The  symptoms  given  by  Kipp  were — sudden  deafness,  vertigo,  disturb- 
ance of  equilibrium,  subjective  noises,  nasopharyngeal  catarrh,  and  some- 
times also  catarrh  of  the  middle  ear.  Hinton  states  that  the  disturbance 
of  hearing  frequently  occurs  first  at  puberty. 

Prognosis. — The  prognosis  is  less  unfavorable  in  recent  cases,  but  it  is 
unfavorable  in  all  cases  of  any  standing.  The  prognosis  is  most  favor- 
able in  those  cases  in  which  the  middle  ear  is  affected,  and  for  which  local 
treatment  may  be  applied. 

Treatment. — The  cutaneous  lesions  of  syphilis  which  may  invade  the 
auricle  and  external  auditory  canal  require  the  treatment  employed  for 
similar  lesions  in  other  parts  of  the  body.  Thus,  in  a  case  of  chancre 
near  the  pharyngeal  orifice  of  the  Eustachian  tube  observed  by  Cohen,  in 
which  there  was  considerable  destruction  of  tissue,  in  addition  to  consti- 
tutional treatment  iodoform  was  applied  locally.  Condylomata  of  the 
external  auditory  canal  had  been  successfully  treated  with  mercurials,  the 
ear  being  cleansed  by  syringing  and  the  meatus  washed  with  a  1  per  cent, 
solution  of  nitrate  of  silver,  and  calomel  dusted  over  the  excrescences. 

Middle  Ear. — Suppuration  of  the  middle  ear  occurring  in  syphilis 
requires  constitutional  and  local  treatment.  The  local  treatment  must  be 
determined  by  the  local  changes  in  the  ear  and  the  nature  of  the  attack. 
If  the  attack  be  an  acute  one,  the  pain  and  congestion  in  the  ear  may  be 
relieved  by  the  application  of  two  or  more  leeches  to  the  tragus,  and  if  the 
mastoid  region  be  red  and  tender,  leeches  to  this  part  are  also  indicated ; 
but  this  complication  may  call  for  radical  treatment.  If  the  drum-mem- 
brane be  bulged  forward  by  fluid  in  the  drum-cavity,  the  drumhead  should 
be  incised  and  the  fluid  removed  by  inflation  through  the  Eustachian  tube 
by  Politzer's  method.  When  the  fluid  in  the  middle  ear  is  purulent,  it 
should  be  removed  by  syringing.  The  selection  of  the  solution  for  syring- 
^  Transactions  of  the  International  3Ied.  Congress,  Washington,  Sept.,  1887. 


TERTIARY  SYPHILIS.  715 

ing  is  not  very  important,  as  it  is  used  chiefly  for  its  mechanical  effect  of 
removing  the  secretion.  Clean,  warm  water,  freshly  boiled,  to  which  1 
per  cent,  of  cooking  salt  or  3  per  cent,  of  boric  acid  is  added,  makes  an 
efficient  cleansing  solution.  The  temperature  of  the  solution  should  be 
about  85°  Fahr.  Carbolic  acid,  1-2  per  cent.,  may  be  used  when  the  dis- 
charge is  offensive.  The  amount  of  secretion  should  determine  the  num- 
ber of  times  a  day  the  syringing  should  be  repeated.  When  the  discharge 
is  very  slight  one  syringing  in  twenty-four  hours  may  suffice ;  when  pro- 
fuse, the  syringing  may  be  repeated  three  times  in  a  day.  After  the 
syringing  the  ear  should  be  inflated  through  the  Eustachian  tube  by 
Politzer's  method,  and  the  meatus  tJioroughly  dried  by  means  of  absorbent 
cotton  wrapped  about  the  end  of  a  dentist's  cotton-holder.  A  good  cleans- 
ing agent  is  hydrogen  peroxide  in  6  per  cent,  solution.  This  simple 
treatment  applies  to  those  cases  of  suppuration  of  the  middle  ear  in  which 
no  granulations  or  polypi  are  present  in  the  drum-cavity  or  caries  of  the 
temporal  bone.  Localized  suppuration  of  the  external  attic,  with  perfor- 
ation of  Schrapnell's  membrane,  will  call  for  special  treatment,  which  can 
scarcely  be  defined  within  the  limitations  of  this  chapter.  The  treatment 
of  the  labyrinthine  syphilis  is  the  same  as  that  of  general  syphilis.  The 
iodide  treatment  is  sometimes  attended  with  improvement  in  the  hearing. 
In  other  cases,  however,  mercurial  inunction  is  more  efficient.  Muriate 
of  pilocarpine,  used  subcutaneously  (2  per  cent.,  four  to  ten  drops  and 
increased),  has  been  useful  in  the  hands  of  some  surgeons. 

Buck^  has  tabulated  his  experience  in  the  treatment  of  the  sudden 
deafness  due  to  syphilis  Avith  large  doses  of  potassium  or  sodium  iodide. 
In  the  favorable  cases  the  improvement  began  to  show  itself  as  early  as 
during  the  second  or  third  week  of  the  iodide-of-potassium  treatment. 
The  treatment  was  begun  Avith  30  grains  a  day,  and  gradually  pushed  to 
the  extreme  limits  mentioned — viz.  270  gr.,  315  gr.,  360  gr.,  525  gr. 
Buck  adopts  the  rule  of  not  giving  more  than  from  one  to  two  drachms 
daily  in  those  cases  in  which  commencing  improvement  is  observed  during 
the  second  or  third  week  of  treatment. 


CHAPTER    LXIX. 

TERTIARY  SYPHILIS. 

When  syphilis  does  not  become  extinct  in  the  secondary  stage  it  passes 
into  a  chronic  condition,  generally  called  tertiary  syphilis,  which  is  desig- 
nated by  French  authors  tertiarism. 

The  evolution  of  tertiary  syphilis,  as  a  rule,  is  slow,  uncertain,  insidi- 
ous, and  unattended  by  local  or  general  prodromata.  While  in  secondary 
syphilis  the  infection  very  often  runs  an  orderly  course,  and  a  general 
estimate  may  be  formed  as  to  what  morbid  conditions  and  lesions  may  be 

^  Transactions  of  the  American  Olological  Society,  1884,  p.  243. 


716  SYPHILIS. 

expected  or  feared,  in  tertiary  syphilis,  as  a  rule,  there  are  no  special 
criteria  to  govern  us  in  our  prognosis,  since  all  is  occult  and  without  order 
or  system.  The  tertiary  stage  has  very  aptly  been  called  the  terra  incog- 
nita of  syphilis. 

Tertiary  syphilis  presents  in  its  evolution  and  course  many  striking 
differences  from  the  secondary  form.  Tertiary  lesions,  as  a  rule,  are  of 
deep  development,  of  compact  structure,  and  of  slow  and  aphlegmasic 
nature.  They  are  usually  less  numerous  and  more  isolated  than  secondary 
lesions,  less  certain  as  to  their  seat,  less  regular  in  their  course,  and  much 
more  deeply  seated  and  destructive  in  their  tendency. 

Tertiary  lesions  attack  the  subdermal  and  submucous  connective  tissues, 
and  produce  in  them  more  or  less  extensive  and  dense  infiltrations,  most 
of  which  shoAv  a  tendency  to  degeneration.  While  in  secondary  syphilis 
the  more  superficial  strata  of  the  skin  and  mucous  membranes  are  involved, 
in  the  tertiary  stage  the  whole  thickness  of  these  structures  is  attacked. 
In  secondary  syphilis  the  skin  lesions  are  more  generalized,  more  numer- 
ous, and  are  symmetrically  placed.  In  the  tertiary  stage  their  number  is 
restricted ;  they  are  usually  irregularly  distributed,  and  very  often  their 
arrangement  is  unsymmetrical.  The  old  eruptions  are  localized  to  one 
region,  and  they  may  perhaps  exist  in  several. 

In  secondary  syphilis  we  not  infrequently^  see  a  tendency  in  the  lesions 
to  undergo  involution  and  resolution  ;  in  tertiary  syphilis  no  tendency  to 
spontaneous  retrogression  of  its  lesions  is,  as  a  rule,  seen.  AVhile  in  the 
majority  of  cases  of  secondary  syphilis  the  viscera  are  spared  or  are  only 
the  seat  of  irritative  or  hypergemic  processes,  in  tertiary  syphilis  they  are 
attacked  more  or  less  deeply  by  a  chronic  progressive  infiltrative  process 
which  produces  nodules,  plaques,  and  tumors  called  gummy  tumors  or 
syphiloma.  Thus  in  its  far-reaching  and  chronic  pathological  action  ter- 
tiary syphilis  involves  not  only  the  superficies  of  the  body,  but  also  its 
internal  parts — the  viscera,  the  bones  and  their  adnexa,  the  muscles,  the 
blood-vessels,  and  the  nervous  system. 

Tertiary  syphilis  therefore  runs  a  long,  indolent,  and  aphlegmasic 
course,  with  little,  if  any,  inherent  tendency  to  resolution ;  but,  on  the 
contrary,  there  is  a  predisposition  to  produce  ulceration,  sloughing,  gan- 
grene, thrombosis,  necrosis,  a  sclerotic  condition  of  the  tissues,  and 
sometimes  cicatrization  not  preceded  by  ulceration. 

The  pathological  processes  in  tertiar}^  syphilis  are,  in  the  main,  similar 
to,  but  more  fully  developed,  intense,  and  exuberant  than,  those  of  the 
secondary  stage.  They  include,  in  brief,  perivascular  cell-changes,  round- 
cell  infiltration  (gummatous  infiltration  and  nodulation),  and  irritative 
processes  which  result  in  the  development  of  fibrous  or  connective  tissues 
(in  bones,  joints,  muscles,  tendons,  synovial  sheaths,  and  the  skin  and 
mucous  membranes),  and  last,  but  not  least,  the  excessive  development  of 
connective-tissue  neuroglia  in  the  nervous  structures  of  the  cerebro-spinal 
axis.  These  processes  may  eventuate  in  the  degenerative  conditions 
already  mentioned. 

It  is  absolutely  impossible  to  write  a  clear  and  thoroughly  systematic 
clinical  history  of  tertiary  syphilis,  since  no  two  cases  are  alike,  and  the 
date  of  invasion,  the  extent,  depth,  course,  and  seat  of  the  morbid  pro- 
cess, and  the  oi'gans  or  tissues  attacked,  are  usually  different  in  each 
instance.     While,  therefore,  no  sharply  and  precisely  drawn  clinical  divis- 


TERTIARY  SYPHILIS.  717 

ions  can  be  presented  in  describing  tertiary  syphilis,  certain  generaliza- 
tions may  be  made,  based  on  the  study  of  my  own  cases  and  supplemented 
by  the  experience  of  many  able  men,  which  will  tend  to  give  a  clear  idea 
of  this  chaotic  and  discordant  stage  of  syphilitic  infection. 

Tertiary  syphilis  in  a  rather  small  proportion  of  cases  develops  more 
or  less  precociously.  In  some  cases  as  early  as  the  second,  third,  or 
fourth  month  of  the  infection,  when  the  roseolous  syphilides  or  the 
papular  syphilides  are  still  present,  the  condition  of  the  patient  takes  a 
turn  for  the  worse.  The  skin  lesions  increase  in  size,  ulcerate,  and  sup- 
purate, perhaps  very  profusely.  The  resulting  ulcers  increase  in  size  and 
depth,  and  may  present  sloughy,  even  gangrenous,  features.  Then  these 
lesions  show  a  tendency  to  spread  over  the  trunk,  the  extremities,  the 
face,  and  the  scalp.  With  these  ulcerations  cutaneous  gummata,  or  more 
superficial  but  thick  tubercles,  may  develop,  soften,  and  lead  to  deep 
ulcers.  The  patient  then  becomes  weak  and  cachectic.  In  a  small  pro- 
portion of  these  cases  such  nervous  affections  as  hemiplegia,  aphasia, 
meningeal  hypersemia,  epilepsy,  paralysis  of  the  motor  oculi  and  facial 
nerves,  and  degenerative  changes  in  the  optic  and  auditory  nerves,  may 
be  seen.  This  form  of  tertiary  syphilis  in  very  rare  instances  runs  an 
unusually  rapid  and  severe  (called  by  some  galloping  or  lightning-like) 
course,  and  soon  ends  in  death,  which  is  due  to  a  decidedly  febrile  state 
and  marasmus.  These  cases  sometimes  present  distinct  features  of  septi- 
csemia.  In  this  very  early  form  of  tertiary  syphilis  we  find  multiple  large 
and  severe  disseminated  and  generalized  ulcerations,  and  an  adynamic 
condition  of  the  system,  shown  by  the  malignancy  of  the  infection  and  a 
tendency  to  ulceration,  gangrene,  and  phagedena.  In  these  cases  the 
syphilitic  infection  seems  to  exuberantly  luxuriate,  and  its  action  is  like 
wild-fire. 

Many  of  these  cases  of  precocious  tertiary  syphilis  are  cured  after  a 
hard  struggle  by  good  treatment  and  good  hygiene. 

Tertiary  syphilis  may  be  rather  less  precocious  than  in  the  form  just 
described.  Toward  the  end  of  the  first  year  of  the  infection,  after  the 
evolution  of  secondary  manifestations,  some  patients  become  weak,  anaemic, 
and  lose  flesh.  One,  several,  or  many  ulcers,  which  may  arise  de  novo  or 
follow  in  the  wake  of  a  secondary  lesion,  may  appear  on  the  scalp,  the 
face,  or  the  extremities,  and  run  an  active  and  rapid  course,  showing 
great  rebelliousness  to  local  and  general  treatment  and  good  hygiene.  In 
some  of  these  cases  there  are  concomitant  bone,  joint,  pharyngo-nasal,  and 
testicular  lesions.  The  patient  is  and  continues  to  be  a  sick  man  upon 
whom  destructive  lesions  seem  prone  to  appear  at  short  intervals.  In 
most  of  these  cases,  after  a  very  severe  ordeal,  the  patient  gradually  gains 
health  and  strength,  and  may  be  in  the  end  cured.  In  these  early  forms 
of  tertiary  syphilis  it  is  not  very  uncommon  to  observe  the  onset  of 
pulmonary  tuberculosis,  which  usually  ends  fatally  in  a  few  Aveeks  or 
months. 

Fournier's^  experience  goes  to  show  that  nervous  disturbances  are 
second  in  order  of  frequency  of  symptoms  in  precocious  tertiary  syphilis. 
According  to  this  observer,  the  brain  is  most  commonly  affected,  and  the 
spinal  cord  less  frequently. 

The  spinal  cord  is  much  less  frequently  affected  than  the  brain  in 

1  "Le  Tertiarisme  pr^coce,"  Gaz.  med.  de  Parii<,  Nos.  49-52,  1893,  and  No-  1,  1894. 


718  SYPHILIS. 

precocious  tertiary  syphilis,  but  the  changes  produced  have  a  malignant 
tendency.  According  to  Fournier,  Gilbert  and  Lion  observed  16  deaths 
in  the  52  cases  of  early  medullary  syphilis. 

Death  from  brain  and  spinal-cord  lesions  is  to  be  feared  in  early  terti- 
ary syphilis.  It  Avill  be  generally  found  that  precocious  tertiary  syphilis 
is  much  more  rebellious  to  treatment  than  the  late  form  is.  In  many 
cases  treatment  seems  to  have  little  if  any  effect. 

In  3032  cases  of  tertiary  syphilis  Fournier  observed  its  precocious 
development  in  158  patients. 

The  results  of  the  experience  of  many  observers  go  to  show  that  the 
onset  of  tertiary  syphilis  occurs  in  the  third  or  fourth  year^  of  the  infec- 
tion in  the  majority  of  cases,  and  that  from  this  date  until  the  tenth  or 
twelfth  year  its  appearance  is  progressively  less  frequent.  Tertiary 
syphilis  may,  in  exceptional  cases,  develop  from  the  twelfth  to  the  twen- 
tieth year.  After  the  lapse  of  two  decades  tertiary  syphilis  very  rarely 
occurs.  In  3600  private  cases  of  tertiary  syphilis  Fournier^  observed  its 
development  in  177  at  periods  beyond  the  twenty-first  year.  Between 
the  twenty-first  and  the  twenty-sixth  years  115  cases  were  noted,  whereas 
between  the  forty-first  and  fifty-first  years  there  were  only  4  cases  re- 
corded. 

It  is  well  to  emphasize  the  point  that  the  possibility  of  error  in  the 
diagnosis  of  very  late  tertiary  lesions  is  very  great,  and  that  errors  are 
very  common.  It  is  always  a  good  plan  to  be  skeptical  about  alleged 
cases  unless  they  are  unqualifiedly  vouched  for  by  an  accurate  and  skilled 
observer.  Many  cases  presenting  lesions  of  tuberculosis,  actinomycosis, 
mycosis  fungoides,  sarcomatous  and  epitheliomatous  hyperplastic  tumors, 
gout,  rheumatism,  traumatism,  and  iodide-of-potassium  intoxication  have 
been  paraded  as  evidence  of  the  activity  of  the  syphilitic  virus  ten, 
twenty,  thirty,  forty,  and  fifty  years  after  infection. 

The  statistics  of  Haslund^  are  very  interesting  as  to  the  percentage 
of  occurrence  and  the  frequency  with  which  various  organs,  systems,  and 
tissues  are  attacked  in  tertiary  syphili's.  In  6364  cases  of  syphilis  (3490 
in  men  and  2874  in  women)  there  were  454  cases  of  tertiary  syphilis  in 
men,  or  13  per  cent.,  and  337  cases  in  women,  11.7  per  cent.  These 
statistics  are  very  much  in  accord  with  those  of  Rollet,  Mauriac,  Vajda, 
and  Jullien. 

Parts  attacked.  In  454  cases  of  men.  In  337  cases  of  women. 

Skin in  235  cases,  in  218  cases. 

Nervous  system ''  144       "  "     56      " 

Osseous  system "  104       "  "108      " 

Mucous  membranes "     72       "  "     79      " 

Internal  organs "     40       ".  »       7       << 

It  will  be  seen  that  the  integument  is  the  tissue  most  commonly  attacked 
in  tertiary  syphilis,  and  that  next  in  frequency  the  nervous  system  is 
involved.     In   3429   private   cases   of  tertiary   syphilis   Fournier  found 

^  "  According  to  the  computaticm  of  Jullien  (Recherches  sur  I'Etiolociie  de  la  Syphilis 
tertiaire,  Paris,  1874),  the  average  date  of  invasion  in  a  large  number  of  cases  was  four 
and  a  half,vears. 

^  "  Des  Etapes  ultimes  de  la  Syphilis,"  Bull,  medical,  Nos.  33  and  34,  1894. 

^  "  On  the  Causation  of  Tertiary  Svphilis,"  British  Journal  of  Dermatology,  vol.  iv., 
1892,  pp.  210  et  seq. 


TERTIARY  SYPHILIS.  719 

nervous  affections  in  1085.  Second  to  cutaneous  lesions,  nervous  dis- 
turbances are  most  frequent  up  to  the  twentieth  year  of  infection,  and 
after  that  date  they  are  very  rare.  Syphilitic  myelopathies  are  very  rare 
in  the  late  years  of  syphilis. 

Concerning  these  late  evolutions  of  tertiary  syphilis,  it  may  be  said 
that  in  many  cases  they  were  preceded  by  other  tertiary  lesions  more  or 
less  remotely  in  the  majority  of  cases.  In  very  exceptional  cases  there 
has  been  no  antecedent  tertiary  manifestation  whatever. 

While  it  is  impossible  to  describe  sharply-marked  type-forms  of  ter- 
tiary syphilis,  a  generalization  of  cases  may  be  made. 

Cases  of  ulcerating  tubercular  syphilide  are  sometimes  seen  in  which 
the  lesions  begin  in  the  third  or  fourth  year,  sometimes  earlier.  I  have 
seen  some  rare  cases  in  which  these  syphilides  invaded  in  persistent  and 
interrupted  outbreaks  the  scalp,  the  face,  the  extremities,  and  the  trunk, 
producing  disfigurement  and  perhaps  mutilation  in  all  parts  attacked. 
Thus,  the  disease  kept  on,  in  spite  of  good  treatment,  for  years ;  then, 
after  an  interval  of  ten  years  of  apparent  health,  gummatous  infiltration 
and  ulceration  occurred,  and  the  skin  became  necrosed  at  slight  trauma- 
tisms. In  these  cases  syphilis  leaves  its  permanent  morbid  impress,  Avith 
a  tendency  to  hyperplasia  and  ulceration  of  the  skin,  for  years.  In  some 
occult  way  a  peculiarly  active  vulnerability  is  engrafted  on  the  tissue. 

Then,  again,  we  see  cases  in  which  resolutive  tubercular  syphilides 
appear  on  one  region  and  remain  limited  to  it  for  a  long  time,  and  in  the 
course  of  ten  or  twenty  years  attack  most  of  the  integument  of  the  whole 
body.  In  these  cases  of  extensive  chronic  skin  lesions  the  patients  may 
enjoy  fairly  good  and  seemingly  robust  health.  In  some  cases  intercur- 
rent nervous,  visceral,  osseous,  and  testicular  affections  develop.  I  think, 
however,  that  in  general  the  nervous  system  is  usually  spared  in  these 
cases  of  extensive  tegumentary  invasion. 

Perhaps  one  of  the  most  frequent  forms  of  tertiary  syphilis  is  that  in 
which  the  serpiginous  syphilide  develops  upon  some  specific  lesion  or  on 
some  simple  ulceration  or  traumatism,  and  travels  over  certain  regions 
or  over  the  trunk  or  the  extremities.  Patients  thus  attacked  may  be 
thin  and  weakly,  or  even  robust  and  well-built.  This  lesion,  to  my 
mind,  indicates  rather  that  the  skin  of  the  patient  remains  vulnerable  to 
microbic  invasion  than  that  it  is  an  evidence  of  the  activity  of  the  syph- 
ilitic diathesis. 

Some  cases  of  late  osseous  lesions  present  a  tolerably  uniform  course. 
Thus,  we  see  that  nodes  appear  on  the  skull  and  long  bones,  and  develop 
in  crops  at  irregular  intervals  for  years.  In  some  of  these  cases  there 
is  coexistent  joint  lesion,  and  in  some  men  testicular  involvement.  In 
some  of  these  bone  cases  there  is  often  severe  and  persistent  rheumatism 
of  the  muscles  or  fibrous  tissues  and  a  markedly  cachectic  condition. 
These  patients  look  sallow  and  unwholesome ;  their  facies  bears  the  stamp 
of  suffering  ;  they  suffer  from  malnutrition  and  from  insomnia  the  result 
of  pain.  In  these  cases  the  morbid  condition  is  very  chronic,  and  it  is 
very  rebellious  to  treatment. 

There  is  a  further  class  of  cases  of  tertiary  syphilis  which  present 
a  tolerably  well-defined  course.  The  patient  suffers  in  the  secondary 
period  with  rashes  and  meningeal  symptoms,  and  on  their  disappear- 
ance a  condition  of  somewhat  impaired  health  supervenes.     This  may 


720  SYPHILIS. 

last  years,  and  then  the  patient  may  be  attacked  by  gummata  of  the 
skin,  bones,  or  testes,  or  he  may  develop  some  hyperplastic  or  arterial, 
brain,  or  cord  affection,  Avhieh  may  be  cured,  may  leave  him  a  cripple, 
or  it  may  kill  him. 

Cases  are  not  at  all  of  infrequent  occurrence  in  which,  after  a  faint 
and  ephemeral  or  a  well-developed  roseolous  syphilide,  an  interval  of 
seemingly  perfect  health  of  a  few  or  many  years  may  occur,  and  then 
cutaneous,  osseous,  testicular,  visceral,  or  cerebro-spinal  symptoms  may 
develop. 

It  is  not  at  all  uncommon,  particularly  in  women  who  have  had  a 
more  or  less  severe  ordeal  in  the  secondary  stage,  to  observe  in  the 
second  and  third,  and  even  later  years  of  the  infection,  the  onset  of 
cachexia  and  a  gummatous  infiltration  into  the  hard  or  soft  palate,  which 
may  produce  much  destruction  of  tissue.  Very  commonly  these  are  the 
only  lesions,  but  in  some  cases  skin  and  bone  gummata  are  found  to  co- 
exist. 

After  this  lugubrious  recital  of  these  grave  and  malignant  morbid 
conditions,  due  to  tertiary  syphilis,  it  is  pleasant  to  state  that  in  the  ma- 
jority of  cases  one  or  more  regions  and  one  or  several  organs  or  tissues 
may  be  attacked,  and  after  a  time,  under  the  influence  of  treatment,  a 
cure  is  induced. 

Though  tertiary  syphilis  is  severe  and  often  threatening  in  its  course, 
fortunately  for  the  human  race  it  is,  as  a  rule,  amenable  to  treatment 
in  a  marked  degree. 

It  is  claimed  by  some  authors  that  tertiary  syphilis  is  not  true  syph- 
ilis, but  a  chronic  morbid  condition  left  behind  by  the  active  infection. 
Other  authors  think  that  in  tertiary  syphilis  the  tissues  have  undergone 
some  changes,  and,  instead  of  reacting  normally  to  any  stimulus,  they 
produce  a  peculiar  growth  of  cells  known  as  gumma.  Seeing  that  ter- 
tiary lesions  may  coexist  and  follow  directly  in  the  wake  of  secondary 
manifestations,  that  the  pathological  processes  of  the  whole  disease  show 
a  distinct  gradation  and  an  intimate  correlation,  it  is  hard  to  see  how 
syphilis  can  stop  short  and  then  develop  a  radically  different  morbid 
condition.  Clinical  observation  and  pathological  researches  show  very 
conclusively  that  in  the  early  part  of  this  infection  the  hypersemia  is 
moderately  active,  and  that  the  cell-proliferations  are  exuberant  and 
widely  scattered.  In  the  late  stages,  on  the  contrary,  the  cell-growth  is 
slow  and  insidious,  and  shows  a  tendency  to  become  localized  deeply  in 
the  tissues  of  regions  and  organs,  and  at  the  same  time  the  hyperemia 
is  very  sluggish. 

It  is  hard  to  explain  the  late  onset  of  connective-tissue  proliferation 
in  the  cerebro-spinal  axis,  in  the  testis,  and  viscera  on  any  other  ground 
than  that  a  morbid  predisposition  or  impress  has  been  engrafted  on  the 
vessels  and  cells  of  these  parts  in  the  period  of  activity  of  the  infection, 
and  that  later  on,  owing  to  some  stimulation,  injury,  or  perhaps  excess 
of  function,  the  new  cell-growth  is  inaugurated. 

Ignored  Syphilis. 

It  is  not  at  all  uncommon  in  clinics  and  hospitals,  and  also,  though 
less  frequently,  in  private  practice,  to  see  cases  of  tertiary  syphilis  in 


TERTIARY  SYPHILIS.  721 

which  no  history  of  primary  or  secondary  lesions  can  be  obtained,  even 
after  very  rigorous  cross-questioning.  These  cases  are  classed  under 
the  heading  of  "ignored  syphilis"  by  Fournier,^  and  under  that  of 
"syphilis  occulta"  by  Fle'iner.^  As  an  example  of  the  frequency  of 
occurrence  of  ignored  syphilis  it  may  be  mentioned  that  in  a  five 
months'  service  at  the  St.  Louis  Hospital,  Fournier  saw  28  cases,  and 
that  Lassar^  in  200  cases  of  late  syphilis,  in  60  (about  30  per  cent.)  no 
evidence  of  the  early  stages  could  be  obtained. 

Ignored  syphilis  is  observed  in  women  much  more  frequently  than  in 
men,  and  in  ignorant  and  careless  persons  of  the  lower  walks  of  life  it  is 
far  from  uncommon.  Many  women  have  but  the  most  elementary  ideas 
regarding  syphilis,  while  men,  as  a  rule,  are  quite  well  informed  upon  the 
subject.  In  many  women  the  initial  lesion  is  extragenitally  placed,  and 
its  true  nature  and  that  of  its  sequelie  are  never  known  to  them.  Then, 
again,  by  many  women  the  genital  chancre  is  not  seen,  or  it  is  so  insig- 
nificant in  appearance  and  mild  in  character  that  its  gravity  is  not  appre- 
ciated. I  have  seen  several  cases  of  intelligent  physicians  who  had 
undoubted  primary  syphilitic  lesions  on  their  fingers,  and  whom  it  was 
impossible  to  convince  that  they  were  the  victims  of  syphilitic  in- 
fection. The  chancre  in  some  men  is  so  insignificant  and  short-lived 
that  it  is  looked  upon  as  a  chafe  or  as  herpes. 

Owing  to  their  mild  character  and  ephemeral  course  the  early  syphi- 
lides  in  some  cases  pass  unobserved  or  unappreciated.  It  is  very  com- 
mon in  clinics  and  hospitals  to  call  a  patient's  attention  to  a  roseolous 
or  a  papular  syphilide  on  his  or  her  body,  of  which  he  or  she  had  no 
knowledge  or  suspicion. 

Then,  again,  in  many  cases  the  inguinal  adenopathies  may  pass  unob- 
served, or,  if  their  existence  is  known,  the  patient  is  ignorant  of  their 
import.  Mild  primary  and  secondary  syphilis  are  the  usual  unrecog- 
nized forerunners  of  tertiary  syphilis. 

Many  women  and  children  have  syphilis,  and  suffer  severely  from  it, 
yet  they  know  nothing  of  the  nature  of  their  disease.  It  often  happens, 
as  Fournier  very  aptly  says,  that  "  in  Avomen  syphilis  is  the  more  likely 
to  remain  ignored,  since  all  that  is  possible  is  done  to  hide  the  nature  of 
the  disease  from  them.  The  husband  or  the  lover  entreats  the  surgeon 
to  treat  his  victim  without  revealing  to  her  the  cause  of  her  malady  ;  and 
amidst  this  '  conspiracy  of  silence '  she  becomes  cured  of  her  sypkilis 
ignoree.'' 

In  some  cases  for  various  reasons  patients  utterly  deny  having  had 
primary  and  secondary  syphilis. 

Errors  in  diagnosis  on  the  part  of  physicians  not  infrequently  lead 
patients  to  think   that  they  never  had  syphilis. 

It  follows,  therefore,  that  we  shall  constantly  meet  with  cases  of  ter- 
tiary syphilis  in  which  the  lesions  or  symptoms  are  so  strikingly  pathog- 
nomonic that  no  doubts  as  to  their  nature  can  be  entertained,  yet  in 
which  no  evidence  of  early  infection  is  at  all  obtainable. 

With  the  foregoing  facts  in  one's  mind,  it  seems  strange  that  at  this 
late  day  the  old-time  syphilis-d'embl<?e  idea  should  be  entertained  by  any 

'  Gazette  des  Hopitniix,  Ang.  8,  1878. 
'  ^  Deut.  Arch,  fiir  klin.  Med.,  1891,  i>p.  292  et  seq.,  vol.  xlviii. 

3  Berl.  klin.  Wochenschr.,  No.  29,  1892. 
46 


722  •  SYPHILIS. 

one,  yet  here  is  what  Lassar^  says:  "  Syphilis  can  creep  into  the  system 
■without  establishing  itself  in  the  usual  manner  at  the  point  of  entrance. 
An  individual  primary  lesion  under  any  circumstances  means  syphilis, 
but  syphilis  does  not  always  require  a  tangible  initial  focus  to  be  received 
into  the  lymphatic  system.  Every  single  irregular  sexual  intercourse, 
even  in  the  absence  of  a  marked  primary  symptom,  may  become  the 
occasion  of  infection." 

Klotz  ^  advances  the  startling  hypothesis  that  primary  and  secondary 
syphilis  are  caused  by  one  parasite,  and  that  there  is  a  "secondary  par- 
asite, which  is  similar  to  the  bacillus  of  tuberculosis  which  can  indefi- 
nitely remain  in  the  organism  in  a  dormant  condition  until  called  into 
activity  by  some  accidental  irritation.  It  then  produces  the  tertiary 
gummatous  manifestations,  but  not  the  diffuse  chronic  visceral  affections, 
like  tabes,  general  paralysis,  etc.,  which  are  the  result  of  intoxication 
with  the  toxines  of  the  primary  parasite.  The  secondary  micro-organism 
is  inoculable  like  the  bacillus  tuberculosis,  and  produces  lesions  identical 
with  tertiary  syphilis,  but  not  primary  syphilis.  Tertiary  syphilitic  man- 
ifestations may  therefore  be  due  to  direct  inoculation,  without  the  necessity 
of  a  primary  or  secondary  stage." 

Etiology  of  Tertiary  Syphilis. — Long  essays  have  been  written  on  the 
etiology  of  tertiary  syphilis,  but  the  essential  facts  can  be  very  briefly 
stated.  Any  depraved  condition  of  the  system  may  cause  the  secondary 
period  of  syphilis  to  be  prolonged  and  to  be  followed  by  tertiary  mani- 
festations. Then,  agaiti,  the  tissues  of  some  persons  seem  to  be  so  pro- 
foundly affected  by  syphilis  that  the  infection  runs  its  full  course  in 
them.  By  far  the  most  potent  and  frequent  cause  of  tertiary  syphilis  is 
the  absence  or  the  insufficiency  of  treatment.  This  statement  almost 
sums  the  case  up.  Marschalko,^  in  an  exhaustive  study  of  673  cases  of 
tertiary  syphilis,  states  that,  as  a  result  of  good  treatment,  tertiarism  was 
only  found  in  2.7  per  cent.,  whereas  in  badly-treated  cases  it  was  19.3 
per  cent.,  and  under  insufficient  treatment  it  reached  as  large  a  figure  as 
23.9  per  cent. 

The  secretions  and  tissue-detritus  of  precocious  and  quite  early  tertiary 
lesions  contain  infectious  qualities,  while  those  of  very  late  lesions  are 
probably  inert.  We  cannot,  to-day,  say  positively  when  syphilitic 
lesions  lose  their  power  of  infecting  healthy  persons. 

'  Berl.  klin.  Wochenschr.,  1892,  pp.  718  et  seq. 

^  "  On  the  Occurrence  of  Tertiary  Lesions  of  Syphilis  as  the  Eesult  of  Direct  Local 
Infection,  with  general  remarks  on  syphilis  as  an  infectious  disease,"  Journal  of  Cutaneous 
and  Gen.-urin.  Diseases,  July  and  Aug.,  1893. 

^  "  Beitrage  zur  Aetiologie  der  tertiaren  Lues,  etc.,"  Archiv  fiir  Derm,  und  Syph.. 
1894,  pp.  225  et  seq. 


THE  TERTIARY  SYPHILIDES.  723 

CHAPTEE   LXX. 

THE   TERTIARY    SYPHILIDES. 

The  Gummatous  Syphilide. 

This  syphilide  is  almost  invariably  a  late  lesion,  and,  although  usually 
invading  the  skin,  it  always  begins  in  the  subcutaneous  connective  tissue. 
It  consists  of  tubercular  infiltrations,  some  as  small  as  a  pea  and  others 
several  inches  in  diameter.  When  great  extent  of  tissue  is  involved,  the 
lesion  is  usually  composed  of  several  tumors  merged  together.  This  is 
not  always  the  case,  Fournier  having  reported  a  single  tumor  fourteen 
centimetres  in  length,  eight  to  ten  in  breadth,  and  from  two  to  six  in 
thickness.  Unlike  other  syphilides,  in  which  the  specific  neoplasm  is 
diffused,  this  lesion  is  a  true  circumscribed  tumor. 

This  syphilide  is  particularly  prone  to  app,ear  in  parts  where  the  con- 
nective tissue  is  loose  and  abundant.  It  may  be  limited  to  the  connective 
tissue,  but  on  invading  the  skin  it  usually  ulcerates.  In  the  former  case 
we  apply  to  the  syphilide  the  term  gummous  or  gummous  tumor  ;  in  the 
latter  case  we  call  it  a  gummous  ulcer. 

The  progress  of  the  lesion  varies  according  to  the  condition  of  the  parts 
upon  Avhich  it  is  developed ;  in  thick  and  copious  adipose  or  cellular  tissue 
the  tumors  may  remain  a  long  time  without  attacking  the  skin ;  under 
contrary  conditions  or  above  a  bony  surface  implication  of  the- skin  is 
■early  and  the  bone  itself  may  be  eroded  superficially  or  deeply.  Some- 
times the  muscles  are  exposed  by  complete  destruction  of  superjacent 
tissues.  Blood-vessels,  nerves,  and  sometimes  bursse  may  be  involved  by 
extension  of  the  lesion. 

We  shall  study  this  syphilide  in  its  three  stages — of  tumefaction,  of 
ulceration,  and  of  repair.  (For  the  description  of  precocious  gummata 
see  page  642.) 

In  the  first  stage  we  find  from  one  to  six  small  tumors,  which  appear 
simultaneously  or  in  succession  and  run  an  indolent  course.  In  excep- 
tional cases,  when  the  eruption  appears  during  the  early  years  of  syphilis, 
the  tumors  may  be  numerous,  their  invasion  quite  rapid,  and  the  attend- 
ant local  and  general  symptoms  well  marked.  Cases  have  been  reported 
in  which  there  were  twenty,  thirty,  and  even  forty  tumors,  and  Lisfranc 
has  recorded  one  instance  in  which  there  were  one  hundred  and  sixty. 
When  they  appear  early  they  are,  as  a  rule,  numerous  and  symmetrical ; 
when  occurring  later  the  reverse  is  true. 

These  small  tumors  are  painless  and  attended  by  slight  tenderness. 
Their  growth  is  generally  slow.  At  first  they  are  freely  movable ;  they 
soon  become  attached  to  the  surrounding  tissues,  especially  when  seated 
over  bony  surfaces  or  in  regions  where  the  connective  tissue  is  scanty. 
They  give  to  the  finger  a  sensation  of  moderate  firmness,  retaining  their 
shape  under  pressure,  having  neither  the  elasticity  of  a  fatty  tumor  nor 
the  hardness  of  scirrhus.  In  many  cases  they  tend  to  invade  the  skin 
rather  than  the  deeper  tissues.  Their  superficial  growth  is  first  shown  by 
slight  reddening  of  the  overlying  skin,  which  rapidly  becomes  thickened 
and  less  supple.     Finally,  we  observe  a  tubercular  infiltration,  round  or 


724  SYPHILIS. 

oval  in  shape,  perhaps  slightly  elevated,  of  a  deep  coppery-red  color,  and 
surrounded  by  a  well-marked  hypersemic  areola.  They  may  remain  in 
this  condition  for  many  weeks,  or  even  months,  and,  still  under  treatment, 
undergo  resolution.  Generally,  however,  their  firm  structure  slowly 
breaks  down,  until  finally  fluctuation  may  be  detected.  In  many  cases 
the  soft,  yielding  character  of  the  tumor  gives  a  false  impression  that  pus 
is  confined  beneath  the  skin.  On  incision  of  such  a  tumor  a  small 
quantity  of  thick,  bloody  fluid  escapes  and  a  soft  mass  is  found,  but  no 
cavity  like  that  of  an  abscess.  In  case  of  true  fluctuation,  however,  there 
is  an  actual  cavity  containing  fluid  resulting  from  disintegration  of  the 
tumor.  Surgical  interference  is,  however,  seldom  required.  The  cavity, 
in  most  cases,  opens  spontaneously,  either  like  a  furuncle  by  a  single 
aperture  or  by  ulceration  at  several  distinct  points. 

The  minute  changes  leading  to  this  condition  are  of  interest.  The 
immediate  product  of  the  death  of  the  subcutaneous  neoplasm  is  a  thick, 
gummy  mass,  the  intermingled  pus  being  supplied  by  the  surrounding 
parts,  which  are  secondarily  inflamed.  The  destructive  process  goes  on 
very  slowly  until  after  the  occurrence  of  ulceration.  The  small  ulcers 
first  formed  are  deep  and  sharply  cut ;  they  extend  in  all  directions,  until 
the  destruction  of  the  entire  neoplasm  results  in  the  formation  of  what 
may  be  called  a  typical  gummous  ulcer.  Such  an  ulcer  is  either  round, 
oval,  or  gyrate  from  fusion  of  the  small  ones,  and  sharply  cut  as  if  punched 
out.  Its  floor,  which  is  greenish-red  or  sometimes  greenish-black,  is  uneven 
and  bathed  with  sanious  fetid  pus.  The  edges  of  the  ulcer  are  thickened, 
and  around  them  is  generally  an  extensive  areola  of  hyperjemia,  which 
may  be  so  persistent  as  to  give  the  impression  that  it  also  is  the  seat  of 
gummatous  infiltration. 

The  course  of  such  ulcers  varies  with  the  care  they  receive.  Some- 
times they  take  on  phagedenic  action,  invading  extensive  surfaces  and 
causing  profound  or  even  fatal  cachexia.  They  may  remain  in  an  indo- 
lent condition  for  months,  discharging  a  foul  secretion,  showing  no  repar- 
ative tendency,  and  inducing  great  oedema  of  surrounding  parts.  Groups 
of  ulcers  may  be  found  connected  by  narrow  bands  of  reddened  and 
detached  skin,  whose  nutrition  is  but  feebly  sustained  by  the  superficial 
vessels ;  hence,  these  bands  soon  melt  away  and  expose  the  subjacent, 
ulcerating  surface. 

The  depth  of  the  ulcers  depends  largely  upon  the  thickness  of  the 
original  infiltration.  In  some  cases  the  gummy  deposit  is  confined  to  the 
cellular  tissue  just  below  the  papillary  layer  of  the  skin,  and  the  resulting 
ulcer  is  relatively  shallow.  In  other  cases  it  is  more  deeply  seated  below 
the  derma,  and  may  be  exposed  by  scraping  ofi"  the  upper  layers. 

In  its  early  stage  the  tissue  of  the  gumma  is  of  a  reddish-yellow  color 
and  has  a  soft  consistence ;  at  a  later  period  it  looks  dry,  firm,  grayish- 
red,  and  non-vascular.  The  changes  in  its  appearance  are  largely  due  to 
gradual  compression  and  obliteration  of  the  blood-vessels.  Repair  can 
never  take  place  until  complete  removal  of  this  tissue,  which  must  be 
hastened  by  local  as  well  as  general  treatment.  The  progress  toward 
cure  is  especially  slow  where  the  surface  of  muscles  has  been  exposed  and 
when  the  destructive  action  has  extended  even  to  the  tissues  of  the  inter- 
muscular septa. 

Under  treatment  the  foul  surface  of  the  ulcer  is  supplanted  by  granu- 


THE  TERTIARY  SYPHILIDES. 


725 


lations  which  eventually  cicatrize.  Sometimes  these  granulations  become 
exuberant  and  rise  above  the  normal  level.  As  the  ulcer  heals  the  sur- 
rounding redness,  which  on  the  legs  may  be  of  a  purple  tint,  gradually 
diminishes,  and,  when  the  cicatrix  is  formed,  there  remains  a  dull  coppery 
areola  which  may  persist  for  many  years. 

The  cicatrices  of  gummous  ulcers  diifer  according  to  the  depth  of  the 
destructive  process.  When  the  ulceration  has  been  superficial  the  scars 
are  slightly  depressed,  thin,  parchment-like,  and  of  a  dead-white  color. 
All  such  cicatrices  become  blanched  from  their  centre  outward. 

The  cicatrices  of  deep  ulcers  are  much  depressed,  and  often  very  un- 
even, oAving  to  fibrous  bands  and  nodules.  Some  are  also  peculiar  in 
being  adherent  to  the  deeper  parts.  In  case  the  gummous  ulceration  has 
involved  the  superficial  portion  of  the  bone,  the  cicatrix  adheres  as  firmly 

Fig.  213. 


Gummatous  infiltration  over  the  wrist  and  dorsum  of  tlie  hand. 


as  did  the  periosteum  to  the  osseous  surface.  In  other  cases  where  much 
destruction  of  bone  has  occurred  no  cicatrix  at  all  is  formed,  the  eroded 
surface  being  surrounded  by  a  firmly-attached  fibrous  band  which  repre- 
sents the  margin  of  what  might  have  been  a  cicatrix. 

This  syphilide  may  appear  on  the  scalp,  on  the  face,  particularly  about 
the  mouth  and  nose,  and  also  on  the  neck.  It  attacks  the  extremities, 
generally  near  the  joints  (see  Fig.  213),  and  those  parts  where  the  integu- 
ment is  soft  and  the  connective  tissue  abundant ;  the  palms  and  soles 
therefore  escape.  It  invades  the  back  oftener  than  the  anterior  aspect  of 
the  trunk,  and  is  seldom  seen  on  the  lower  part  of  the  abdomen. 

Gummy  tumors  present  certain  peculiarities  in  different  regions  of  the 
body,  and  may  be  complicated  by  intercurrent  morbid  processes.  Erysip- 
elas may  attack  the  ulcers,  especially  when  seated  on  the  head  or  extrem- 
ities. The  oedema  which  accompanies  gummous  ulcers  of  the  leg  may  be 
so  severe  and  chronic  as  to  induce  a  condition  similar  to  elephantiasis 
Arabum.  Again,  in  various  parts  of  the  body  the  appearance  of  the 
ulcers  may  be  totally  changed  by  a  serpiginous  or  phagedenic  process. 

Gummy  tumors  of  the  scalp  are  seldom  isolated  and  movable ;  usually 
the  entire  integument  is  thickened,  and,  although  at  first  movable  over 


726  SYPHILIS. 

the  bones,  soon  becomes  adherent.  Small  ulcers  form  at  follicular  open- 
ings, and  gradually  increase  in  size.  Sometimes  the  outer  table  of  the 
skull  is  destroyed,  and  in  other  cases  the  whole  thickness  of  bone  becomes 
necrosed ;  the  dura  mater,  however,  resists  the  destructive  action  in  a 
remarkable  manner,  and  is  rarely  involved.  The  scalp  over  the  frontal 
and  parietal  bones  is  most  commonly  attacked,  and  not  infrequently  the 
forehead,  chiefly  toward  the  median  line,  is  invaded.  The  secretions  from 
ulcers  occurring  in  the  latter  situation  sometimes  accumulate  between  the 
bone  and  the  integument,  and  produce  much  swelling  in  the  supraorbital 
regions.  The  eyes  may  become  closed  by  swelling  of  the  lids  caused  in  a 
similar  way.  A  more  serious  complication  of  these  ulcers  of  the  scalp  is 
erysipelas,  which  in  some  instances,  as  already  stated,  may  excite  repara- 
tive action. 

Upon  the  face  we  find  both  the  movable,  subcutaneous  tumor  and  the 
infiltration  which  involves  the  deeper  layers  of  the  skin.  Such  swellings, 
being  discovered  here  earlier  than  in  other  regions,  usually  receive  treat- 
ment soon  enough  to  prevent  their  reaching  an  extraordinary  size.  In 
neglected  cases,  however,  the  infiltration  may  be  very  extensive.  Caze- 
nave  has  reported  an  instance  in  which  the  face  was  so  distorted  as  to  be 
unrecognizable,  having  a  leonine  expression  as  in  elephantiasis  Grsecorum. 
Bidon^  calls  this  condition  diffuse  hypertrophic  syphiloma  of  the  face,  in 
preference  to  the  term  leontiasis  syphilitique  proposed  by  Goutard.^  This 
syphilide  is  dangerous  by  reason  of  the  sclerotic  and  cicatricial  conditions 
which  it  may  leave.  I  have  seen  a  case  in  which  the  nose,  lips,  and  chin 
were  excessively  hypertrophied.  The  peculiarities  of  this  syphilide  in  the 
stage  of  tumefaction  are  similar  here  and  elsewhere,  except  that  about  the 
lips  and  nose  it  sometimes  has  a  cartilaginous  hardness.  Gummata  of  the 
lips  have  been  carefully  described  by  Tuffier,'  who  in  an  extended  study 
found  that  true  gummata  and  a  resulting  sclerosis  are  the  most  common 
late  lesions  of  these  parts.  The  gummata  are  nodular  and  lumpy,  and 
movable  in  the  upper  lip,  and  are  found  in  the  form  of  plates  m  the 
lower  lip.  In  these  cases  a  mistake  for  cancer  is  liable  to  be  made.  Can- 
cer begins  superficially  in  a  crack  or  little  lump.  These  labial  syphilides 
distort  the  countenance  very  much.  Hypersemia  is  soon  seen,  and  the 
progress  toward  ulceration  is  quite  rapid.  The  resulting  ulcer  has  the 
peculiarities  of  similar  syphilitic  lesions  in  other  regions.  The  crusts, 
which  frequently  form,  have  a  greenish-black  color.  About  the  nose 
much  destruction  is  often  produced,  either  limited  to  the  skin  or  involving 
the  cartilage  and  the  bones.  Erysipelas  may  complicate  gummous  ulcers 
of  this  region,  and  in  rare  cases  phagedena,  which  has  been  known  to 
destroy  the  greater  part  of  the  face. 

The  gummatous  syphilide  of  the  arms  and  forearms  is  not  especially 
peculiar,  but  in  most  cases,  when  it  is  seated  over  nerves,  severe  neural- 
gias are  produced.  In  somewhat  rare  cases  gummy  deposits  in  the  fingers 
produce  a  swelling  resembling  that  occurring  in  a  specific  lesion  called 
dactylitis.  Although  prone  to  appear  near  the  joints,  this  syphilide  seldom 
invades  the  articulations  themselves.  In  one  case,  however,  a  gummous 
tumor  over  the  sterno-clavicular  articulation  ulcerated,  destroyed  the  joint, 

1  I^ase  rfe  Pam,  ]  886.  '■'76(^,1878. 

^  "  Gonimes  et  Scleroses  syphilitiques  des  Levres  (Labialites  tertiaires),"  Rev.  de  Chir., 
vol.  vi.,  1886,  pp.  777  et  seq. 


THE  TERTIARY  SYPHILIDES.  727 

and  perforated  the  lung,  death  resulting.  In  another  case  a  gumma  the 
size  of  a  hen's  egg  was  developed  in  an  intercostal  space,  eroded  the  bone, 
and  perforated  the  pleura.  The  liability  to  this  accident  in  the  case  of 
gummata  situated  on  the  side  of  the  thorax  should  lead  to  the  adoption 
of  very  vigorous  treatment. 

Gummata  are  very  important  clinically,  for  they  are  so  frequently  mis- 
taken for  sarcomatous  tumors  and  removed  with  the  knife.  Von  Langen- 
beck  ^  reports  the  case  of  a  man  having  a  tumor  of  the  size  of  the  fist  on 
the  scapula,  Avhich  had  been  diagnosticated  as  a  lipoma,  and  was  sent  to 
him  for  operation.  It  disappeared  under  specific  treatment.  He  also 
speaks  of  a  case  of  a  tumor  of  the  size  of  a  pigeon's  egg  seated  in  the 
internal  border  of  the  sterno-mastoid  muscle,  which  was  extirpated,  and 
was  later  on  followed  by  gummata  of  the  pharynx,  tongue,  and  cheek. 
Von  Langenbeck  himself  removed  a  tumor  of  the  size  of  a  goose's  egg 
from  the  groin,  where  it  had  contracted  adhesions  with  the  large  vessels. 
The  patient  died,  and  the  microscope  showed  that  the  neoplasm  was  a 
gumma. 

Von  Langenbeck  also  speaks  of  a  case  of  sublingual  tumor  which  was 
a  gumma,  but  diagnosticated  as  carcinoma.  Also  two  cases — the  one  a 
gummy  tumor  of  the  tongue,  and  a  similar  tumor  over  the  biceps  muscle — 
which,  after  the  diagnosis  of  cancer  had  been  made,  were  dissipated  by 
specific  treatment. 

These  facts  should  be  kept  prominently  in  mind  by  surgeons. 

As  showing  the  size  and  extent  of  some  gummy  tumors  the  case  of 
De  Amicis^  is  very  interesting.  It  was  that  of  a  man  fifty-eight  years 
old  who  had  been  syphilitic  twenty-three  years.  In  nine  months  this 
tumor  extended  from  the  axillary  line  to  the  spine,  and  was  23  centimetres 
long,  21  wide,  and  10  in  thickness.  This  mass  was  composed  of  round 
and  oval  nodosities,  not  painful  even  on  pressure,  which  were  movable 
over  the  ribs  and  covered  with  a  partly  adherent  integument  which  Avas 
ulcerated  in  one  spot.  This  tumor  disappeared  in  two  and  a  half  months 
under  the  influence  of  specific  treatment.  Ferrara^  also  records  an  inter- 
esting case  by  reason  of  the  seat  of  the  lesion.  It  was  a  tumor  of  the 
size  of  a  pigeon's  egg,  and  seated  in  the  abdominal  wall.  This  lesion 
developed  very  slowly,  but  disappeared  rapidly  under  treatment. 

Gummata  not  infrequently  form  in  the  female  breast,  less  commonly 
in  both  breasts.  The  importance  of  their  diagnosis  is  here  very  great ; 
failure  to  recognize  their  true  character  may  lead  to  unnecessary  surgical 
interference.  They  appear,  as  elsewhere,  slowly ;  they  are  only  mode- 
rately hard,  and  are  painless.  There  is  no  retraction  of  the  nipple,  and 
the  axillary  glands  are  unaffected.  The  ulceration  which  occurs  is  charac- 
teristic and  quite  unlike  the  indurated,  fungoid  ulceration  of  cancer.  In 
all  cases  of  limited  tumors  of  the  breast  a  suspicion  of  their  gummatous 
character  should  be  entertained,  especially  when  the  patient  is  young  or 
of  middle  age.  A  mistake  is  liable  to  occur  only  when  the  gumma  is  vei'y 
large  and  of  unusual  depth. 

The  cellular  tissue  of  the  buttocks  being  very  copious,  gummata  of  the 
gluteal   regions   often   attain   remarkable  size  and   depth.      I   have  seen 

^  "  Ueber  Gurami  Geschwiilste  (granulome  sypliilome),"  Arch,  fur  kiln.  Chir.,  vol.  xxvi., 
1881,  pp.  265  et  seq. 

^  //  Mor(jagni,  April,  1890.  ^  La  Medicina  contemporanea,  June,  1887. 


728  SYPHILIS. 

several  instances  in  which,  the  sharply-cut  walls  of  the  ulcer  led  down  to 
a  base  four  inches  from  the  surface  of  the  skin.  The  genitals  and  thighs 
are  very  apt  to  be  attacked  by  these  tumors,  which,  upon  the  penis,  scro- 
tum, and  labia  majora,  are  often  almost  ligneous  in  consistence.  The 
perineum  is  sometimes  the  seat  of  circumscribed  gummy  deposit.  I  have 
seen  one  case  in  which  urethral  fistula  resulted  from  ulceration  of  a  gumma 
in  this  region. 

Little  need  be  said  of  gummy  tumors  of  the  thighs  beyond  the  fact 
that  they  are  often  of  very  large  size.  When  they  occur  on  the  legs  the 
question  of  diagnosis  is  particularly  interesting.  The  ulcerating  gummy 
tumor  is  usually  seen  on  the  upper  and  middle  thirds  of  the  leg,  and 
where  the  connective  tissue  is  abundant,  differing  markedly  from  simple 
ulcers,  which  most  commonly  form  on  the  lower  third  and  over  a  bony 
surface.  They  may  appear  lower  down,  but  usually  where  the  tissues  are 
lax,  and  seldom  over  a  bony  surface.  They  are  often  multiple,  but  more 
than  eight  are  rarely  observed.  They  select  the  sides  of  the  leg  rather 
than  the  posterior  aspect.  They  are  always  surrounded  by  intense  hyper- 
£emia,  and  frequently,  late  in  their  course,  they  resemble  non-specific 
ulcers,  especially  the  varicose.  Their  edges  become  rounded  and  callous, 
and  their  surface  is  studded  with  granulations,  thus  losing  their  charac- 
teristic features. 

Gummata  may  be  situated  in  almost  any  region  over  a  nerve,  and  may 
then  cause  pain.  Ricord  reports  one  case  in  which  a  gumma  of  the  size 
of  a  chestnut,  seated  in  the  groin,  caused  pain  in  the  crural  nerve,  and 
another  in  which  two  such  tumors,  seated  in  the  course  of  the  ulnar  nerve, 
provoked  severe  pain  in  the  forearm  and  in  the  two  inner  fingers.  Nela- 
ton  reports  two  cases  :  in  one  a  gumma  of  the  axilla,  besides  causing 
neuralgia  in  the  whole  arm  and  shoulder,  produced  by  compression  a 
souffle  in  the  axillary  artery,  venous  stasis,  and  oedema  of  the  extremity. 
The  tumor  speedily  subsided  under  the  use  of  iodide  of  potash.  The 
second  case  was  that  of  a  lady  who  had  consulted  several  physicians  on 
account  of  pain  in  the  foot,  which  was  found  by  N^laton  to  be  caused  by 
a  gumma  compressing  the  plantar  nerves.  In  a  case  seen  by  Fournier 
two  gummata  were  found,  one  upon  the  median  and  the  other  upon  the 
radial  nerve,  each  of  which  was  the  cause  of  pain,  numbness,  and  muscu- 
lar weakness.  In  another  case,  seen  by  the  same  author,  a  small  gumma 
over  the  track  of  the  supraorbital  nerve  gave  rise  to  considerable  pain. 

The  extensive  hyperaemia  which  usually  accompanies  these  ulcers  of 
the  leg  is  the  cause  of  localized  oedema.  In  very  chronic  and  extensive 
ulceration  the  oedema  begins  about  the  ankle  and  involves  a  portion  or 
the  whole  of  the  leg,  which  becomes  swollen,  hard,  and  brawny,  the  in- 
tegument above  the  ankle  being  thrown  into  the  folds.  This  condition, 
which  is  very  obstinate  and  altogether  resists  internal  treatment,  resem- 
bles elephantiasis  Arabum.  When  their  edges  become  thickened  and 
callous  these  ulcers  do  not  extend  rapidly,  but  persist  for  many  years. 
Their  base  is  covered  by  a  layer  of  greenish-black  slough,  and  from  it 
exudes  a  thin,  fetid,  bloody  secretion. 

Phagedena  is  happily  an  infrequent  complication  of  this  syphilide. 
In  broken-down  subjects  the  ulceration  rapidly  destroys  the  skin  and  sub- 
jacent tissues,  sometimes  even  denuding  the  bones.  The  process  is 
extremely  painful,  and  is  attended  by  constitutional  reaction,  which  some- 


THE  TERTIARY  SYPHILIDES.  729 

times  reaches  a  typhoid  condition.  The  parts  most  subject  to  this  com- 
plication are  the  face,  feet,  and  genitals.  Unless  pi-omptly  checked  there 
may  be  great  destruction  of  tissue. 

This  syphilide  may  appear  within  the  first  year  of  syphilis,  but  it  is 
generally  a  late  symptom,  appearing  at  any  time  from  the  third  to  the 
fifteenth  or  twentieth  year.  Fournier  reports  a  case  of  gummy  tumor  of 
large  size  which  was  developed  fifty  years  after  infection,  and  was  cured 
by  iodide  of  potash. 

The  prognosis  is  influenced  by  the  date  of  the  appearance  of  the  syphi- 
lide, its  extent,  and  the  general  condition  of  the  patient.  Its  early  and 
malignant  appearance  indicates  an  active  and  severe  form  of  syphilis,  in 
which  visceral  gummata  are  to  be  feared-  Although  only  one  or  two 
gummous  tumors  or  ulcers  may  be  present  and  the  general  health  is  not 
much  affected,  thorough  internal  treatment  is  none  the  less  necessary. 

The  diagnosis  is  to  be  made  in  its  stages  of  tumefaction  and  of  ulcera- 
tion. When  it  exists  as  a  movable,  subcutaneous  tumor,  it  may  be  mis- 
taken for  a  fibrous,  a  sarcomatous,  or  a  fatty  tumor,  or  perhaps  an 
enlarged  ganglion.  The  syphilitic  lesion  is  usually  multiple,  and  is  not 
compressible  like  the  fatty  tumor  nor  as  hard  as  the  sarcoma.  Sarcomata 
tend  to  attach  themselves  to  subjacent  parts  ;  the  gummy  tumors  invade 
the  skin.  The  history  of  the  case,  the  absence  of  pain  in  the  tumor,  and 
its  situation  may  be  of  assistance.  Tumor-like  infiltrations  upon  the  face, 
in  the  female  breast,  about  the  genitals,  near  joints,  and  wherever  con- 
nective tissue  is  abundant  should  always,  in  case  of  doubt,  be  subjected 
to  specific  treatment.  Numerous  cases  have  occurred,  particularly  with 
French  surgeons,  in  which  mixed  treatment  has  dissipated  tumors  con- 
demned to  excision. 

The  general  appearance,  situation,  and  history  of  gummatous  ulcers 
are  generally  sufficient  to  establish  their  character ;  but  sometimes,  espe- 
cially on  the  face  and  lower  extremities,  they  may  be  confounded  with 
ulcerating  lupus  or  with  simple  eczematous  or  varicose  ulcers.  Lupus 
begins  as  small  tubercles  of  the  skin,  which  slowly  ulcerate  and  become 
partially  incrusted,  and  it  extends  by  the  formation  of  new  tubercles, 
which  in  turn  ulcerate.  Lupus  usually  begins  in  early  life  and  on  the 
nose. 

Eczematous  ulcers  are  always  preceded  by  eczema  of  the  skin,  which 
lies  tense  over  a  bony  surface.  They  are  painful,  superficial,  always 
accompanied  by  a  good  deal  of  inflammation,  and  are  seated,  as  a  rule, 
on  the  lower  third  of  the  leg.  Similar  general  features  are  observed 
in  varicose  ulcers,  together  with  enlarged  veins  and  more  or  less  oedema. 

Subcutaneous  nodular  infiltrations  which  resemble  in  nearly  all  their 
features  gummata  are  sometimes  seen,  particularly  in  weakly  and  so-called 
strumous  subjects.  These  nodules,  called  erytheme  indure  des  scrofuleux 
by  Bazin,  and  gommes  scrofuleuses  by  Besnier,^  may  be  of  the  size  of  a 
pea  or  of  a  hazelnut  or  walnut,  and  they  may  exist  in  the  form  of  diff"use 
plaques.  They  run  a  chronic  course,  they  contract  adhesions  Avith  the 
skin,  and  they  may  lead  to  ulceration.  In  all  particulars  these  lesions  as 
to  physical  appearances,  site  of  development,  and  course  resemble  syph- 
ilitic gummata.      They   occur   most   frequently  in   young    subjects,   and 

'  Annales  de  Derm,  et  de  Syph.,  1883,  pp.  257  et  seq.  See  also  an  essay  by  T.  Colcott 
Fox,  British  Journal  of  Dermatologi/,  Aug.  and  Oct.,  1893. 


730 


SYPHILIS. 


rather  rarely  in    older  persons.     They  are  influenced  by  antisyphilitic 
treatment.     In  these  cases  no  history  of  syphilis  can  be  obtained. 


The  Tubercular  Syphilide. 

Fig.  214.  This  syphilide  consists  of  deeply-seated, 

circumscribed  infiltrations  into  the  skin, 
resembling  in  appearance  the  large,  flat, 
papular  syphilide,  and  being,  in  reality, 
nothing  more  than  an  exago-erated  form 
of  the  latter  lesion.  The  -whole  thickness 
of  the  skin  is  involved,  whereas  in  the  pap- 
ular syphilide  the  deeper  layers  escape; 
the  latter  is  a  secondary  manifestation, 
■while  the  tubercular  syphilide  is  a  tertiary 
lesion. 

The  tubercular  syphilide  seldom  ulcer- 
ates, but  disappears  by  interstitial  absorp- 
tion ;  hence  it  has  been  called  non-uleerative 
or  resolutive. 

The  resolutive  tubercular  syphilide  may 
appear  even  before  the  second  year  of 
syphilis  ;  it  is  usually  developed  between 
the  third  and  sixth  years,  but  may  be 
seen  as  late  as  the  eighth  or  tenth  year, 
and,  according  to  some  authors,  even  as 
late  as  the  fifteenth  or  twentieth.  It  is 
usually  met  with  in  cases  that  have  not 
been  thoroughly  treated  at  the  outset.  Its 
course  is  very  chronic  and  marked  by 
numerous  relapses,  many  years  passing 
while  it  travels  over  the  body.  It  causes 
no  pain,  heat,  or  itching,  but  merely  pro- 
duces thickening  of  the  skin.  AVhen  it 
appears  early  it  may  form  a  general  and 
copious  eruption  (see  Fig.  214),  but  later 
the  tubercles  may  be  limited  in  number 
and  confined  to  a  single  region. 

The  tubercles  begin  as  deep-red  spots, 
which  slowly  increase  in  size  and  thickness 
until,  when  fully  developed,  they  have  a 
diameter  of  from  half  an  inch  to  an  inch. 
Sometimes  they  are  as  small  as  a  split  pea, 
and  again  they  are  more  than  an  inch  in 
diameter.  Their  surface  is  flat  or  rounded, 
and  their  borders  are  sharply  defined.  The 
smaller  lesions  are  more  elevated  and 
rounder  than  the  larger.  Upon  the  face 
they  often  have  a  shining  appearance,  and 
on  parts  where  the  epidermis  is  thick  and  rough  they  look  dull  and  dry. 
The  color  of  the  tubercles  is  at  first  dark-red,  with  possibly  a  tinge  of 


Early  generalized  and  copious  tuber- 
cular syphilide. 


TRE  TERTIARY-  SYPHILIDES.  731 

crimson,  but  frequently  it  is  of  a  light  pinkish  red.  Their  surface  is 
usually  quite  smooth  and  free  from  scales,  but  sometimes  a  layer  of  small 
size  and  quite  adherent  is  seen.  Where  the  epidermis  is  thick  the  pro- 
liferation is  occasionally  free,  giving  the  tubercles  some-what  the  appear- 
ance of  psoriasis. 

The  tubercles  first  appear  on  the  forehead  or  back  of  the  neck  near 
the  scapulae.  They  may  be  limited  to  these  regions  or  may  invade  the 
trunk,  always  more  copiously  on  the  back  and  over  the  gluteal  regions. 
In  front  they  are  generally  scattered,  but  in  some  cases  they  occur  in  large 
numbers  over  the  sternal  region,  on  the  borders  of  the  axillie,  and  over 
the  deltoid  muscle.  They  are  more  copious  on  the  outer  aspects  of  the 
extremities  near  the  joints  than  on  the  inner.  The  backs  of  the  hands 
and  feet  may  be  spared,  but  tubercles  are  sometimes  developed  on  the 
palms  and  soles,  and  soon  pass  into  a  scaling  condition. 

The  course  of  the  eruption  is  very  slow  ;  several  weeks  or  even  months 
and  years  may  pass  before  the  entire  body  is  covered.  When  the  eruption 
is  general  the  tubercles  are  usually  disseminated  without  order,  rarely 
showing  a  tendency  to  circular  distribution.  Fresh  crops  often  fill  the 
interspaces  of  those  first  developed.  When  precocious  the  eruption  may 
be  very  copious.  In  several  of  the  cases  I  have  seen  of  recurrence  of 
this  eruption  the  tubercles  were  almost  in  contact  with  each  other.  Such 
cases  are  rare,  and  belong  to  the  group  of  malignant  precocious  syphilides. 

An  eruption  of  tubercles  is  likely  to  be  general  when  occurring  within 
two  years  after  infection  and  in  those  who  suffer  from  a  severe  form  of 
syphilis  or  who  have  been  improperly  treated  during  the  eai'ly  months. 
Far  more  commonly  several  regions  are  successively  invaded. 

These  tubercles  are  prone  to  appear  in  an  irregularly  triangular  group, 
with  the  apex  at  the  glabella  and  the  base  near  the  margin  of  the  scalp. 
They  may  form  a  sort  of  corona  in  the  latter  regions,  Avith  sometimes  a 
number  on  the  scalp  itself.  On  the  face  they  sometimes  run  together  and 
form  patches.  Again,  several  tubercles  on  the  nose  blend  together  and 
extend  to  the  cheeks,  forming  a  butterfly-shaped  patch.  When  the 
tubercles  spread  in  a  rapid  manner,  a  distinctly  elevated  margin  or  rim 
is  formed,  the  enclosed  patch  being  depressed.  In  this  serpiginous  form  the 
whole  face  may  become  invaded.  The  centre  of  the  patch  gradually  loses 
its  color  and  becomes  thinner,  until  in  bad  cases  a  cicatricial  tissue  is  left. 
This  process  is  usually  rapid,  and  then  slight  destruction  of  the  skin 
results ;  when  it  is  slow  more  or  less  atrophy  of  the  skin  is  produced. 
In  one  of  my  cases,  in  which  resolution  was  rather  rapid,  the  patient's 
face  was  covered  by  tubercular  rings,  which  merged  together,  the  enclosed 
spaces  being  normal.  Some  authors  call  this  the  serpiginous  tubercular 
syphilide^  but  I  prefer  to  reserve  that  name  for  an  eruption  which  is 
serpiginous  by  ulceration.  This  may  very  properly  be  called  the  annular 
tubercular  syphilide.     (See  Fig.  215.) 

These  tubercular  rings  are  not  seen  in  all  cases ;  in  some  the  lesion 
extends  merely  at  certain  portions  of  its  margin.  Thus,  kidney-shaped 
growths  are  produced,  or  new  tubercles  may  form  and  finally  coalesce 
around  the  entire  periphery  of  the  patch.  Tubercular  patches  seated  on 
non-hairy  parts  are  smooth,  while  those  developed  in  regions  supplied 
with  hair  are  often  uneven  and  warty.  The  latter  condition  is  due  to 
fusion  of   the   tubercles   and   excessive   prominence  of  the   follicles    and 


732 


SYPHILIS. 


papillae.  Their  surface  may  be  covered  with  a  crust  of  serum  and  epi- 
dermis, or  the  scanty  pus  may  dry  between  the  numerous  elevations. 
Cases  of  invasion  of  the  entire  scalp  in  this  way  have  been  recorded,  and 
doubtless  many  of  the  cases  of  framboesia  of  the  old  writers  were  nothing 
more  than  aggravated  instances  of  this  vegetating  or  papillomatous  tuber- 
cular syphilide.  It  has  been  stated  that  the  papular  syphilide  may 
undergo  a  similar  metamorphosis.  AYe  have,  therefore,  two  kinds  of 
sypldlide  vegefante  or  papillomateuse,  which  differ  merely  in  degree — a 

Fig.  215. 


Annular  tubercular  syphilide. 

papular  and  tubercular.  The  head  and  face  are  most  commonly  attacked, 
but  the  trunk  about  the  shoulders,  over  the  sternum,  and  in  the  inguinal 
and  gluteal  regions  may  be  invaded.  When  this  syphilide  is  thus  altered 
in  character  its  course  is  even  more  chronic  than  usual.  The  papilloma- 
tous or  vegetating  appearance  of  this  form  of  tubercular  syphilide  is  due 
to  the  exuberant  new  cell-growth  in  the  papillae,  Avhich  become  greatly 
hypertrophied.     (See  Fig.  216.) 

Several  peculiar  features  are  presented  by  this  syphilide  when  occur- 
ring on  the  face.  In  some  instances  a  thin  yellow  crust.  Avhich  is  quite 
adherent,  covers  the  smooth,  shining  surface  of  the  tubercles.  This  may 
be  so  thick  as  to  be  mistaken  for  pus  resulting  from  ulceration.  In  very 
chronic  cases  it  may  form  a  rim  around  the  margin  of  the  tubercle,  the 
enclosed  surface  being  quite  scaly.  The  skin  generally  retains  its  supple- 
ness, although  its  entire  thickness  is  involved  by  the  infiltration ;  but  in 
some  cases,  especially  about  the  nose  and  on  the  lips,  it  becomes  as 


THE  TERTIARY  SYPHILIDES. 


733 


hard  and  unyielding  as  cartilage.  Much  annoyance  is  caused  by  the  im- 
mobility of  the  parts  and  by  the  hideous  deformity  which  often  results. 
In  extreme  cases  the  skin  of  the  entire  face  may  become  thus  aifected. 
Although  a  severe  lesion  and  often  very  rebellious,  the  effect  of  proper 
treatment  in  causing  absorption  of  the  infiltration  and  in  restoring  the 
natural  softness  of  the  parts  is  frequently  astonishing.     Where  this  com- 

FiG.  216. 


The  late  variety  of  the  vegetating  syphilide,  showing  its  annular  form  and  its  serpiginous 

tendency. 

plication  has  existed  for  a  long  time  the  efi'ect  of  medicine  may  be  less 
rapid. 

These  tubercles,  especially  on  the  face,  and  exceptionally  elsewhere 
wherever  the  integument  is  soft  and  thin,  sometimes  undergo  colloid 
degeneration.  When  this  occurs  the  color  of  the  tubercle  slowly  changes 
to  a  dull  brown,  the  lesion  becomes  less  resistant,  and  on  incision  a  soft, 
gluey,  non-diffluent  mass  is  revealed.  Such  a  tubercle  is  rather  more  ele- 
vated than  others,  and  appears  as  if  infiltrated  with  glue.  This  condition 
is  most  frequently  seen  on  the  forehead.  Usually  these  colloid  tubercles 
slowly  subside  by  absorption  of  the  cells,  leaving  a  depressed  cicatrix. 

Next  in  frequency  to  the  face,  the  shoulders  and  forearms  are  the 
parts  attacked  by  the  tubercular  syphilide.  Sometimes  these  parts  are 
primarily  invaded. 

In  the  early  years  of  syphilis  the  tubercles  are  usually  disseminated 
over  the  body,  but  at  later  periods  successive  groups  appear  at  long  inter- 
vals in  different  regions.  The  eruption  may  thus  continue  for  many  years, 
the  general  health  deteriorates,  and  visceral  lesions  may  be  developed. 
Not  infrequently  this  syphilide  becomes  localized  about  the  buttocks,  and 
there  remains  in  a  sluggish  condition,  and  the  surface  of  the  patch  be- 


734 


SYPHILIS. 


comes  unevenly  covered  with  tenacious  scales,  giving  the  lesion  the 
appearance   of   psoriasis.     This  is   well   shown   in   Fig.  217. 

The  course  of  the  eruption  depends  almost  altogether  upon  treatment. 
In  its  early  stages  it  will  usually  be  dispersed  by  vigorous  measures.  A 
limited  relapse  is  very  likely  to  occur  in  case  of  inadequate  treatment. 

In  no  other  syphilitic  eruption  can  a  prognosis  be  made  with  equal 

Fig.  217. 


Tubercular  syphiUde,  forming  a  large  area  and  covered  with  scales. 


confidence.  If  untreated,  it  will  probably  invade  nearly  every  part  of 
the  integument.  I  have  seen  two  cases  in  which  more  than  six  hundred 
tubercles  formed  during  a  period  of  about  ten  years,  leaving  permanent 
cicatrices  upon  the  face  and  body,  particularly  on  the  posterior  aspect 
and  on  the  extremities.  Although  the  alge  of  the  nose  and  the  lobes  of 
the  ears  were  destroyed,  not  a  particle  of  ulceration  had  ever  occurred. 
The  atrophy  which  follows  this  eruption  probably  results  from  some 
occult  change  in  the  normal  cells  induced  by  the  presence  of  the  infiltra- 
ting cells.  It  is  certain  that  the  infiltration  and  the  tissue  framework 
which  holds  it  degenerate  and  are  absorbed  at  the  same  time. 

In  case  of  a  relapse  a  group  of  pustules  is  usually  observed  in  some 
one  particular  region.  When  the  tubercles  are  scattered  over  the  body 
we  may  be  sure  that  the  period  of  infection  has  been  within  two  or  three 
years.     When  the  eruption  is  early  it  is  usually  symmetrical,  but  when 


THE  TERTIARY  SYPHILIDES.  735 

late  it  is  often  unsymmetrical.  The  tubercles  are  usually  less  copious 
witli  each  succeeding  outbreak,  but,  on  the  contrary,  cases  are  occasion- 
ally met  with  in  which  their  size  and  number  are  about  the  same  with 
each  relapse.  The  face,  back,  and  forearms  are  the  most  frequent  seats 
of  relapses.  In  some  cases  the  face,  and  exceptionally  the  scalp,  is 
attacked  by  recurring  tubercles  until  most  of  its  integument  is  left  in  a 
cicatricial  state. 

After  full  development  the  course  of  these  tubercles  is  slow  and  with- 
out marked  features,  and  they  are  generally  amenable  to  treatment. 
When  they  retrograde  they  sometimes  first  sink  in  the  middle,  and  may 
thus  be  converted  into  tubercular  rings.  If  left  alone,  they  remain  un- 
changed for  months.  Their  red  tinge  gradually  fades  to  brown ;  they 
flatten  and  finally  disappear,  leaving  a  pigmented  spot.  This  syphilide 
may  pass  away  without  causing  disorganization  of  the  skin,  especially  if 
treated  early.  Upon  the  face  and  where  the  tissues  are  soft  and  delicate 
cicatrices  are  apt  to  result.  Hence  the  necessity  of  active  and  prolonged 
treatment.  Tubercles  that  have  remained  on  the  face,  uninfluenced  by 
treatment,  for  two  or  three  months,  almost  inevitably  leave  cicatrices. 
On  other  parts  of  the  body  they  may  remain  longer  without  leaving  any 
deformity,  but,  as  a  rule,  atrophy  of  the  skin  follows  when  they  have 
lasted  three  months. 

In  some  cases  this  syphilide  ulcerates,  the  process  usually  being  lim- 
ited to  a  portion  of  the  eruption.  This  may  occur  in  a  malignant  and 
precocious  manner,  ulcers  forming  with  great  rapidity.  Happily,  such 
cases  are  rare.  When  ulceration  attacks  a  tubercle  a  yellow  crust  forms 
on  its  surface,  which  soon  covers  the  whole  tubercle  and  attains  consider- 
able thickness.  Its  color  gradually  becomes  greenish  black,  its  surface 
is  rough,  and  it  is  surrounded  by  a  dull-red  or  even  livid  areola.  Under- 
neath, and  coextensive  with  the  crust,  is  a  smooth  ulcer,  with  a  foul, 
grayish-red  surface,  sharply-cut  edges,  as  if  "punched  out,"  and  perhaps 
a  little  undermined,  secreting  an  ichorous  pus.  The  progress  of  the  case 
varies  in  different  patients.  In  broken-down  subjects,  especially  from 
alcoholism,  the  ulcers  may  extend  and  merge  together,  forming  large 
patches.  Under  favorable  conditions  the  destructive  process  is  more  lim- 
ited, but  such  ulcers  are  invariably  followed  by  depressed  cicatrices.  The 
face,  thighs,  and  forearms  are  the  parts  most  frequently  attacked.  On 
the  face  particularly  they  are  very  destructive  and  leave  unsightly  scars. 

Strange  as  it  may  seem,  the  cicatrices  following  resolutive  tubercles 
are  often  as  well  marked  as  those  subsequent  to  deep  ulceration.  When 
resolution  has  occurred  without  any  damage  to  the  skin,  coppery  pigment 
spots  remain  for  a  time.  When  a  cicatrix  is  formed,  it  is  always  deeply 
pigmented  and  surrounded  by  a  similar  areola.  These  cicatrices  form 
very  slowly.  After  complete  absorption  of  the  lesion  the  tissue  is  toler- 
ably thick,  but  it  gradually  becomes  thinner  and  less  brown,  until  in 
about  a  year  there  remains  merely  a  soft,  glistening  membrane,  either 
perfectly  smooth  or  perforated  with  minute  holes,  the  seat  of  follicles. 
Very  often  a  narrow  coppery  areola  remains  for  a  long  time.  When  the 
ulceration  has  been  particularly  deep  and  extensive,  and  especially  when 
it  has  occurred  near  a  joint,  thick  and  long  fibrous  bands  sometimes 
traverse  the  scar,  and  in  some  cases  its  surface  is  studded  with  tubercles 
of  false  keloid.     The  occurrence  of  these  neoplasms  has  been  considered 


736  SYPHILIS. 

diagnostic  of  lupus.  As  a  matter  of  fact,  they  are  developed  as  well^ 
though  less  frequently,   on  syphilitic  cicatrices. 

The  prognosis  of  this  syphilide  is  good,  although  it  indicates  an  active 
and  persistent  form  of  syphilis.  Early  treatment  may  prevent  or  modify 
cicatricial  deformity,  which  otherwise  may  be  extensive.  Persistence  in 
treatment  will  also  prevent  or  postpone  relapses. 

Ulceration,  complicating  this  eruption,  calls  for  the  exercise  of  the 
greatest  skill  and  care.  In  addition  to  the  use  of  proper  internal  and 
local  treatment,  the  nutrition  of  the  patient  should  be  improved  by  every 
possible  means.  In  those  rare  cases  in  which  ulceration  and  gangrene 
attack  the  tubercles  the  outlook  is  very  bad ;  the  destruction  of  tissue 
may  be  extreme,  cachexia  may  appear,  and  a  typhoid  condition,  resulting 
fatally,  may  be  induced. 

This  syphilide,  when  occurring  in  the  secondary  period,  often  coexists 
with  lesions  of  the  intermediary  stage,  such  as  perionychia,  alopecia, 
iritis,  cerebral  affections,  testicular  lesions,  mucous  patches,  and  condy- 
lomata. Later  on  it  is  generally  accompanied  by  a  varying  degree  of 
cachexia  and  sometimes  by  visceral  lesions. 

Diagnosis. — This  syphilide  is  to  be  diagnosed  from  lupus  vulgaris,  ele- 
phantiasis Grsecorum,  carcinoma,  and  psoriasis.  Lupus  generally  begins 
in  early  life,  and  is  never  so  diffusely  scattered  as  the  tubercular  syph- 
ilide. The  resemblance  is  seldom  striking  except  when  the  latter  is 
limited  to  the  face.  Lupus-tubercles  are  usually  more  irregular  in  out- 
line and  deeper  than  those  of  syphilis.  They  are  pinkish-red  rather  than 
brownish-red,  as  in  the  latter  disease.  Lupus-tubercles  are  more  com- 
monly studded  with  small  colloid  masses  and  are  prone  to  ulcerate.  The 
scars  left  by  lupus  are  not  soft  and  thin  as  in  syphilis,  but  are  hard  and 
seemingly  adherent  to  the  subcutaneous  tissues.  The  crusts  of  lupus 
are  not  so  regular  and  round  as  those  of  the  tubercular  syphilide,  and 
have  not  their  peculiar  dark,  greenish-black  color.  The  underlying  ulcers 
are  not  as  deep,  smooth,  and  sharply  cut  as  those  of  syphilis. 

In  some  cases  of  true  leprosy  tubercles  occur  which  resemble  in 
size,  shape,  and  color  those  of  syphilis,  but  they  are  usually  accompanied 
by  white,  angesthetic  patches,  large  spots  of  brown  pigmentation,  nerve- 
swellings  with  perverted  sensations,  large  nodular  infiltrations  and  ulcer- 
ations, or  other  manifestations  which  characterize  leprosy. 

Although  superficial  carcinomatous  tubercles  may  somewhat  resemble 
those  of  syphilis,  they  are  never  so  scattered,  and  are  always  much  larger, 
sometimes  involving  an  entire  region. 

The  tubercular  syphilide  occasionally  presents  two  appearances  w^hich 
resemble  psoriasis.  The  first  is  when  the  tubercles  are  covered  with  an 
unusual  number  of  scales,  especially  on  the  outer  aspect  of  the  arms, 
where  psoriasis  is  prone  to  appear.  The  second  is  when  the  tubercles 
undergo  involution  and  form  rings.  Psoriasis,  however,  is  a  disease 
beginning  in  youth,  and  is  essentially  scaly.  The  tubercles  of  syphilis 
are  infiltrations,  and,  though  some  may  be  covered  with  scales,  others  will 
be  found  free  from  them.  In  syphilis,  again,  we  have  the  history  of 
the  case  and  perhaps  other  manifestations  of  the  disease.  In  rare  cases 
in  which  the  eruption  is  limited  and  the  history  obscure  mercurial  treat- 
ment settles  all  questions,  since  it  cures  a  syphilide  and  does  not  influence 
psoriasis. 


THE  TERTIARY  SYPHILIDES. 


737 


Some  authors  call  this  syphilide  lupus  syphiliticus,  a  term  inapplicable 
for  reasons  already  given. 


The  Serpiginous  Syphilide. 

This  syphilide  creeps  over  large  surfaces  by  ulcerating  at  the  periphery 
of  patches  while  it  heals  in  the  centre.  It  may  occur  as  early  as  the 
second  or  as  late  as  the  tenth  or  fifteenth  year  of  syphilis,  possibly  later. 
Its  course  is  very  chronic,  and,  although  unattended  by  pain,  it  fre- 
quently causes  great  inconvenience.  Its  effects  on  the  skin  may  be 
slight  or  it  may  leave  disfiguring  cicatrices.  There  are  two  varieties  of 
this  lesion,  a  superficial  and  a  deep. 

The  superficial  serpiginous  syphilide  begins  as  a  pustule,  generally 
of  the  impetigoform  or  of  the  variolaform  syphilide.  In  its  early  stage 
it  consists  of  a  superficial  ulceration,  which  has  no  characteristic  features 
indicative  of  its  future  course,  but  which  extends  in  the  shape  of  a  round 
or  oval  patch.  If  treatment,  and  particularly  local  treatment,  is  not 
employed,  the  process  continues  and  crusts  form  until  the  patch  reaches 
a  diameter  of  about  two  inches ;  granulations  then  spring  up  from  the 
centre,  and  the  crust  falls  oif  except  at  the  periphery,  where  it  adheres  as 
an  encircling  ring.  Thus  is  formed  not  a  continuously  incrusted  surface, 
but  a  ring  of  crusts  enclosing  a  more  or  less  hypersemic  area  of  a  round 
or  oval  shape.     (See  Fig.  218.)     The  color  of  the  crusts  is  usually  yel- 


The  superficial  serpiginous  syphilide.    The  area  of  skin  enclosed  (over  elbows)  within  the  rings 
of  crusts  is  pigmented,  but  not  at  all  cicatricial  in  character. 

lowish-brown  or  greenish-black,  and  their  thickness  about  one-third  of 
an  inch.  The  underlying  surface  is  smooth,  of  a  grayish-red  color,  and 
ulcerated  at  the  margins.  Around  the  edges  is  a  narrow  red  areola. 
The  ulcerative  process  slowly  progresses  at  the  margins  of  the  patch,  a 
rim  of  crust  at  the  same  time  forming.  Healing  of  the  enclosed  surfiice 
keeps  pace  with  the  peripheral  extension  of  the  ulceration,  so  that  the 
width  of  the  crust,  varying  from  half  an  inch  to  an  inch,  is  steadily  main- 
tained. The  centre  of  this  surface  is  blanched ;  its  margins  are  always 
red,  and  they  merge  gradually  into  the  ulceration.  This  process  may 
continue  many  years  and  involve  extensive  surfaces.  When  healing 
begins  the  crusts  become  harder  and  darker,  and  the  redness  of  the  cen- 
tral patch  and  of  the  areola  diminishes.  Then  segments  of  crusts,  having 
been  lifted  by  the  granulations  beneath,  fall  off'  and  expose  an  ulcerated 

47 


738 


SYPHILIS. 


ring.  Unless  cauterized  witli  a  solution  of  nitrate  of  silver,  as  it  should 
be,  it  may  persist  for  a  long  time.  At  first  the  ulcer  generally  increases 
throughout  its  whole  periphery ;  subsequently  it  may  increase  only  in  one 
direction,  thus  becoming  oval  or  reniform.  The  extension  of  the  ulcer  is 
largely  influenced  by  the  tissues  on  which  it  is  seated.  Thus  an  ulcer  on 
the  inner  surface  of  the  forearm  creeps  up  the  arm  much  more  rapidly 
than  toward  its  outer  surface,  where  the  tissues  are  firmer,  and  thus  a 
long,  oval  ulcer  is  formed.  A  similar  occurrence  is  observed  on  the 
thighs,  while  on  the  face,  where  the  tissues  are  more  uniform,  the  ulcers 
are  generally  round.  The  result  of  this  superficial  ulceration  may  be 
simply  coppery  pigmentation,  which  lasts  several  months,  or  very  slight 
atrophy  of  the  skin.  The  ulceration  may  even  be  extensive  and  chronic 
in  course,  and  yet  induce  wonderfully  little  structural  change. 

Fig.  219. 


Thy  deep  serpiginous  syphilide,  showing  much  cicatrization  of  tlie  abilominal  wall. 

The  deep  serpiginous  syphilide  has  for  its  focus  of  ulceration  one  of 
the  late  or  tertiary  lesions,  such  as  a  tubercle,  an  ecthymaform  pustule, 
an  ulcerating  gumma,  or  some  traumatism.  Whatever  the  starting- 
point,  there  is  soon  developed  a  deep,  sharply-cut,  active  ulcer  with  un- 
dermined edges  and  a  coextensive  crust.  This  ulcer  increases  in  size, 
more  or  less  rapidly,  until  it  attains  a  diameter  of  two  or  three  inches, 
when  changes  similar  to  those  observed  in  the  superficial  variety  may 
occur.  The  crust  becomes  thin  at  its  centre  and  thick  at  its  margin ;  the 
thin  portion  soon  falls  off,  leaving  a  round,  deep-red  cicatrix,  surrounded 
by  a  thick,  greenish-black    crust  less   than  an  inch  in   width  and  quite 


THE  TERTIARY  SYPHILIDES.  739 

thick.  Whea  this  syphilide  is  fully  developed  and  has  attained  a 
diameter  of  from  four  to  six  inches,  its  changes  are  more  marked.  (See 
Fig.  218.)  In  the  centre  is  a  round  or  oval  patch  of  cicatricial  tissue 
having  a  coppery-red  color,  and  as  yet  firmly  attached  to  the  subcutaneous 
connective  tissue.  This  is  completely  enclosed  by  a  ring  of  crust.  The 
ulcerative  process  is  not  equally  active  at  all  parts  of  the  ring ;  hence 
result  certain  modifiations  in  the  shape  of  the  crust.  The  ulcerating  ring 
which  encircles  the  central  cicatrix  forms  a  furrow  half  an  inch  to  one 
inch  in  Avidth  and  at  its  most  active  portions  a  line  or  more  in  depth ;  it 
has  a  foul,  grayish-red  floor,  and  sharply-cut,  somewhat  everted,  and 
undermined  edges,  which  have  a  deep-red  color  and  are  continuous  with 
an  areola  of  similar  tint.  Portions  of  this  ulcerating  furrow  may  be  par- 
tially filled  by  granulations  or  even  entirely  cicatrized.  Over  the  more 
active  segments  there  is  a  yellowish-brown  crust,  slightly  depressed  below 
the  level  of  the  skin,  and  which  may  be  raised  as  a  film  from  the  surface. 
In  portions  further  advanced  toward  healing  the  crust  is  thicker,  harder, 
slightly  above  the  surrounding  level,  and  of  a  greenish-brown  color ;  con- 
tinuous with  it,  on  parts  where  the  process  is  quiescent  or  where  healing 
is  nearly  complete,  the  crust  is  greenish-black  in  color,  is  hard  and  ad- 
herent, and  its  base  on  a  level  with  the  skin.  Thus  we  can  always  esti- 
mate the  age  of  the  ulceration  from  the  size,  color,  consistence,  thickness, 
and  prominence  of  the  crusts. 

Relapses  may  occur  by  ulceration  of  the  cicatrix,  sometimes  destroying 
the  whole  of  it.  This  occurs  most  frequently  in  debilitated  and  poorly- 
nourished  persons  and  in  those  who  use  alcohol  to  excess.  The  cicatrix 
following  such  a  relapsing  ulcer  is  very  rough  and  unsightly.  Sometimes 
the  cure  is  retarded  by  repeated  relapses  at  the  margins  of  large  ulcers, 
segments  which  had  healed  being  again  attacked  by  the  ulcerating  pro- 
cess, or,  again,  parts  more  remote  may  be  attacked. 

The  course  of  this  syphilide  is  always  slow,  often  occupying  many 
years.  In  some  cases  it  is  accompanied  by  profound  cachexia,  while  in 
others  there  is  no  disturbance  of  the  general  health. 

This  syphilide  is  of  rather  rare  occurrence.  It  may  appear  as  early 
as  the  third  year,  but  generally  later,  even  up  to  the  fifteenth  year,  after 
infection.  It  appears  usually  on  the  inner  surface  of  the  forearms  and 
arms,  on  the  breast,  and  on  the  legs.  It  causes  little  if  any  pain,  but 
frequently  gives  great  annoyance  when  near  the  joints.  When  the  re- 
sulting cicatrices  are  small  they  are  generally  thin  and  parchment-like ; 
but  if  large  they  are  thick,  uneven,  and  often  traversed  by  fibrous  bands, 
and  covered  by  tubercles  of  false  keloid.  Often,  however,  even  the 
large  scars  are  thin — a  fact  of  importance  in  making  a  diagnosis  between 
the  syphilide  aud  serpiginous  lupus.  Blanching  of  the  cicatrix  extends 
from  the  centre  toward  the  periphery.  In  large  scars  there  may  be  a 
white  central  patch  surrounded  by  a  dull  coppery-red  areola,  even  long 
before  healing  is  completed.  In  all  cases  the  pigmentation  fades  slowly, 
and  remains  longest  in  the  areola.  Contraction  of  the  scar  near  joints 
often  results  in  permanent  deformity. 

The  prognosis  of  this  syphilide  is  never  very  good.  Still,  a  fiital 
result  is  by  no  means  inevitable,  and  proper  treatment  is  in  many  cases 
quite  effective. 

The  diagnosis  from  serpiginous  lupus  and  serpiginous  chancroid  is 


740  SYPHILIS. 

seldom  difficult.  Lupus  usually  begins  in  early  life,  and  attacks  the  face. 
Its  ulcerations  are  less  definite  and  sharply  cut  than  those  of  the  syph- 
ilide.  In  lupus  red  tubercles  of  ulceration,  covered  by  crusts  of  light- 
yellow  or  bluish-brown  are  mingled  with  the  cicatrices,  which  are  always 
uneven  and  fibrous.  Th-e  history  of  the  case  may  add  to  the  certainty  of 
diagnosis. 

A  serpiginous  chancroid  usually  has  such  a  clear  history  that  no  mis- 
take can  occur.  Its  locality,  its  extensively  undermined  edges,  its  fun- 
goid surface,  and  its  erratic  course  are  also  sufficiently  diagnostic. 

In  opposition  to  the  view  of  some  that  this  eruption  is  not  syphilitic, 
it  is  only  necessary  to  say  that  it  always  begins  in  a  syphilitic  lesion,  that 
its  ulcers  and  crusts  have  features  similar  to  those  of  other  syphilitic 
lesions,  and,  finally,  that  its  cicatrices  are  typical  of  syphilis. 

Rupia,  or  the  Rupial  Syphilide. 

This  name,  derived  from  the  Greek  puno^,  dirt,  is  applied  to  an  eruption 
composed  of  ulcers  surmounted  by  laminated  crusts.  It  appears  some- 
times precociously  during  the  first  year  of  syphilis,  but  it  really  belongs 
among  the  late  lesions.  It  usually  shows  intense  syphilitic  infection, 
and  is  often  accompanied  by  fever.  It  has  never  been  seen  in  hereditary 
syphilis.  Although  a  pustulo-crustaceous  eruption,  it  partakes  of  the 
nature  of  tertiary  lesions  in  the  deep-seated  infiltration  always  present 
beneath  the  crusts. 

Rupia  may  be  divided  into  two  varieties :  one,  in  which  the  crusts 
are  small,  numerous,  and  quite  generally  scattered ;  another,  in  which 
they  are  large,  less  numerous,  and  more  localized.  All  of  the  lesions 
of  rupia  begin  as  a  red  spot,  which  soon  becomes  a  flat  pustule  which 
dries  into  a  greenish-brown  crust.  Subsequent  changes  are  very  slow 
and  of  great  interest.  The  initial  crust  is  usually  small,  and  underneath 
it  is  a  superficially  ulcerated,  infiltrated  surface.  The  infiltration  and 
ulceration  extend  somewhat  beyond  the  original  crust,  and  another 
layer  of  crust  is  formed  beneath  it  by  the  secretion  from  the  ulcerated 
surface.  Thus  several  distinct  but  adherent  laminations  are  formed  as 
the  ulcer  increases  in  size,  each  succeeding  one  being  larger  than  its 
predecessor.  This  result  is  mainly  due  to  the  fact  that  the  pus  is  quite 
thick,  and  that  it  is  secreted  slowly  and  dries  very  quickly.  The  process 
may  continue  until  the  crusts  reach  a  diameter  of  half  an  inch  or  even 
two  inches.  (See  Fig.  219.)  In  rare  cases  they  have  been  seen  with  a 
diameter  of  fully  six  inches.  When  completed  the  rupial  crust  is  coni- 
cal, distinctly  laminated,  of  a  brownish-black  color  tinged  with  green, 
similar  to  a  dirty  oyster-shell.  The  crust  itself  is  hard,  firm,  and 
adherent,  although  its  layers  are  often  perfectly  distinct.  Underneath 
it  we  find  an  unhealthy,  grayish-red,  ulcerated  surface  bathed  in  thick, 
ichorous  pus  and  surrounded  by  a  slightly  undermined  margin.  The 
depth  of  this  ulcer  is  rarely  so  great  as  that  of  the  severe  ecthymaform 
syphilide.  It  generally  involves  about  one-half  the  thickness  of  the 
derma.  Around  each  ulcer  is  an  areola  of  a  coppery-red  color,  which 
merges  into  healthy  tissue.  The  growth  of  these  encrusted  ulcers  is 
quite  slow  and  often  intermittent. 

The  small  rupial  eruption  begins  either  about  the  face  or  on  the  inner 


THE  TERTIARY  SYPHILIDES. 


741 


and  outer  surfaces  of  the  forearms.  It  may  then  invade  the  trunk  and 
lower  extremities.  The  crusts  vary  in  diameter  from  half  an  inch  to  an 
inch.  Lamination  is  first  visible  when  their  diameter  is  about  one- 
quarter  of  an  inch.  Their  number  varies ;  sometimes  upon  the  face 
only  a  small  portion  of  healthy  skin  is  left  intact.  Upon  the  face  and 
forearms  their  height  is  often  greater  than  their  breadth.  They  are 
more  common  on  the  forehead  and  near  the  nose  and  mouth  than  on 
other  parts  of  the  face.  In  some  cases  only  one  region  is  invaded,  as 
the  face  or  the  forearms,  but  the  eruption  is  rarely  seen  on  the  lower 
extremities  alone.  It  generally  appears  in  crops  of  a  limited  number, 
which  may  follow  each  other  at  short  intervals  and  extend  over  periods 

Fig.  220. 


Rupia,  or  rupial  syphilide. 


of  several  months  or  a  year.  Proper  medication,  however,  will  certainly 
abort  such  an  eruption  more  or  less  promptly.  In  some  cases  of  an 
eruption  composed  of  many  small  pustules,  even  when  no  treatment  has 
been  followed,  the  crusts  have  been  known  to  reach  a  diameter  of  nearly 
or  quite  one  inch,  and  then  to  dry  and  fall  oif,  the  subjacent  ulcer  heal- 
ing meanwhile.  In  other  cases  the  crusts  may  run  into  each  other  and 
assume  a  horseshoe  shape.  This  eruption  may  occur  during  the  first 
year  of  syphilis,  but  is  generally  observed  later. 

The  eruption,  composed  of  large  crustaceous  ulcers,  usually  presents  a 
limited  number  of  lesions.  Exceptionally  we  find  only  one  crust,  but 
in  some  cases  as  many  as  twenty  or  thirty.  The  diameter  of  a  crust  in 
a  case  that  has  been  long  neglected  may  be  even  more  than  two  inches. 
This  eruption  is  most  common  on  the  face  and  trunk,  but  may  occur  on 
the  extremities  and  may  be  unsymmetrical.  The  lesions  appear  singly, 
or  two  or  three  may  be  developed  at  the  same  time;  they  grow  slowly 
and  painlessly.  After  having  reached  a  diameter  of  an  inch  their 
growth  is  much  slower,  many  months  being  occupied  in  the  growth  of  a 
crust  four  inches  in  diameter.     The  ulcers  underlying  the  crusts  of  the 


742  SYPHILIS. 

large  variety  of  rupia  are  rather  deep,  but  rarely  involve  the  whole 
thickness  of  the  derma.  They  resemble  those  of  the  small  variety. 
After  removal  of  one  of  the  conical  crusts  a  thinner  one  of  a  similar 
color  is  formed,  unless  the  surface  is  thoroughly  stimulated.  Profuse 
granulations  may  spring  up  which  hinder  cicatrization.  Under  proper 
treatment  the  ulcer  slowly  heals,  until  a  deep-red  glazed  spot  is  left, 
which  gradually  becomes  thinner  and  lighter-colored,  and,  finally,  a 
white,  shining  surface  is  left,  Avhich  is  depressed  below  the  general  level, 
and  around  which  a  rim  of  brown  pigment  remains  for  months,  corre- 
sponding with  the  former  areola.  These  cicatrices  are  usually  not 
traversed  by  fibrous  bands,  but  scattered  over  them  are  minute  holes 
which  indicate  the  openings  of  sebaceous  follicles. 

The  prognosis  of  rupia  is  not  good  as  to  the  lesion  itself  nor  as  to  the 
general  condition  of  the  patient.  In  some  rare  cases  of  precocious  evolu- 
tion this  eruption  becomes  general,  the  lesions  being  large  and  numerous, 
and  the  general  condition  being  at  the  same  time  much  depressed.  With- 
out careful  and  vigorous  treatment  this  malignant  form  of  syphilis  may  be 
fatal.  The  small  and  general  form  of  rupia,  although  accompanied  by 
cachexia,  may  be  cured  in  a  few  months.  The  ulcers  usually  occasion 
much  annoyance  and  suffering. 

The  large  form  of  rupia  is  of  considerable  gravity  and  calls  for  ener- 
getic local  and  constitutional  treatment.  Although  many  cases  recover, 
death  sometimes  occurs. 

A  question  of  diagnosis  cannot  arise,  since  no  simple  eruption  resem- 
bles rupia. 

The  Bullous  Syphilide. 

Much  confusion  has  been  introduced  into  syphilography  by  the  latitude 
given  to  the  term  "pustule."  From  the  fact  that  some  forms  of  syphilitic 
pustules  are  not  situated  upon  an  elevated  base  and  are  large  and  globular, 
with  a  tendency  to  run  together,  the  existence  of  a  true  pemphigoid  syph- 
ilide has  been  asserted.  Further  study  has  proved  these  lesions  to  be 
pustular,  and  not  bullous,  yet  in  some  cases  true  bullae  are  developed  on 
syphilitic  patients. 

The  eruption  begins  like  ordinary  pemphigus  by  an  effusion  of  serum 
beneath  the  epidermis,  which  slowly  increases,  until  at  the  end  of  a  week 
or  two  a  bulla  the  size  of  a  pea  is  formed.  The  serum  soon  becomes  turbid 
and  milky,  and  is  finally  converted  into  a  thick  yellow  pus.  The  bullas 
vary  in  size,  some  being  as  large  as  a  walnut.  They  are  surrounded  by 
a  dull-red  areola,  which  on  the  legs  may  be  due  to  effusion  of  blood.  The 
pus  soon  dries  into  a  dark,  greenish-black,  adherent  crust. 

Under  favorable  circumstances  the  underlying  ulcer,  which  is  usually 
not  very  deep,  becomes  cicatrized  and  the  crust  falls  off,  leaving  deeply 
pigmented,  more  or  less  atrophic  spots.  Sometimes,  however,  no  change 
is  produced  in  the  skin.  Without  treatment,  especially  in  cachectic 
patients,  the  ulceration  increases  in  depth  and  extent,  and  the  lesion  may 
then  resemble  rupia. 

This  eruption  occurs  mostly  on  the  forearms  and  legs,  where  it  may  be 
aggregated.  When  it  invades  the  trunk  it  is  more  copious  about  the 
chest,  but  is  genei'ally  discrete.  Its  invasion  is  usually  very  slow.  Its 
course  is  also  very  chronic  and  unattended  by  any  marked  symptoms. 


GANGRENE  AND   GANGRENOUS   ULCERS.  743 

except  soreness  and  sometimes  heat  in  the  bullae  and  ulcers.  Fresh  bullae 
may  form  during  the  course  of  the  eruption  or  after  it  has  once  disap- 
peared. 

The  bullous  syphilide  is  almost  always  a  late  eruption.  Mistakes 
have  arisen  from  considering  certain  exceptionally  large  pustules,  or  those 
which  have  been  formed  by  the  fusion  of  several  of  the  variolaform  pus- 
tules, as  bullae  and  calling  them  syphilitic  pemphigus.  These  bullae  are 
found  even  at  a  late  period  only  in  those  who  have  had  repeated  relapses 
of  syphilis  in  a  severe  form  and  in  those  having  visceral  lesions.  The 
opinion  has  been  expressed  that  an  eruption  of  this  kind  is  a  mere  coin- 
cidence, a  pemphigus  occurring  in  a  syphilitic  subject.  In  many  cases 
there  are  certainly  no  distinguishing  marks  between  the  bullous  eruption 
of  syphilis  and  pemphigus,  and  the  diagnosis  must  then  be  made  from  the 
history  and  from  the  associated  lesions  and  symptoms.  There  are  cases 
in  which  the  syphilitic  history  is  clear,  and  the  bullae  soon  form  rupial 
crusts  and  leave  typical  tubercular  infiltrations. 


CHAPTER    LXXI. 
GANGRENE  AND  GANGRENOUS  ULCERS. 

In  some  cases  of  syphilis,  as  a  result  of  the  changes  in  the  coats  of 
arteries  and  veins,  gangrene  is  produced  by  which  portions  of  the  integu- 
ment and  of  the  extremities  are  destroyed. 

Until  within  recent  years  all  ulcerations  occurring  in  syphilitic  sub- 
jects were  regarded  as  evidences  of  the  breaking  down  of  syphilitic  infil- 
trations. To-day  we  clearly  recognize  the  fact  that  spontaneous  gangrene 
of  the  skin  and  its  resulting  ulcers  may  be  due  to  syphilitic  arteritis  or  to 
endarteritis  obliterans.  I  have  seen  a  number  of  well-marked  ulcers 
upon  the  legs  near  the  ankles  and  on  the  dorsum  of  the  foot.  Klotz  ^ 
has  published  several  interesting  cases  of  this  form  of  gangrene. 

This  degenerative  condition  usually  begins  in  persons  of  poor  nutri- 
tion, in  those  who  are  debilitated  in  consequence  of  bad  regimen  or 
excesses  in  subjects  who  have  not  been  properly  treated  and  who  live  in 
squalor. 

The  first  evidence  of  syphilitic  cutaneous  gangrene  is  a  mottling, 
with  perhaps  some  scaling  of  the  skin.  The  color  then  changes  to  a 
greenish-brown,  and  it  finally  becomes  blackish-brown.  In  some  cases 
this  eschar  is  soft  and  succulent ;  in  others  it  is  tough,  dry,  and  withered. 
Very  soon  separation  occurs  at  the  base  and  the  periphery  of  the  lesion, 
and  in  a  few  days  or  a  week  or  two  the  slough  is  removed  or  foils  out, 
and  a  deep  punched-out  ulcer  with  an  uneven,  anfractuous,  and  dirty 
surfiice  is  left.    The  surrounding  skin  may  be  red  and  oedcmatous. 

In  some  cases  there  is  local  pain ;  in  others  a  want  of  sensibility  and 
coldness  of  the  parts  are  complained  of. 

1  New  York  Med.  Journal,  Oct.  8,  1887. 


744  SYPHILIS. 

Trauma,  heat,  cold,  or  caustic  applications  have  nothing  to  do  with 
these  lesions. 

Under  the  title  "primitive  gangrene"  Fournier-  describes  a  syphilitic 
manifestation  Avhich  Bazin  called  "  tuberculo-gangrenous  syphilide."  He 
thus  describes  the  morbid  process :  The  lesion,  as  soon  as  it  has  been 
formed,  takes  a  livid  color  in  the  centre  and  a  chocolate  color  in  the 
peripheral  portions,  with  insensibility  of  the  diseased  part ;  for  in  reality 
the  formation  of  an  eschar  takes  place,  under  which  the  mortified,  insensi- 
ble, sloughy  tissues  are  found,  no  external  occasional  cause  being  recog- 
nizable. The  mortified  parts  take  on  the  appearance  of  gangrene,  they  be- 
come detached,  and  underneath  the  syphilitic  ulcer  is  found  at  last.  The 
symptoms  perfectly  bear  the  character  of  spontaneous  primary  gangrene. 

Gangrene  of  the  extremities,  both  upper  and  lower,  is  not  very  un- 
common. I  have  had  several  such  cases  under  my  care.  Prof.  Podres^ 
of  Crakow  has  reported  the  case  of  a  man,  forty-five  years  old,  who  six 
years  after  infection  began  to  have  pain  in  his  legs,  which  became  very 
anaemic,  sensitive  to  cold,  oedematous,  and  finally  gangrenous.  This  con- 
dition necessitated  amputation  first  of  the  toes,  then  of  the  foot,  and 
finally  of  the  thigh.  Microscopic  examination  showed  inflammation  of 
the  external  tunic  of  the  arteries,  degeneration  of  their  endothelium,  with 
thickening  of  their  walls  and  obliteration  of  their  calibre.  There  was 
also  atrophy  of  the  cutaneous  glands  and  nerves.  All  of  these  changes 
were  attributed  by  Podres  to  syphilis. 

Lang^  refers  to  cases  in  which,  as  a  result  of  arteritis,  gangrene  of 
entire  extremities  or  portions  thereof  was  observed.  In  some  cases  the 
hardening  of  the  affected  vessels  can  be  felt  by  palpation. 

Cabot  and  Warren  also  report  a  case  in  which  gangrene  of  the  two 
lower  thirds  of  the  right  leg  and  a  gangrenous  spot  four  inches  in  diameter 
on  the  inner  surface  of  the  right  thigh  were  observed. 

Further,  Aune  *  reports  a  very  interesting  case  among  the  seven  which 
form  the  basis  of  his  thesis.  It  was  that  of  a  man  thirty-five  years  old 
who  in  late  syphilis  suffered  from  gangrene  of  the  hand,  forearm,  and 
lower  part  of  arm.  In  the  unobstructed  part  of  the  member  endarteritis 
obliterans  with  periarteritis  was  found. 

Mendel  ^  reports  the  case  of  a  man  fifty-five  years  old  in  Fournier's 
service  who  lost  part  of  his  tongue  by  gangrene  which  it  was  thought  was 
caused  by  old  syphilis. 

An  interesting  case,  reported  by  Schuster,^  in  which  gangrene  of  the 
foot  occurred,  is  worthy  of  consideration. 

Several  cases  have  been  published  in  which  symmetrical  gangrene  of 
the  fingers  (the  so-called  "Raynaud's  disease")  has  been  observed  in 
syphilitic  subjects,  all  of  which  are  worthy  of  close  study .^ 

1  Gazette  des  HopHaux,  Nos.  37  and  40,  1887.       ^  Centralblatt  fur  Chirurgie,  No.  33,  1876. 

^  Vorlesungen  liber  Pathologic  unci  Therapie  der  Syphilid  Wiesbaden,  1895,  pp.  390  et  seq. 

*  "  Essai  sur  les  Gangrenes  des  Membres  consecutives  a  I'Arterite  svphilitique," 
These  de  Lyon,  1890. 

^  Annales  de  Derm,  et  de  St/ph.,  1894,  pp.  1365  et  seq. 

®  Archiv  fur  Derm,  itnd  Syphilis,  1889,  p.  779. 

''  Hutchinson  :  "  A  Case  of  Syphilis  in  which  the  fingers  of  one  hand  became  cold  and 
livid — suspected  arteritis,"  Med.  Times  and  Gaze^^e,  vol.  i.,  1884,  p.  374;  D'Ornellas:  "Gan- 
grene spontan^e  des  Doights  par  Arterite  syph.,"  Annales  de  Derm,  et  de  Syph.,  1888,  pp. 
35  et  seq  ;  Morgan  :  "  Raynaud's  Symmetrical  Gangrene  in  a  Patient  suffering  from  con- 
stitutional syphilis,"  Lancet,  July  6  and  27,  1889  ;  and  Elsenbei'g  :  "  Die  Sogenannte  Ray- 
naud'sche  Krankheit.  Syphilit.  Urspruugs,"  Arch.  Jiir  Derm,  und  Syphilis,  1892,  pp.  577. 


AFFECTIONS  OF  THE  TONGUE,  ETC.  745 

In  summing  up  the  subject  Lang  very  pertinently  says  :  "Naturally, 
the  symptoms  which  follow  an  affection  of  the  blood-vessels  will  vary  a 
good  deal  according  to  the  nature  and  extent  of  the  pathological  process, 
to  the  size  of  the  affected  vessel,  and  in  smaller  ones  according  to  the 
dignity  of  the  organ  the  vascular  supply  of  which  is  the  seat  of  the  affec- 
tion. Either  dilatation  or  narrowing  and  obliteration  may  result ;  there- 
fore we  must  expect  in  due  time  either  an  aneurysm  or  such  phenomena 
as  usually  follow  obliteration  of  blood-vessels.  The  constringing  and 
obliterating  arteritis  Avill  be  the  less  pronounced  the  smaller  the  area  sup- 
plied by  the  affected  vessel,  the  less  important  its  physiological  function, 
and  the  more  favorable  the  circumstances  for  the  establishment  of  a  col- 
lateral circulation,  which  in  the  slow  development  of  the  arteritis  may  be 
effected  with  hardly  any  disturbance.  But  if  terminal  or  a  larger  number 
of  blood-vessels  are  the  seat  of  the  affection,  an  insufficient  or  entirely 
interrupted  circulation,  and  consequent  diminished  nutrition  and  necrobi- 
osis, are  inevitably  produced." 

Phlebitis. 

The  veins  are  attacked  by  syphilis  much  in  the  same  way  that  the 
arteries  are,  in  both  the  secondary  and  tertiary  stages.  MendeP  published- 
an  essay  on  this- subject,  based  on  the  study  of  two  cases  operated  on  by 
V.  Langenbeck. 

One  or  many  veins  may  be  attacked  simultaneously  or  in  succession. 
According  to  Mendel,  the  lesion  is  a  gummatous  deposit  around  the  vessel. 

Lang^  states  that  he  found  phlebitis  and  periphlebitis  of  the  right 
saphenous  vein  in  a  twenty-six-year-old  man  five  months  after  the  appear- 
ance of  the  chancre. 

Breda ^  reports  two  cases  :  in  one  the  left  aural,  the  cephalic,  the  basilic, 
and  the  left  median  veins  were  attacked ;  in  the  second  the  veins  of  the 
left  leg  were  involved,  and  the  morbid  condition  was  quickly  cured  by 
antisyphilitic  treatment. 

Charvot*  also  reports  two  cases  of  phlebitis  of  the  saphenous  vein 
which  were  cured  by  mercurial  treatment. 


CHAPTER    LXXII. 

AFFECTIONS  OF  THE  TONGUE,  THE  SOFT  PALATE,  THE  PHARYNX, 
THE  LARYNX,  AND  THE  (ESOPHAGUS. 

The  Tongue. 

In  late  secondary  and  in  tertiary  syphilis  the  tongue  may  be  the  seat 
of  sclerosis  and  of  gummata. 

Sclerosis. — Sclerosis  of  the  tongue  is  most  frequent  about  the  fifth 
year  of  syphilis.  It  is  usually  developed  near  the  median  line,  and  always 
on  the  upper  surface  of  the  tongue,  and  may  be  superficial  or  deep. 

^  "  Contribution  a  I'Etude  de  la  Phlebite  svpliiliti(iue,"  Arch.  (/en.  de  Med.,  Marcli,  1894. 

2  Op.  cit.,  p.  398.  ^  lieriKta  Veneta  di.  Science  Med.,  vol.  ii.,  1889. 

♦  Archiv.med.  Bely.,  1891,  p.  122;  quoted  from  Archivfiir  Derm,  und  Sijph.,  1892.  p.  172. 


746  SYPHILIS. 

Superficial  sclerosis  involves  the  mucous  membrane  only,  and  produces 
a  lamellated  induration  analogous  to  the  "parchment"  induration  of  the 
chancre.  It  may  be  circumscribed  or  diffuse,  and  ulcerates  only  as  a  result 
of  injury  by  the  teeth,  tobacco,  or  similar  irritants. 

Parenchymatous  or  deep  sclerosis  may  be  considered  an  aggravated 
form  of  the  superficial  lesion,  and  invades  the  muscular  as  well  as  the 
mucous  tissue.  The  tongue  may  be  greatly  increased  in  size,  but  after 
long  persistence  of  the  lesion  the  newly-formed  fibrous  tissue  retracts,  and, 
as  in  cirrhosis  of  other  organs,  atrophy  results.  At  first  the  hypertrophied 
tongue  receives  the  imprint  of  the  teeth  at  its  margin,  the  body  of  the 
organ  being  lobulated  in  a  manner  almost  pathognomonic.  The  lobules 
are  separated  by  furrows  which  cannot  be  effaced  by  stretching,  in  this 

Fig.  221. 


Parenchymatous  sclerosis  of  the  tongue. 

respect  offering  a  contrast  with  the  rugae  which  occur  on  the  tongue  in 
dyspepsia  and  other  depraved  conditions  of  the  system.  The  induration 
is  deep  and  cartilaginous,  and  the  mucous  membrane  becomes  changed  in 
color  and  perfectly  smooth.  Ulceration  may  result  from  causes  similar  to 
those  which  produce  it  in  the  milder  form  of  sclerosis.  When  parenchym- 
atous sclerosis  involves  the  whole  tongue — which,  fortunately,  it  seldom 
does — the  tumefaction  may  be  enormous. 

GuMMATA. — Like  scleroses,  gummata,  which  are  later  lesions,  may  be 
designated  as  superficial  or  parenchymatous.,  since  they  may  be  found  in 
the  mucous  or  the  muscular  tissue  of  the  tongue.  The  superficial  or 
mucous  gumma  begins  as  a  small  nodule,  which  soon  softens  and  ulcerates, 
leaving  an  excavation  with  perpendicular  margins  and  an  infiltrated  base, 
which  is  often  covered  by  tenacious  false  membrane  of  a  yellowish-white 
color. 

Parenchymatous  gummata  are  developed  in  the  muscular  tissue  of  the 


AFFECTIONS  OF  THE  TONGUE,  ETC.  747 

tongue,  taking  their  origin  in  the  connective  tissue.  They  begin  as  small 
tumors,  which  are  sometimes  difficult  of  detection  on  account  of  their  depth 
and  of  the  surrounding  induration.  The  process  of  degeneration  extends 
from  the  middle  of  the  tumors  until  the  thinned  mucous  membrane  over 
them  on  the  upper  surface  of  the  tongue  becomes  ruptured,  exposing  a 
deep  cavity  with  overhanging  and  sloughy  walls,  surrounded  by  an  areola 
of  induration.  In  view  of  the  great  size  of  the  cavity,  one  would  expect 
excessive  deformity,  but  cicatrization  often  takes  place  with  relatively 
slight  permanent  damage.  In  rare  cases  two  or  more  gummatous  tumors 
coalesce,  and  lead  to  enormous  enlargement  of  the  tongue  and  proportion- 
ate destruction  of  its  tissue.  The  ulcers  may  be  attacked  by  phagedena, 
when  the  condition  becomes  still  more  aggravated.  Without  treatment 
these  ulcers  are  remarkably  chronic.  One  has  been  reported  which  per- 
sisted, Avith  comparatively  little  change,  for  twenty  years.  Gummatous 
tumors  occasionally  undergo  calcific  degeneration. 

Their  insidious  formation,  their  seat  at  the  sides  and  toward  the  tip  of 
the  tongue,  their  chronic  course,  and  their  freedom  generally  from  spon- 
taneous pain  are  characteristic  features  of  gummatous  tumors.  The  obser- 
vation of  Anger,  that  lancinating  pain  shooting  toward  the  ear  is  diagnostic 
of  cancer  of  the  tongue,  has  been  repeatedly  confirmed.  Gummatous 
tumors  may  appear  at  a  period  much  earlier  than  is  usual  with  cancerous. 
A  gumma  begins  as  a  nodule  which  breaks  down ;  epithelioma  as  a  firm, 
a  warty,  or  an  exuberant  growth.  In  addition  to  these  facts,  and  to  the 
individual  and  family  antecedents  of  a  patient,  the  ulcerating  surfaces  of 
the  tumors  present  somewhat  constant  features,  which  may  assist  in  the 
diagnosis. 

Gummatous  ulcers  are  usually  multiple,  bilateral,  and  are  always  upon 
the  upper  surface  of  the  tongue ;  cancerous  ulcers  are  usually  single,  and 
may  occupy  its  under  surface.  The  ulcerative  process  of  gummata  destroys 
the  tumor  ;  carcinomata  present  an  ulcerating  tumor,  the  induration  of 
which  extends  with  the  eroding  process.  The  floor  of  a  gummatous  ulcer 
is  sometimes  sloughy  and  is  slightly  vascular ;  that  of  a  cancerous  ulcer 
bleeds  readily,  and,  at  an  advanced  stage,  secretes  an  ichorous  pus.  Zeissl 
gives  diagnostic  importance  to  the  fact  that  "  sebum-like  plugs  "  may  be 
pressed  from  the  mucous  membrane  in  epithelioma  of  the  tongue. 

Interference  with  the  functions  of  the  tongue  is  much  less  in  gummata 
than  in  cancer.  Ganglionic  enlargement  is  rare  in  syphilitic  lesions  of 
the  tongue,  with  the  exception  of  the  chancre,  Avhile  in  cancer  it  always 
occurs. 

Confirmatory  evidence  may  be  furnished  by  microscopic  examination 
of  the  tumor  and  by  the  effect  of  antisyphilitic  treatment,  which,  in  can- 
cer, is  sometimes  evidently  harmful. 

The  diagnosis  between  syphilis  and  tuberculosis  of  the  tongue  is  some- 
times difficult,  especially  in  those  cases  where  the  two  diseases  coexist,  and 
in  rare  instances  where  tubercular  deposit  takes  place  in  the  tongue  prior 
to  the  development  of  pulmonary  symptoms. 

In  all  cases  of  hypoplastic  growth  on  or  in  the  tongue  the  suspicion  of 
syphilis  should  be  entertained,  and  a  tentative  active  treatment  should  be 
instituted. 


748  SYPHILIS. 

Atrophy  and  Hemiatrophy  of  the  Tongue. 

Atrophy  of  the  Tongue. — Le^yin  and  Heller  ^  have  recently  called 
attention  to  a  superficial  and  localized  atrophy  of  the  tongue,  particu- 
larly at  its  base.  In  this  form  the  follicular  glands  are  involved  by 
circumferential  round-cell  infiltration.  This  neoplasm  is  unstable  in 
structure,  and  soon  degenerates  and  is  absorbed.  This  condition,  with 
the  possible  obliteration  of  the  vessels  of  the  immediate  part,  is  the  cause 
of  the  atrophy,  which  has  a  smooth,  somewhat  depressed,  and  compact 
surface.  By  this  process  several  or  all  of  the  follicular  glands  become 
atrophied,  more  or  less  of  the  adenoid  tissue,  particularly  of  the  lingual 
tonsil,  becomes  absorbed,  and  the  epithelial  layer  is  diminished  in  thick- 
ness. Lewin  and  Heller  state  that  this  form  of  atrophy  is  quite  fre- 
quently observed. 

Hemiatrophy  of  the  Tongue. — Leudet  ^  reports  the  case  of  a 
woman  thirty-two  years  old  who  had  headache  on  the  right  side  for 
eighteen  months,  and  who  for  five  months  experienced  difficulty  in  masti- 
cation, and  had  a  decidedly  nasal  voice.  The  right  side  of  the  tongue 
was  atrophied  ;  its  tactile  sensibility  was  preserved,  but  its  gustatory 
sensibility  was  impaired.  There  was  also  an  ulcer  of  the  palatine  vault, 
paralysis  of  the  vocal  cord,  and  rhinitis.  All  the  symptoms,  except  the 
hemiatrophy  and  the  paralysis,  were  cured  by  specific  treatment. 

Mauriac  at  the  International  Medical  Congress  in  1889  mentioned 
the  case  of  a  man  forty-four  years  old,  syphilitic  fourteen  years,  who 
sufi"ered  from  various  nervous  phenomena  and  had  right-sided  hemiatrophy 
of  the  tongue. 

Gummatous  Infiltration  into  the  Soft  Palate. 

There  are  very  few  syphilitic  lesions  which  develop  so  insidiously  and 
produce  such  almost  irreparable  injury  as  gummatous  infiltration  of  the 
soft  palate. 

Early  symptoms  are  insignificant  or  entirely  wanting.  Possibly  the 
patient  notices  a  slight  uneasy  or  tickling  sensation  in  the  fauces,  and  ex- 
periences some  difficulty  in  deglutition,  which  he  naturally  attributes  to 
an  ordinary  cold  ;  he  may  even  find  when  attempting  to  swallow  liquids 
that  they  regurgitate  through  the  nostrils,  but  this  he  regards  as  acci- 
dental. Suddenly,  however,  and  without  further  warning,  he  is  nearly 
deprived  of  the  power  of  speech  and  deglutition.  His  voice  is  trans- 
formed to  an  almost  unintelligible  nasal  whisper,  and  upon  attempting  to 
eat,  solids,  and  especially  liquids,  are  returned  through  the  nose. 

If  we  are  so  fortunate  as  to  observe  this  affection  in  its  earliest  stage, 
we  find  that  it  has  two  modes  of  commencing : 

1st.  A  deposit  of  gummy  material  may  take  place  in  a  circumscribed 
mass  within  the  substance  of  the  soft  palate  and  between  its  buccal  and 
nasal  surfaces.  This  mode  of  origin  is  the  one  usually  described  by 
authors.  The  deposit  then  appears  as  a  flattened  tumor,  of  the  size  of  a 
bean   or  almond,  encroaching  upon  the  cavity  of  the  mouth.      It  is  at 

^  *'  Die  glatte  Atrnphie  der  Ztingenwurzel  und  ihr  Verhaltniss  zur  Syphilis,"  Arch, 
fur  Path.  Anal.,  etc.,  1894,  vol.  cxxxviii.  pp.  1  et  seq. 

^  "  Hemiatrophie  de  la  Langue  d'Origine  syithiYitique"  Annales  des  Mai.  de  l' Oreille 
et  du  Larynr,  Dec,  1887. 


AFFECTIONS  OF  THE  TONGUE,  ETC.  749 

first  hard  to  the  touch,  but  subsequently,  when  secondary  degeneration 
has  taken  place,  soft  and  fluctuating. 

2d.  In  other  cases  the  infiltration  is  difi'use.  No  tumor  exists,  but  the 
velum  is  generally  thickened,  its  mucous  membrane  reddened,  and  its 
mobility  unpaired,  as  is  evident  when  the  patient  attempts  to  articulate  or 
to  swallow. 

Rupture  of  the  abscess  or  ulceration  of  the  infiltrated  tissues  may  in- 
volve both  mucous  surfaces  or  only  one;  in  the  latter  case  it  is  usually 
the  buccal :  a  cavity  with  sharply-cut  and  ulcerated  edges  is  then  visible 
in  the  soft  palate,  while  possibly  the  voice  and  the  power  of  swallowing 
remain  unimpaired.  The  destructive  process,  however,  may  proceed  with 
great  rapidity,  and  complete  perforation  may  soon  follow.  The  perfora- 
tion may  be  limited  in  extent,  but  frequently  a  large  portion  or  the  whole 
of  the  velum  is  destroyed,  together  with  the  uvula  and  the  pillars  of  the 
fauces,  and  thus  an  immense  door  of  communication  is  opened  between 
the  mouth  and  nose.  It  is  thus  easy  to  account  for  the  indistinct  and 
nasal  voice — or  "  duck's  voice,''  as  the  French  call  it — of  such  patients, 
and  also  for  the  reflux  of  liquids  and  even  solids,  and  yet  the  absence  of 
pain  which  characterized  the  onset  of  the  disease  is  still  a  remarkable 
feature,  since  deglutition,  although  so  difiicult,  is  attended  with  a  merely 
triflins:  sensation  of  discomfort.  In  addition,  there  is  often  some  dulness 
of  hearing,  due,  doubtless,  to  the  oedema  of  the  tissues  composing  the 
walls  of  the  pharynx  and  surrounding  the  orifices  of  the  Eustachian 
tubes. 

In  time  the  subsidence  of  the  infiltration  is  followed  by  amelioration 
of  these  symptoms.  What  remains  of  the  velum  recovers  in  a  measure 
its  pliability  and  renews  its  function.  Practice  also  assists  in  teaching 
the  patient  how  to  avoid  regurgitation  of  solids  and  even  fluids.  Some 
improvement  also  takes  place  in  the  voice,  and  this  may  be  greatly  in- 
creased by  wearing  a  proper  plate  made  of  hard  rubber  or  gold.  The 
impairment  of  hearing  is  only  temporary. 

It  remains  to  speak  of  a  remarkable  sequel  of  this  affection — viz.  the 
change  which  usually  takes  place  in  the  fauces  as  a  consequence  of  the 
process  of  repair.  Directly  after  the  mischief  has  occurred  the  remains 
of  the  soft  palate  are  dependent,  and  the  opening  communicating  between 
the  mouth  and  nares  is  very  large.  One  would  naturally  suppose  that 
this  condition  would  continue,  or  would  even  be  aggravated  at  a  subse- 
quent period  after  cicatrization  had  taken  place.  Strange  to  say,  such  is 
not  the  course  of  events.  The  dependent  remains  of  the  palate  become 
elevated,  the  ulcerated  edges  contract  adhesion  with  the  ulcerated  walls 
of  the  pharynx,  and  the  opening,  which  at  first  was  simply  immense, 
gradually  contracts,  until  finally  complete  ati-esia  is  the  result,  or,  more 
frequently,  a  diminutive  channel  of  communication  remains  between  the 
buccal  and  nasal  cavities,  less  in  diameter  than  the  normal  opening. 

Cases  not  unfrequently  occur  in  which  the  surgeon  may  hesitate  to 
express  an  opinion  as  to  the  cause  of  ulceration  and  perforation  of  the 
soft  palate.  Two  causes  only  are  likely  to  produce  this  result :  syphilis 
and  tuberculosis,  and  the  former  by  far  more  frequently  than  the 
latter. 

If  the  patient  be  an  adult  who  has  enjoyed  at  least  tolerable  health 
until  the  present  attack,  there  can  be  little  doubt  but  that  the  cause  is 


750  SYPHILIS. 

syphilis.  No  matter  if  a  syphilitic  history  is  obscure  or  even  denied. 
Admitting  the  honesty  of  the  patient,  the  primary  and  secondary  symp- 
toms may  have  been  overlooked  or  forgotten  and  have  left  no  traces. 

Tertiary  lesions  often  appear  years  after  the  secondary  stage,  and 
when  least  expected.  Then,  too,  they  are  isolated,  without  concomitant 
symptoms  to  assist  the  diagnosis. 

The  diagnosis  rests  between  syphilis  and  tuberculosis,  with  the  chances 
in  favor  of  the  former.  The  history  of  the  patient  should  be  carefully 
inquired  into,  and  the  eyes,  the  nose,  and  the  teeth  should  be  carefully 
examined  to  determine  whether  they  were  ever  affected  by  syphilis. 

In  all  cases  the  effect  of  treatment  is  a  valuable  aid  to  diagnosis. 
Syphilitic  ulceration  usually  yields  to  full  doses  of  the  iodide  of  potas- 
sium and  mercury.  Tuberculous  ulceration  may  be  benefited  by  the 
same  remedy,  especially  if  combined  with  tonics,  but  it  exhibits  no  such 
marked  improvement  within  a  few  days. 

The  Pharynx. 

Lesions  similar  to  those  occurring  in  the  mouth  are  met  Avith  in  the 
pharynx.  Erythema,  superficial  ulcers,  and  deep  ulcerations  resulting 
from  degeneration  of  gummatous  deposit  may  be  observed.  The  occur- 
rence of  mucous  patches  of  the  pharynx  has  been  noted  by  several  au- 
thorities, but  they  are  not  common.  Frequently  ulcers  extend  into  the 
pharynx  from  the  posterior  nares. 

The  symptoms  of  pharyngeal  syphilis  are  usually  insignificant,  except 
in  the  case  of  ulcers,  when  there  may  be  pain,  aggravated  in  the  act  of 
swallowing  and  especially  on  the  ingestion  of  acrid  or  irritating  sub- 
stances. The  posterior  portion  of  the  lateral  Avails  of  the  pharynx  is 
more  often  attacked  than  the  posterior  wall.  Gummy  tumors  have  been 
observed  on  the  vault  of  the  pharynx  and  on  the  upper  part  of  its  pos- 
terior wall.  After  destroying  the  mucous  membrane  the  disease  may 
even  invade  the  vertebrae  and  produce  necrosis,  or  even  inflammation  of 
the  contents  of  the  vertebral  canal. 

Syphilitic  ulcerations  of  the  pharynx  are  of  special  interest  on  account 
of  the  traces  which  they  leave  in  the  form  of  cicatrices  or  of  adhesions, 
which  diminish  the  capacity  of  the  cavity  and  interfere  with  its  functions. 
The  cicatrices  seen  upon  the  pharyngeal  wall  are  quite  characteristic. 
They  may  present  a  stellate  appearance  or  may  assume  the  form  of 
prominent  bands.  The  cicatricial  tissue  is  white  and  glistening,  and 
may  persist  indefinitely  or  gradually  contract. 

In  rare  cases  the  entire  soft  palate  is  destroyed  by  ulceration  ;  necrosis 
of  the  hard  palate  occurs,  and  the  mouth,  the  nose,  and  the  pharynx  are 
converted  into  one  enormous  cavity.  In  milder  cases,  when  the  ulcerative 
process  is  limited  to  the  border  of  the  velum  and  pharyngeal  wall,  ad- 
hesions may  form,  which  divide  the  cavity  of  the  pharynx  into  tAvo  dis- 
tinct chambers,  one  communicating  with  the  posterior  nares  and  the  other 
with  the  mouth.  There  may  be  a  very  narroAV  passage  between  these 
two  cavities,  or  they  may  be  completely  shut  off  from  each  other,  respira- 
tion being  carried  on  exclusively  through  the  mouth. 

It  is  often  very  difficult  to  distinguish  betAveen  the  deep  ulcerations 
of  syphilis  and  those  of  tuberculosis.     There  are  at  least  four  points  to 


AFFECTIONS  OF  THE  TONGUE,   ETC.  751 

be  considered  in  making  a  diagnosis.  In  syphilis  other  lesions  are 
usually  found.  Syphilitic  ulcerations  follow  the  formation  of  a  gum- 
matous tumor ;  in  but  few  cases,  however,  on  account  of  the  very  slight 
inconvenience  occasioned  by  even  extensive  lesions,  is  the  patient  ob- 
served before  complete  destruction  of  the  original  gummy  tumor.  Spe- 
cific ulcers  usually  progress  more  rapidly  than  tubercular  ulcers,  and 
finally  they  yield  to  specific  treatment.  Some  observers  claim  that  the 
ulcers  themselves  present  distinctive  characteristics,  but  this  can  be  very 
rarely  the  case. 

The  diagnosis  must  be  based  chiefly  on  the  antecedents  of  the  patient 
and  the  history  of  the  lesion. 

Affections  of  the  Larynx. 

In  tertiary  syphilis  the  larynx  may  be  attacked  by  chronic  inflam- 
mation, by  deep  ulcerations,  and  by  gummy  tumors.  As  secondary  re- 
sults of  these  processes  perichondritis  and  caries  and  necroses  may  be 
developed. 

Chronic  Inflammation. — Chronic  inflammation  of  the  larynx  is  an 
intermediate  lesion ;  it  may  follow  an  early  catarrh  or  may  not  appear 
until  three  or  four  years  after  infection.  The  color  of  the  mucous 
membrane  is  decidedly  darker  than  in  the  early  erythemas,  although 
Whistler  affirms  that  it  never  deserves  the  name  "coppery,"  which  has 
been  applied  to  it  by  some  authors.  The  afiection  is  very  persistent, 
and  commonly  leads  to  thickening  or  hypertro'phy  of  the  mucous  mem- 
brane, which,  according  to  Krishaber,  is  the  only  one  of  the  early 
lesions  which  does  not  disappear  spontaneously.  This  thickening  is 
quite  diff'erent  from  the  oedema  occurring  with  an  erythema,  in  which 
the  mucous  membrane  has  a  puffy  appearance.  The  thickening  of  the 
cords  may  be  so  great  as  to  require  operative  interference  for  the  relief 
of  the  dyspnoea.  A  remarkable  instance  of  this  condition  has  been  re- 
ported, in  which  tracheotomy  was  done  four  times  during  a  period  of 
five  years.  Associated  wuth  this  condition  chronic  ulcers  are  almost 
always  found.  These  ulcers  have  ragged  and  thickened  edges ;  fre- 
quently vegetations  spring  from  them  which  may  reach  a  considerable 
size,  even  to  the  degree  of  producing  aphonia  and  of  impeding  respira- 
tion. The  vocal  cords,  which  are  thickened  and  rough,  are  very  often 
the  seat  of  these  ulcers.  The  ventricular  bands  may  be  so  swollen  as  to 
overlap  the  cords.  The  vegetations  which  may  grow  from  the  margins 
of  an  ulcer  or  from  other  portions  of  the  mucous  membrane  are  often 
difficult  to  distinguish  from  simple  polypoid  growths.  Their  favorite 
seat  is  at  the  insertion  of  the  inferior  vocal  cords.  Ferras  states  that 
they  may  appear  in  the  ventricles  of  the  larynx,  where  natural  papillcie 
are  scanty.  The  history  of  the  case,  or  even  the  empirical  use  of  spe- 
cific treatment,  may  sometimes  be  required  to  determine  their  character. 

Deep  Ulcerations. — Deep  ulcerations  occurring  in  the  later  stages 
of  syphilis  may  form  by  extension  from  the  pharynx  or  by  degeneration 
of  gummatous  deposit.  The  epiglottis  may  be  entirely  destroyed  by 
the  ulcerative  process.  Next  in  order  of  frequency  the  aryteno-epi- 
glottic  ligaments  are  attacked,  then  the  superior  vocal  cords,  and  more 
rarely  the  true  cords.     The  ulcerations,   especially  those  of  gummy 


752  SYPHILIS. 

tumors,  are  very  irregular  and  indurated.  Frequently,  vegetations  like 
those  occurring  in  connection  -svitli  the  ulcers  described  in  the  preceding 
section  accompany  these  deep  ulcerations.  Extensive  regions  may  be 
destroyed  in  a  chronic  and  insidious  manner,  irreparable  injury  being 
done.  These  ulcerations  can  hardly  be  confounded  T\ith  those  of  tuber- 
cular origin,  -which  are  smaller,  more  numerous,  and  more  superficial. 
The  lardaceous  base  and  the  general  appearance  of  the  lesions,  in  con- 
nection with  cicatrices  of  previous  ulceration,  suggests  their  specific 
character.  They  are  much  more  likely  to  be  mistaken  for  malignant 
disease.  In  cancer  the  tonsils  and  the  submaxillary  glands  are  at  an 
early  period  the  seat  of  infiltration.  Pain,  often  extreme,  is  distinctive 
of  cancer,  while  the  syphilitic  lesion  makes  much  slower  progress,  and 
is  generally  painless  until  the  tissues  have  been  extensively  destroyed. 
In  most  cases  of  syphilis,  moreover,  there  is  a  clear  history  of  infection, 
and  traces  of  former  lesions  may  be  discovered  in  the  mouth  or  pharynx 
or  in  other  regions  of  the  body. 

Gummy  Tumors. — Gummy  tumors  of  the  larynx  are  much  more 
common  than  has  been  supposed.  Two  forms  of  gummatous  deposit 
are  described  by  Simyan  :  a  circumscribed  variety  of  a  grayish-red 
color,  and  a  diffuse  infiltration  which  has  a  yellowish  color.  Virchow 
describes  gummy  tumors  of  the  larynx  as  extremely  vascular  nodules, 
of  softer  consistence  than  those  developed  in  other  regions,  which  grad- 
ually ulcerate  and  penetrate  the  deeper  tissues.  The  lesion  is  often 
single,  and  may  attain  a  very  large  size ;  frequently  the  tumors  are 
small  and  multiple,  and  may  be  limited  to  the  mucous  and  submucous 
tissues.  The  deposit  sometimes  undergoes  absorption,  but  more  fre- 
quently it  degenerates,  forming  the  deep,  ragged  ulcers  already  de- 
scribed, which  may  involve  the  framework  of  the  larynx  and  produce 
permanent  deformity.  The  epiglottis  and  the  arytenoids  are  most  often 
involved,  but  any  of  the  laryngeal  cartilages  may  suifer.  A  fatal  ter- 
mination may  ensue  in  the  course  of  these  lesions  from  impediment  to 
respiration,  due  to  the  size  of  the  tumor  or  to  an  acute  oedema  of  the 
larynx.  A  single  case  of  death  from  hemorrhage  has  been  recorded  by 
Tlirck. 

Perichoxdritis. — Perichondritis  is  generally  the  result  of  the  ex- 
tension of  an  inflammatory  or  ulcerative  process  from  the  mucous  and 
submucous  tissues.  The  cartilage  itself  may  be  involved.  Pain  of  a 
marked  character  is  a  common  symptom  of  this  lesion,  and  the  parts 
are  sensitive  to  external  pressure.  Crepitation  on  palpation  of  the  car- 
tilage is  referred  to  by  Jullien  and  others  as  a  sign  of  its  invasion. 
(Edema  of  the  soft  parts,  and  deformity  from  the  structural  changes  in 
the  afi"ected  cartilage,  are  frequently  observed.  The  epiglottis  and  the 
arytenoid  cartilages  are  most  often  involved,  more  rarely  the  cricoid. 
They  may  be  entirely  destroyed. 

Caries. — Caries,  or  true  necrosis,  in  cases  where  ossification  of  the 
cartilage  has  taken  place  is  a  common  sequel  of  the  invasion  of  the 
perichondrium  by  inflammation  or  gummatous  ulceration.  It  is  always 
a  very  late  accident,  and  frequently  induces  structural  changes  in  the 
larynx  which  cannot   be  remedied. 


AFFECTIONS  OF  THE  TONGUE,  ETC.  753 

The  (Esophagus. 

The  oesophagus  is  very  rarely  attacked  in  the  tertiary  stage  of  syph- 
ilis, and  no  cases  are  on  record  in  which  it  was  the  seat  of  morbid  change 
in  the  secondary  stage.  Hermann  ^  could  only  find  twelve  recorded  and 
trustworthy  cases  in  medical  literature  of  tertiary  disease  of  the  tube. 
The  case  of  Mr.  West^  is  one  of  the  most  satisfactory  thus  far  reported. 
It  was  that  of  a  girl  aged  twenty-one  who  had  suffered  for  several  years 
from  well-marked  syphilitic  manifestations,  such  as  eruptions  upon  the 
skin,  ash-colored  ulcerations  of  the  fauces,  rheumatic  pains,  and  syph^ 
ilitic  cachexia,  and  who  was  admitted  into  Queen's  Hospital,  May  18, 
1858,  for  stricture  of  the  oesophagus.  Treatment  by  means  of  tonics, 
iodide  of  potassium,  and  mercurials  afforded  only  temporary  relief,  and 
she  succumbed  on  Sept.  2d  of  the  same  year.  The  following  appear- 
ances were  found  at  the  post-mortem  examination  :  "  The  upper  portion 
of  the  oesophagus  for  about  four  inches  was  much  dilated ;  its  mucous 
membrane  thickened,  and  marked  by  spots  having  the  appearance  of 
recent  cicatrices.  At  this  distance  from  the  upper  end  it  was  suddenly 
constricted,  and  terminated  in  a  narrow  canal  which  would  barely  admit 
a  No.  4  catheter.  This  constricted  portion,  which  was  about  two  inches 
and  a  half  in  length,  was  formed  by  the  thickening  of  the  mucous  mem- 
brane and  by  fibrous  deposit  in  the  form  of  bands  and  bridles,  having 
very  much  the  appearance  of  an  old  stricture  of  the  urethra.  Below 
this  track  the  oesophagus  continued  perfectly  healthy  to  its  termination 
in  the  stomach.  Both  lungs  contained  tubercular  deposit  in  diff"erent 
degrees  of  softening,  with  several  small  cavities  in  the  upper  lobe  of 
each,  one  in  the  left  apex  being  as  large  as  a  pigeon's  egg." 

Birch-Hirschfeld  ^  speaks  of  a  gummatous  ulcer  which  extended  down 
the  oesophagus  to  the  stomach. 

This  affection  begins  in  submucous  gummatous  infiltrations,  runs  a 
chronic  course,  and  leads  either  to  ulceration  or  absorption,  stricture 
inevitably  resulting  in  either  case.  If  the  case  is  seen  early,  active 
antisyphilitic  treatment  may  bring  about  resolution.  When  cicatricial 
stenosis  has  developed,  internal  treatment  will  be  of  no  use,  and  gradual 
dilatation,  if  possible,  should  be  tried.  In  extreme  cases  gastrostomy 
may  be  necessary. 

All  cases  of  stricture  of  the  oesophagus  arise  from  caustics,  from 
syphilis,  and  from  cancer.  Traumatism  being  excluded,  the  diagnosis 
rests  between  syphilis  and  cancer.  It  is  always  well  to  give  the  patient 
a  thorough  tentative  antisyphilitic  course  of  treatment.  It  is  Avell  to 
remember  that  in  cases  of  syphilis  of  the  oesophagus  epithelioma  is 
liable  to  attack  the  specific  neoplasm  or  its  sequelae. 

*  "  St^nose  de  I'Qilsophage  d'Origine  syphilitique,"  These  de  Paris,  1890. 
^  Dnblin  Quarterly  Journal  of  Medical  Science,  Feb.,  1860. 

*  Lehrbuck  far  Path.  AnaL,  M  ed.,  1887,  vol.  ii.  p.  518. 

48 


754  SYPHILIS. 

CHAPTER    LXXIIL 

AFFECTIONS  OF  THE  TRACHEA,  BRONCHI,  LUNGS,  AND  HEART. 

The  trachea,  bronchi,  lungs,  and  heart  may  be  the  seat  of  morbid 
changes  in  tertiary  syphilis.  The  trachea  alone  may  be  attacked ;  in  some 
patients  the  bronchi  are  involved;  and  in  rather  rare  cases  the  trachea, 
bronchi,  and  lungs  are  affected. 

These  affections  are  not  common,  and  we  are  not  to-day  in  possession 
of  sufficient  knowledge  to  allow  us  to  give  a  full  description  of  the  clinical 
history. 

Undoubtedly  some  cases  of  late  syphilitic  changes  in  these  parts  are 
diagnosticated  as  of  cancerous  origin,  and  in  many  their  syphilitic  nature 
is  only  ascertained  after  death. 

Trachea. 

Parrain,^  who  has  gone  over  the  subject  of  gummatous  affections  of 
the  trachea  quite  fully,  reports  two  cases  in  which  a  diagnosis  of  syphilis 
was  made  during  life.  The  first  case  was  that  of  a  woman  forty-nine 
years  old,  who  early  in  her  trouble  suffered  from  a  raucous  cough  and 
dyspnoea,  but  whose  voice  was  not  much  changed  from  normal.  Gradu- 
ally the  respiration  became  more  difficult,  and  was  attended  with  a  whist- 
ling sound  and  a  roaring  noise  in  the  trachea,  frequent  cough,  and  much 
muco-purulent  expectoration.  There  were  also  nocturnal  paroxysms  of 
suffocation.  Under  the  use  of  the  mixed  treatment  improvement  began 
and  a  complete  cure  resulted. 

Parrain's  second  case  was  that  of  a  man  aged  thirty-nine  years,  who 
had  much  dyspnoea  and  tracheal  roaring  sounds  and  coincident  drawing 
in  of  the  substernal  and  epigastric  walls.  At  the  autopsy  mucous  and 
submucous  swelling  was  found,  which  extended  into  and  nearly  obliterated 
the  left  bronchus. 

Frankel  ^  reports  the  case  of  a  woman  forty-one  years  old  who  had  a 
raucous  voice  and  coughed  for  six  months  before  she  died.  The  trachea 
was  found  to  be  normal  down  to  the  fourth  ring,  and  from  there  to  the 
bifurcation  it  was  studded  by  a  number  of  small  salient  nodules,  some  of 
which  were  ulcerated,  and  interspersed  among  them  were  several  star- 
shaped  cicatrices.  In  this  case  the  bronchi  were  surrounded  by  a  hard, 
cartilaginous  connective  tissue.     The  thyroid  gland  was  also  affected. 

The  case  of  a  sixty-year-old  woman  in  which  extensive  gummatous 
ulceration  of  the  trachea,  extending  into  the  bronchi,  was  found,  together 
with  chronic  interstitial  pneumonia,  has  been  reported  by  Scheck.^ 

The  lesions  in  tertiary  syphilis  of  the  trachea  are  gummatous  infiltra- 
tion and  dense  connective-tissue  proliferation.  As  a  result  of  these  con- 
ditions ulceration,  cicatrization,  and  stenosis  follow. 

^  "  Sur  les  Gommes  syphilitiqnes  de  la  Trachee,"  Th'^se  de  Bordeaux,  1894. 

^  "Ueber  Tracheal  und  Schilddriisen  Syphilis,"  Deut.  med.  Wochemchri/t,  1887,  No.  48, 
p.  1035. 

^  "  Beitrag  zur  Lehre  von  der  Syphilis  der  Lunge,  Trachea,  imd  Bronchien,"  Intemat. 
klin.  Rundschau,  1887,  p.  142. 


AFFECTIONS  OF  THE  TRACHEA,  ETC.  755 

According  to  Dreschfeld/  the  most  prominent  symptoms  of  tracheal 
stenosis  are — 1.  Dyspnoea,  most  marked  during  inspiration,  and  especially 
so  on  any  exertion  of  the  patient.  This,  though  a  most  prominent  symp- 
tom, may  occasionally  be  absent,  though  the  obstruction  to  the  entrance 
of  air  into  the  lungs  may  be  very  great.  '2.  A  hoarse,  weak,  or  croupy 
voice,  even  if  the  larynx  be  free  from  disease,  due  to  the  weak  air-cur- 
rent. 3.  Swelling  of  the  jugulars  with  every  expiration,  due  to  the 
abnormally  increased  pressure  in  the  large  veins  within  the  thorax  during 
expiration.  4.  Slight  downward  movement  of  the  larynx  with  every 
inspiration.  This  movement  is  much  more  considerable  in  stenosis  of  the 
larynx.  5.  The  patient  breathes  easier  Avith  his  chin  depressed,  as  this 
causes  relaxation  and  dilatation  of  the  trachea.  In  laryngeal  stenosis,  on 
the  other  hand,  the  head  is  thrown  back  to  facilitate  the  breathing.  6. 
Retraction  of  the  lower  part  of  the  chest  with  every  inspiration.  7.  Loud 
inspiratory  stridor,  heard  best  over  the  sternum,  occasionally  accompanied 
by  a  thrill  to  be  distinctly  felt  over  the  place  of  constriction.  Ausculta- 
tion of  the  luncps  reveals  weak  breathing  and  loud  rhonchi,  unless  there 
be  some  lung  complication.  It  often  happens  that  the  stricture  is  at  the 
bifurcation  of  the  trachea,  and  extends  to  one  bronchus  rather  than  to 
both.  In  such  cases  we  have  the  characteristic  symptoms  of  stricture  of 
a  bronchus  (diminished  fremitus,  diminished  breathing,  and  more  marked 
inspiratory  retraction  of  the  ribs)  on  that  side.  8.  The  laryngoscopic 
examination  may  enable  us  to  see  the  affected  part,  especially  if  the  stric- 
ture is  high  up  in  the  trachea  or  if  the  ulceration  is  extensive ;  and  the 
introduction  of  a  sound  through  the  larynx,  recommended  first  by  Demme, 
may  in  doubtful  cases  assist  us  in  our  diagnosis.  In  spite  of  these  definite 
symptoms,  the  diagnosis  between  syphilitic  stricture  of,  and  pressure  on, 
the  trachea  is  sometimes  a  matter  of  great  difficulty. 

Bronchi. 

The  bronchi  are  similarly,  and  often  synchronously,  affected  by  the 
same  processes  which  attack  the  trachea.  There  are  many  more  or  less 
satisfactorily  reported  cases  of  late  syphilitic  disease  of  the  bronchi,  in  all 
of  Avhich  stricture  is  the  prominent  feature.  A  recent  and  very  well- 
observed  case  is  that  of  Oestreich.^  It  was  that  of  a  Avoman  who  was 
supposed  to  suffer  from  tuberculosis,  although  no  bacilli  were  found  in  the 
sputum.  This  woman's  voice  was  normal,  and  the  respiratory  movements 
of  the  left  chest  Avere  very  weak.  She  suffered  from  paroxysms  of  dysp- 
noea, and  over  the  left  lung  dulness  in  some  places  and  tympanitis  in 
others  were  heard.  At  the  autopsy  the  lumen  of  the  left  bronchus  was 
found  to  be  nearly  obliterated.  This  stenosis  Avas  due  to  a  radiating  cica- 
trix Avhich  began  at  the  bifurcation  and  extended  into  the  bronchus. 

The  Lungs. 

Our  knowledge  of  the  pathological   anatomy  of  syphilitic  processes 

in  the  lungs  is  far  in  advance  of  that  of  its  symptomatology  and  clinical 

history.     The  truth  is,  that  Ave  have  not  yet  such  criteria  as  Avill  enable 

us  to  sharply  distinguish  in  the  living  subject  the  differences  between 

^  Medical  Chronicle,  Dec,  1885.  ^  Bed.  klin.  Wochemchrifl,  1894,  2so.  44,  p.  1008. 


756  SYPHILIS. 

pulmonary  tuberculosis  and  syphilitic  infiltration  into  the  lungs.  Many 
mild  cases  of  localized  lung  disease  in  syphilitics  are  seen  which  get 
well  under  specific  treatment,  and  from  these  very  important  cases  we 
can  derive  no  anatomico-pathological  facts  which  will  show  us  just  what 
has  taken  place.  Then,  again,  in  many  cases  of  syphilitic  infection  the 
resulting  lung  trouble  is  complicated  by  essential  tubercular  lesions,  and 
this  symbiosis  makes  our  clinical  studies  uncertain  or  of  no  value. 

The  morbid  anatomy  of  syphilis  of  the  lungs  has  been  carefully 
studied  by  Lancereaux,^  who  in  a  recent  essay  states  that  the  lesions  are 
rather  rare,  but  the  anatomical  changes  are  sufficiently  Avell  marked  as 
to  be  readily  recognized.  They  occur  in  the  form  of  indurations  and 
gummata.  Syphilitic  sclerosis  differs  from  tuberculous  induration  of 
the  lung  in  many  ways.  It  is  met  with,  as  a  rule,  in  the  lower  or 
middle  lobes  rather  than  at  the  apices,  and  in  the  form  of  bands  and 
fibrous  tracts  which  are  not  welded  together  into  a  compact  mass,  but 
may  enclose  islets  of  lung-tissue,  generally  more  or  less  emphysematous. 
The  fibrous  tissue  is  not  pigmented.  The  bronchi  in  relation  with  these 
indurations  are  often  flattened,  and  the  alveoli  are  filled  with  exudative 
fluid  containing  leucocytes  and  desquamated  endothelial  cells.  The 
pleura  is  often  thickened  and  adherent  about  such  diseased  areas,  and 
the  surface  of  the  lung  is  puckered  and  furrowed  in  much  the  same 
manner  as  the  surface  of  a  cirrhosed  liver.  Syphilis  and  tubercle  may 
be  combined  in  the  same  organ,  but  the  appearance  of  the  sclerosed 
tissue  is  distinct  in  each.  Cavities  and  the  presence  of  fresh  tubercle 
in  other  parts  will  aid  the  diagnosis.  It  is  probable  that  many  cases  of 
chronic  tuberculous  disease  have  been  classed  in  literature  as  syphilitic. 
Chronic  pneumonia  gives  a  firm,  compact,  indurated  mass,  soft  and 
glossy  to  the  feel  and  not  puckered  on  the  surface.  Leprosy  of  the 
lung  is  very  rarely  seen,  and  the  characteristic  bacilli  would  serve  to 
distinguish  it.  Gumma  of  the  lung  is  met  with  rather  more  frequently 
than  syphilitic  induration,  but  is  still  very  uncommon,  and  no  case 
should  be  accepted  as  such  without  absolute  proof.  Lancereaux  gives 
the  details  of  a  case,  and  from  the  microscopic  structure  of  the  gum- 
matous masses  he  believes  that  they  are  formed  by  peripheral  increase 
from  a  starting-point  of  periarteritis.  Fatty  degeneration  takes  place 
in  the  centre  of  the  mass,  but  the  remains  of  alveolar  walls  and  flattened 
epithelium  can  often  be  recognized.  The  parts  around  may  be  thickened 
by  proliferation  of  lymphoid  cells  and  congestion,  and  about  the  whole 
mass,  which  is  indicated  under  the  term  "gumma,"  there  is  always  a 
zone  of  indurated  tissue  more  or  less  firm  and  vascular.  The  fatty 
degeneration  of  the  centres  of  the  masses  may  lead  to  liquefaction,  and 
the  evacuation  of  the  fluid  thus  produced  causes  considerable  irritation 
of  bronchi.  Cicatrices  are  often  found  in  the  neighborhood  of  the  gum- 
mata, and  a  dry  pleurisy  is  usually  set  up,  which  results  in  dense  adhe- 
sions. Syphilis  never  causes  a  purely  serous  exudation  in  the  pleura. 
The  diagnosis  by  physical  signs  is  exceedingly  difficult,  and  the  symp- 
toms are  apt  to  be  very  misleading.  Cough,  dyspnoea,  haemoptysis,  and 
muco-purulent  sputum  may  all  be  present,  but  the  absence  of  the  bacilli 

^  "Syphilis  des  Poumons,  etc.,"  U  Union  medieale,  1891,  No.  13,  pp.  145  et  seq.  The 
reader  is  also  referred  to  an  excellent  essay  by  Satterthwaite  ("Pulmonary  Syphilis  in 
the  Adult,"  Boston  Med.  and  Surg.  Journal,  June  11  and  18,  1891). 


AFFECTIONS  OF  THE  TRACHEA,  ETC.  757 

from  the  latter  will  form  an  important  element  in  the  diagnosis.  Wasting, 
as  a  rule,  only  occurs  when  the  liver  or  spleen  is  attacked  by  the  disease, 
and  it  may  thus  happen  that  Avasting  will  be  progressive  while  the  con- 
dition of  the  lung  is  improving.  The  latter  tends  to  become  stationary 
after  a  while,  and  if  other  organs  are  not  affected  the  prognosis  is  good. 
The  suspicion  of  syphilis  should  always  attach  to  lesions  beginning  in 
the  lower  parts  of  the  lung,  and  slowly  progressing  without  the  produc- 
tion of  fever.     (See  section  on  Pleurisy,  page  588.) 

Affections  of  the  Heart. 

In  late  syphilis  the  heart  may  be  attacked  by  a  chronic  inflammation 
which  produces  a  sclerosing  fibrous  tissue,  and  it  may  be  the  seat  of  gum- 
mata.  The  endocardium,  the  myocardium,  and  the  pericardium  may  be 
attacked. 

Endocarditis  usually  coexists  with  myocarditis.  In  an  exhaustive 
study  of  the  reliable  published  cases  T.  Lang  ^  traces  the  course  of  these 
affections.  The  walls  of  the  heart  are  more  commonly  attacked  than  the 
valves.  The  most  frequent  location  of  endocarditis  is  in  the  left  ventricle, 
at  the  apex  or  at  the  base  of  the  heart  near  the  opening  of  the  aorta. 
The  vegetative  or  verrucous  form  is  much  less  common  than  the  fibrous 
or  sclerotic.  Gummy  endocarditis  is  usually  combined  with  the  fibrous 
form  of  syphilitic  myo-  and  pericarditis.  Its  clinical  symptoms  are  indef- 
inite and  little  known.  Very  often  it  runs  its  course  without  apparent 
symptoms.     The  prognosis  is  unfavorable. 

Syphilitic  endocarditis  is  always  circumscribed,  and  rarely  occurs  prior 
to  the  second  year  after  infection.  The  fibrous  form  generally  attacks 
the  left  ventricle,  especially  at  the  apex,  the  anterior  wall,  and  the  septum 
ventriculorum.  Its  origin  is  found  in  the  interfibrillar  connective  tissue. 
The  gummy  form  is  generally  associated  with  the  fibrous,  and  affects  all 
parts  of  the  organ  and  all  the  layers  of  its  wall.  The  tumors  may  attain 
the  size  of  a  hen's  egg  or  a  billiard-ball.  As  long  as  the  destruction  of 
muscular  substance  is  inconsiderable  or  compensated  by  hypertrophy  of 
the  intact  tissue,  and  as  long  as  the  neuro-muscular  apparatus  of  the 
heart  is  unaffected,  the  myocarditis  occasions  no  considerable  functional 
disturbance. 

Syphilitic  pericarditis  is  rarely  primary,  but  usually  follows  myocar- 
ditis, and  therefore  involves  especially  the  visceral  layer.  But  the  entire 
pericardium  may  be  implicated.  The  chronic  or  fibrous  form  leads  to  the 
formation  of  a  compact,  coarse-fibred  tissue,  to  contraction,  deformation 
of  the  contiguous  surface  of  the  heart,  and  constriction  of  the  sreat 
vessels. 

Gummata  of  the  pericardium  rarely  occur  except  as  the  result  of  the 
extension  of  myocarditis.  In  one  of  Mracek's^  cases,  besides  a  gumma  of 
the  left  ventricle,  the  pericardium  was  injected  and  infiltrated  by  gray 
granulations  of  the  size  of  the  head  of  a  needle  and  disseminated  in  little 
groups.  In  several  cases  it  has  been  noted  that  the  process  began  in  the 
aorta  and  extended  to  the  heart. 

^  Die  SyphiUs  rles  Herzenn,  Vienna,  1889. 

"^  "  Die  Syphilis  des  Herzens,  etc,"  ArchivfUr  Derm,  unci  Syph.,  Erganzungsheft,  No.  2, 
1893,  pp.  279  et  seq.  yj    >      h  S        ,  . 


758  SYPHILIS. 

The  symptomatology  of  syphilis  of  the  heart  has  been  well  studied  hj 
Buchwald/  and  shows  a  wide  range.  It  includes  headache,  dizziness, 
flashes  of  light,  loss  of  strength,  palpitation,  dyspnoea,  feverishness,  sore 
throat.  In  some  cases  there  were  symptoms  of  angina  pectoris,  and  neur- 
algic pains  like  those  of  aneurysm.  In  all  cases  there  was  irregularity 
of  the  heart,  more  or  less  hypertrophy,  and,  what  is  especially  noteworthy, 
alterations  in  the  peripheral  vessels,  such  as  are  commonly  ascribed  only 
to  old  age.  The  arteries  were  hard  and  tortuous,  more  especially  the 
temporal  arteries,  and,  to  a  less  extent,  the  radials. 

The  course  of  the  disease  was  also  characteristic.  The  cases  in  which 
the  heart  insufficiency  could  no  longer  be  influenced  favorably  quickly 
became  worse,  developing  marasmus,  and  kidney  disease  and  sometimes 
pulmonary  infarction,  with  hsemoptysis. 

The  majority  of  cases  showed  a  rapid  improvement  under  antisyphilitic 
treatment.  One  case  that  developed  aortic  insufficiency  while  under 
observation  was  so  much  improved  that  no  trace  of  this  lesion  was  recog- 
nizable. Another,  whose  heart  lesion  was  cured,  developed  sudden 
aphasia  and  cerebral  disease,  but  recovered  from  this  also  under  large 
doses  of  iodide  of  potash.  In  other  cases  the  peripheral  arteries  recovered 
from  their  hard  and  tortuous  condition.  (See  sections  on  Aneurysm  and 
on  Gangrene  for  further  information  relative  to  changes  in  the  vessels.) 


CHAPTER    LXXIV. 

AFFECTIONS  OF  THE  LIVER  AND  SPLEEN. 

The  Liver. 

The  liver  is  more  frequently  attacked  by  syphilis  than  any  other  abdom- 
inal organ.  The  mild  and  ephemeral  jaundice  has  already  been  described. 
(See  page  591.) 

The  late  syphilitic  lesions  of  the  liver  have  been  very  exhaustively 
described  by  Chvostek.^  According  to  this  observer,  syphilis  causes  in 
the  liver — (1)  amyloid  degeneration,  Avhich  results  from  cachexia ;  (2) 
perihepatitis,  usually  with  decided  thickening  of  the  capsule,  leading  to 
adhesions  with  surrounding  parts ;  (3)  hepatitis,  in  which  there  is  con- 
siderable increase  in  the  connective  tissue,  followed  by  shrinking  and  the 
formation  of  cicatrices.  Of  hepatitis  there  are  two  forms — the  diff"use  and 
the  gummatous. 

The  symptoms  are  usually  so  mild  that  the  patient  has  no  suspicion 
that  his  liver  is  attacked  until  considerable  time  has  elapsed. 

The  liver  may  be  somewhat  enlarged,  and  is  frequently  irregular,  and 

^  Op-  cit. 

^  "  Ueber  Svphilitische  Hepatitis,  etc.,"  Vierteljahr.  filr  Derm,  und  Syphilis,  vol.  xiii., 
18S1,  pp.  325  et  seq. 


AFFECTIONS  OF  THE  LIVER  AND  SPLEEN.  759 

on  its  surface  there  may  be  nodular  protuberances  of  the  size  of  a  ^yalnut 
or  egg,  between  which  are  deep  sulci. 

Pain,  either  localized  or  diffused,  in  the  hepatic  region  is  the  most 
common  symptom.  It  may  be  sharp  and  severe  or  dull  and  persistent. 
It  is  made  worse  by  pressure  upon  the  organ.  This  symptom  generally 
ceases  in  a  gradual  manner. 

In  cases  of  perihepatitis  pain  is  sometimes  very  severe,  and  when  the 
process  is  recent  a  friction-sound  may  be  heard.  In  these  cases  the  peri- 
toneum is  involved  by  the  extension  of  the  morbid  process.  As  a  result 
of  pressure  upon  the  portal  vein  ascites  may  occur.  The  spleen  may  also 
become  affected,  and  in  some  cases  there  is  hemorrhage  from  the  stomach. 
Albuminuria  is  a  very  common  complication.  Patients  thus  aifected  have 
a  sickly,  earthy  look,  with  perhaps  some  bronzing  of  the  skin. 

The  diagnosis  of  liver-syphilis  should  be  based  on  the  history  of  the 
case,  on  its  symptoms,  and  on  concomitant  visceral  lesions.  From  cancer 
it  is  distinguished  by  the  synchronous  albuminuria  and  splenic  enlarge- 
ment, by  the  very  great  irregularity  of  surface  produced  by  the  protuber- 
ances, and  by  its  slow  stationary  condition  during  a  long  period  of  time. 
In  cirrhosis  there  is  usually  no  history  of  syphilis,  but  one  of  alcoholism 
is,  as  a  rule,  readily  obtained. 

The  prognosis  of  syphilis  of  the  liver  is  not  good,  but  relief  may  result 
from  treatment  if  begun  sufficiently  early. 

Syphilis  of  the  liver  occurs  more  frequently  in  men  than  in  women, 
and  appears  from  two  to  twenty  years  after  the  onset  of  the  infection. 
Peiser,^  as  the  result  of  the  study  of  34  cases  of  liver-syphilis  (21  men, 
13  women),  in  which  the  date  of  infection  and  of  the  onset  of  the  visceral 
disease  was  clearly  made  out  in  15,  found  that  it  began  as  follows :  At  2|- 
months  in  1  case ;  2  years  in  1 ;  3  to  4  years  in  4 ;  6  to  7  years  in  3 ;  12 
years  in  1 ;  14  years  in  1 ;  18  years  in  1 ;  20  years  in  1 ;  23  years  in  1 ; 
25  years  in  1.  Structural  changes  in  the  liver  are  most  commonly  found 
in  patients  between  twenty  and  fifty  years  of  age. 

Late  Jaundice. 

Besides  the  mild  and  ephemeral  variety  already  described  (see  page 
591),  we  sometimes  observe  in  the  course  of  syphilis  at  late  periods  a 
severe  form  of  jaundice.  This  variety  differs  in  the  great  severity  of 
the  symptoms,  in  the  well-marked  and  persistent  discoloration  of  the 
skin,  and  in  the  existence  of  a  very  profound  cachexia.  There  may  or 
may  not  be  coexisting  syphilitic  lesions  on  the  body,  but  such  patients 
are  usually  afflicted  with  severe  neuralgias  and  persistent  headache. 
Unless  the  patient  is  carefully  attended  to,  this  condition  goes  from  bad 
to  worse,  and  is  sometimes  followed  by  a  fatal  result.  It  is  a  condition 
which  indicates  grave  disease,  and  should  not  be  underestimated.  Its 
duration  is  generally  chronic,  and  the  affection  is  not  prone  to  be  easily 
influenced  by  treatment.  This,  besides  combining  specific  medication, 
should  be  addressed  to  the  visceral  trouble.  Tonics,  nutritious  food,  with 
stimulants  used  with  judgment,  should  be  administered. 

The  causes  of  this  affection  of  the  liver  are  very  obscure  and  have  not 
been  cleared  up  by  post-mortem  studies.     Lancereaux  thinks  that  it  is 

'■  Die  Lehersypldlis,  brochure,  Leipsic,  1886. 


760  SYPHILIS. 

due  to  compression  of  the  biliary  ducts  by  enlarged  lymphatic  ganglia, 
while  Fournier  is  of  the  opinion  that  it  has  its  origin  in  gastro-intestinal 
catarrh.  That  syphilis  has  an  influence  in  its  causation  is  now  generally 
admitted,  since  so  many  observers  have  noted  its  development  in  infected 
persons  who  had  not  previously  been  thus  affected,  and  who  had  not 
taken  mercury  nor  been  addicted  to  the  excessive  use  of  alcoholics. 

Precocious  hepatitis  and  perihepatitis  are  somewhat  infrequently  ob- 
served. Driihe  ^  reports  the  interesting  case  of  a  man  twenty-one  years 
old  who  had  a  chancre  and  small  papular  eruption.  Fourteen  days  after 
the  onset  of  the  secondary  period  the  area  of  liver  dulness  became  much 
diminished,  and  the  spleen  became  swollen.  The  man  also  suffered  from 
albuminuria  and  hemorrhages  from  the  nose  and  intestine.  After  death, 
which  occurred  two  months  after  infection,  diffuse  hepatitis  and  peri- 
hepatitis were  found. 

* 
Acute  Yellow  Atrophy  of  the  Liver. 

Engel-Reimers  ^  reports  three  cases  of  acute  yellow  atrophy  of  the 
liver  in  adult  syphilitics  in  the  early  months  of  the  infection.  The  clin- 
ical history  and  pathological  anatomy  were  in  accord  with  that  of  the 
non-specific  form  of  the  disease.  Every  other  pathogenic  cause,  phos- 
phorus-poisoning, etc.,  was  excluded,  and  the  dependence  of  the  disease 
on  syphilis  was  established  to  the  author's  satisfaction.  Senator^  also 
reports  two  cases  similar  to  those  of  Reimers. 

The  Spleen. 

The  spleen  may  be  the  seat  of  structural  change  in  the  late  period  of 
syphilis.  The  early  affection  has  already  been  described.  (See  page 
590.) 

The  late  syphilitic  processes  in  the  spleen  consist  of  an  interstitial  and 
a  gummatous  infiltration. 

In  interstitial  inflammation  the  process  begins  around  the  blood- 
vessels, and  a  diffuse  connective  tissue  which  presses  on  the  pulp  is  pro- 
duced. In  this  condition  the  organ  may  be  much  diminished  in  size. 
The  connective-tissue  bands  are  paler  than  the  normal  tissue,  from  which 
they  do  not  project  at  all,  but  merge  diffusely  into  the  surrounding 
spleen-tissue,  contain  but  little  blood  and  few  cells,  and  in  the  centre 
consist  of  a  finely  granular  material  in  which  a  few  cells  and  nuclei  are 
imbedded. 

GUMMATA    OF    THE    SpLEEN. 

Gummata  vary  in  size  from  that  of  a  millet-seed  to  that  of  a  walnut, 
and  may  be  few  in  number  or  very  numerous.  Their  number  is  usually 
greater  when  their  size  is  small.  In  some  cases  the  spleen  itself  is  en- 
larged. The  tumors  are  usually  found  near  the  trabeculse  and  deeply 
seated,  or  at  the  periphery  of  the  organ  ;  in  the  latter  case  the  capsule  is 
thickened.     Recent   tumors   have   a   reddish-gray  color,  and  are  more 

1  "Zwei  Falle  von  Maligner  Lebersyphilis," /wa?/.*/.  Dissert,  Munchen,  1888. 

'^  "  Ueber  die  Visceraleii  Erkrankungen  in  der  Friihperiode  der  Syphilis,"   Monat- 

'te  fur  Prakt.  Dermatol.,  1892,  vol.  xv.  pp.  481  et  seq. 

^  Charite  Annalen,  vol.  xviii.,  1893,  pp.  322  et  seq. 


AFFECTIONS  OF  THE  STOMACH,  INTESTINES,  AND  RECTUM.     761 

dense  and  tough  than  the  normal  spleen-tissue  ;  when  old  they  are  dry 
and  of  a  yellowish-gray  color.  When  young  they  are  less  clearly  de- 
fined than  at  a  later  period,  when  they  may  become  distinctly  encapsu- 
lated. The  vessels  and  the  structure  of  the  organ  in  the  neighborhood 
of  the  tumors  are  more  or  less  destroyed.  Cicatricial  contraction, 
especially  in  the  capsule,  subsequently  occurs.  The  spleen  has  several 
times  been  found  adherent  to  the  diaphragm  in  consequence  of  peritonitis 
from  irritation  by  gummy  tumors. 

We  know  little  of  the  symptomatology  of  this  affection.  Enlarge- 
ment of  the  spleen  is  sometimes  demonstrable,  and  in  some  cases,  when 
the  tumors  are  superficial,  inflammation  of  the  capsule  and  localized 
peritonitis  occur. 

In  the  cases  hitherto  observed  the  lesion  has  generally  been  accom- 
panied by  similar  affections  of  other  viscera,  and  the  patients  have  suf- 
fered from  cachexia  or  marasmus. 

Gold  ^  publishes  the  pathological  results  derived  from  the  study  of 
ten  cases  of  late  syphilis  of  the  spleen.  He  also  gives  the  literature  of 
the  subject  up  to  the  date  of  his  essay. 


CHAPTER    LXXV. 

AFFECTIONS  OF  THE  STOMACH,  INTESTINES,  AND  RECTUM. 

The  Stomach. 

There  are  no  symptoms  which  are  pathognomonic  of  syphilitic 
lesions  of  the  stomach.  Syphilis  of  the  stomach  is  of  very  rare  occur- 
rence, and  it  is  generally  recognized  after  death  by  means  of  the  micro- 
scope. Many  of  the  old  cases  reported  in  literature  are  so  wanting  in 
clinical  and  pathological  data  that  they  are  of  no  scientific  use.  The 
cases  of  Cornil  ^  and  Chiari  ^  are  worthy  of  record.  Cornil's  case  was 
that  of  a  woman  who  had  gummata  of  both  liver  and  stomach.  On  the 
mucous  membrane  of  the  small  curvature  near  the  pylorus  was  a  number 
of  flattened  reddish  tumors  of  a  diameter  of  from  two  to  five  centimetres. 
The  gummata  were  developed  in  the  submucous  layer,  and  their  structure 
consisted  of  a  dense,  compact,  felt-like  tissue  formed  of  fasciculi  of  con- 
nective tissue  infiltrated  with  small  round  cells. 

Chiari's  case  was  that  of  a  man  twenty-three  years  old  and  two  years 
syphilitic,  and  who  died  of  tuberculosis.  He  had  suffered  from  gastric 
pains  and  vomiting.  The  stomach  was  the  seat  of  numerous  gummatous 
infiltrations  and  of  an  ulcer  of  about   ten   centimetres   in  diameter.     In 

^  "  Zur  Kenntniss  der  Milzsyphilis,"  Arch,  fur  Derm,  and  S]jph.,  vol.  xii.,  1880,  pp. 
463  et  seq. 

^  Lemons  sur  la  Syphilis,  Paris,  1879,  p.  406. 

'  "  Ueber  Magensyphilis,"  Internal.  Beitr.  zur  Wissensch.  Med.,  Virchov/s  Festschr.,  1891, 
pp.  295  et  seq. 


762  SYPHILIS. 

this  case  there  were  similar  lesions  in  the  intestines.  Chiari  states  that 
gummatous  lesions  of  the  stomach  may  after  ulceration  become  cicatrized. 
Zavadski  and  Luxembourg^  report  the  case  of  a  man  who  suffered  from 
vomiting  and  a  sensation  of  heat  near  the  xyphoid  appendix,  and  died 
eight  months  after  the  onset  of  his  illness.  The  stomach  was  the  seat 
of  a  round  ulcer,  and  the  mucous  membrane  near  it  was  very  much  thick- 
ened. Round-cell  infiltration  around  the  vessels  in  the  submucous  con- 
nective tissue  was  found  by  microscopic  examination.  Galliard^  has 
also  described  round  ulcers  of  the  stomach  resulting  from  syphilitic 
infiltrations. 

Intestines. 

Our  knowledge  of  the  effect  of  syphilis  on  the  intestines  is  based  on 
post-mortem  studies,  and  it  is  at  best  very  meagre.  The  older  writings 
of  Oser,  Meschede,  and  Wagner  have  shown  that  ulceration  of  the  ilium 
may  sometimes  be  found  in  old  syphilitics. 

Bjornstrom  reported  the  case  of  a  man  fifty-one  years  old  who  died 
of  symptoms  of  acute  peritonitis,  in  whom  perforation  of  the  large  in- 
testine was  found.  Besides,  there  were  six  ulcers,  seated  chiefly  in  the 
jejunum,  which  caused  thickening  of  the  intestinal  walls. 

Ulceration  of  the  ilium  and  of  the  rectum,  which  Avas  the  seat  of 
stricture,  was  found  after  death  by  Hahn^  in  a  thirty-three-year-old 
woman  Avho  died  of  exhaustion. 

De  Michel^  and  Sorrentino  ■*  give  the  details  of  two  autopsies  in  which 
firm,  round,  elongated  patches  with  irregular  ulcerated  surfaces  were 
found,  together  with  great  hypertrophy  of  the  muscular  fibres.  The 
minute  morbid  appearances  resembled  those  of  gummata. 

Hayem  ^  and  Tissier  report  the  case  of  a  woman  presenting  very  exten- 
sive cutaneous  lesions,  who  Av,as  in  a  typhoidal  state  and  was  delirious. 
After  death  several  small  circular  ulcers  were  found  in  the  caecum,  together 
with  some  cicatrices  of  previous  lesions.  These  authors  think  that  this 
case  was  one  of  typhoidal  syphilis  with  intestinal  lesions. 

The  Rectum. 

Syphilitic  affections  of  the  rectum  are  to-day  not  Avell  understood,  but 
it  is  possible  to  describe  them  in  a  clear  manner.  The  facts  here  given 
were  learned  by  me  in  the  long  observation  of  many  women  afflicted  with 
vulvar,  vaginal,  and  rectal  syphilitic  lesions. 

Syphilis  attacks  the  rectum  in  three  distinct  forms:  first,  early  or 
rather  late  in  the  course  of  the  disease  by  the  extension  of  indurating 
oedema,  which  may  accompany  infiltrating  or  ulcerating  lesions,  and  which 
tends  to  the  production  of  more  or  less  complete  rings  of  connective 
tissue ;  second,  by  the  formation  of  true  gummatous  infiltration ;  and, 
third,  by  the  development  of  a  form  of  inflammation  with  the  production 
of  new  connective  tissue,  in  which  congestion  and  exudative  products  are 

^  Gaz.  Lekaroka,  1893,  vol.  xiii.  pp.  1233  et  seq. 

^  "Syphilis  gastrique,  etc.,"  Arch.  gen.  de  Med.,  Jan.,  1886,  pp.  66  et  seq. 

^  Deut.  med.  Wochcnschrift,  1892,  vol.  xviii.  pp.  G9  et  seq. 

♦  La  Riforma  Medica,  Aug.  3,  1892,  pp.  302  et  seq. 

*  Revue  de  Medecine,  April,  1889. 


AFFECTIONS  OF  THE  STOMACH,  INTESTINES,  AND  RECTUM.      763 

absent.  This  third  form  is  a  chronic  productive  or  cellular  inflammation 
of  slow  invasion  and  of  persistent  nature. 

Indurating  oedema  complicates  early  and  late  syphilitic  infiltrations 
and  ulcerations  which  are  seated  in  the  vulva  or  vagina  and  near  and  in 
the  anus.  The  indurating  process  then  extends  to  and  surrounds  the 
anus,  either  between  the  two  sphincters  or  about  one,  two,  or  three  inches 
above  the  internal  one.  The  walls  of  the  rectum  become  thickened,  less 
supple  and  extensible,  than  they  are  normally,  and  if  proper  treatment  is 
not  adopted  in  the  course  of  several  months  or  a  year  or  two  a  tough  and 
difi'use  stricture  is  formed.  This  form  of  rectal  stricture  is  usually  found 
in  syphilitic  women  in  the  secondary  or  early  tertiary  stage.  It  is  gen- 
erally the  result  of  neglect  of  treatment  of  their  lesions. 

In  some  cases  there  are  ulcerations  Avhich  present  points  of  resemblance 
to  chancroids,  and  for  this  reason  some  authors  speak  of  chancroidal 
stricture  of  the  rectum.  Chronic  chancroids  may  produce  stenosis  of 
this  tube,  but  it  will  generally  be  found  that  their  bearers  also  suffer  from 
syphilis. 

This  form  of  rectal  stricture,  if  seen  and  treated  early  by  local  and 
systemic  medication,  is  curable.  Its  prognosis  is  better  in  proportion  as 
the  infection  is  recent. 

The  second  form  of  syphilis  of  the  rectum  may  or  may  not  result  in 
stricture.  The  essential  features  of  four  cases  of  this  affection  observed 
by  me  will  give  a  clear  idea  of  its  nature  and  course.  The  first  case  was 
that  of  a  man  thirty-three  years  old  who,  after  a  prolonged  attack  of  diar- 
rhoea, suffered  from  obstinate  constipation  and  experienced  an  uneasy 
sensation  in  the  rectum,  particularly  at  the  anus,  when  at  stool  and  at 
various  times  during  the  day.  About  two  inches  above  the  sphincter,  on 
the  posterior  wall  of  the  rectum,  a  thickened  patch  of  mucous  membrane 
two  inches  long  and  one  and  a  half  wide,  with  sharp  and  abrupt  margins, 
could  be  seen.  The  surface  of  this  lesion  was  somewhat  papillomatous, 
and  its  structure  was  firm.  Under  active  local  and  general  treatment 
resolution  slowly  took  place,  and  a  firm  cicatrix  which  did  not  materially 
contract  the  tube  was  left. 

The  second  case  was  that  of  a  woman  forty  years  of  age  who,  besides 
having  a  well-marked  tertiary  lesion,  complained  of  a  sensation  of  a 
hindrance  or  impairment  of  the  expulsive  power  in  defecation.  The 
anus  was  normal,  but  rather  more  than  two  inches  above,  on  the  anterior 
wall  of  the  rectum,  was  a  hard,  firm  patch  or  tumor  of  oval  shape,  of  a 
diameter  of  fully  two  inches.  It  was  elevated  fully  half  an  inch  and 
had  a  convex,  slightly  papillated  surface.  There  was  slight  tenderness 
in  and  around  the  tumor,  but  no  abnormal  heat  nor  discharge.  On 
examination  of  the  swelling  bimanually  with  the  fingers  in  rectum  and 
vagina,  it  was  found  to  involve  the  mucous  membrane  of  the  rectum  and 
seemingly  to  encroach  on  the  subcutaneous  tissue  between  that  and  the 
vagina.  Its  shape  was  readily  made  out,  and  it  Avas  found  to  be  distinctly 
movable.     This  woman  was  cured  by  treatment. 

The  third  case  was  also  that  of  a  woman  twenty-eight  years  old,  who 
in  the  sixth  year  of  syphilis  complained  of  pain  and  uneasiness  in  the 
rectum,  from  which  a  discharge  flowed.  On  examination  I  found  the 
anus  red  and  inflamed,  and  on  introduction  of  the  finger  two  inches  into 
the  rectum,  on  its  posterior  and  lateral  wall  was  a  deep  ulcer  with  thick- 


764  SYPHILIS. 

ened  and  sliarply-cut  edges  and  of  an  area  of  fully  two  inches.  This 
ulcer  was  very  rebellious  to  treatment,  but  it  finally  yielded. 

The  lesion  in  this  case  was  undoubtedly  a  gumma  which  underw^ent 
degeneration. 

The  fourth  case  was  that  of  a  twenty-three-year-old  woman,  syphi- 
litic for  five  years.  On  examination,  on  the  posterior  wall  of  the  vagina, 
about  two  and  a  half  inches  deep,  was  a  ragged  opening  through  which 
a  probe  could  be  passed  into  the  rectum  and  withdrawn  through  the 
anus ;  there  was  also  a  stricture  of  the  rectum  about  two  and  a  half 
inches  up.  The  woman  stated  that  she  had  discovered  a  lump  in  the 
posterior  wall  of  the  vagina  about  two  months  before,  which  was  not 
accompanied  with  pain.  She  had  for  several  months  previously  suffered 
from  the  local  effect  of  the  stricture  of  the  rectum. 

I  have  seen  several  cases  in  which  syphilitic  infiltration  of  the  pos- 
terior vaginal  wall  increased  in  depth  and  attacked  the  rectum,  which 
as  a  result  became  stenosed. 

The  following  somewhat  similar  cases,  reported  by  Zeissl  ^  and  Zap- 
pula,^  are  worthy  of  record.  Zeissl's  case  was  that  of  a  man  syphilitic 
fourteen  years,  who  presented  a  fungous  mass  growing  from  the  scrotum. 
The  slow,  painless  course  of  this  lesion  suggested  its  syphilitic  nature. 
While  under  treatment  for  this  affection  the  patient  complained  of  pain 
in  the  rectum,  attended  by  bloody  and  diarrhoeal  discharges;  very  soon 
a  brownish-black,  ill-smelling  mass  was  found  protruding  from  the  anus, 
which  after  removal  proved  to  be  composed  of  connective  and  elastic 
tissue.  On  digital  examination  a  SAvelling  the  size  of  a  walnut  was  dis- 
covered on  the  right  wall  of  the  rectum,  from  which  a  sanious  pus  could 
be  expressed.  Periosteal  nodes  were  also  present  at  this  time.  Zeissl 
concludes  that  the  anal  tumor  was  a  syphilitic  new  growth,  and  that  it 
was  of  exceptional  importance  on  account  of  its  occurrence  in  a  male 
patient. 

In  Zappula's  case  of  rectal  stricture  a  cure  was  effected  by  the 
internal  use  of  iodide  of  potassium,  A  case  with  a  similar  result  is  also 
mentioned  by  Allingham.  The  patient,  a  man  thirty-six  years  of  age, 
had  gonorrhoea  and  an  ulcer  on  the  glans  fifteen  years  before.  Mer- 
curial treatment  was  at  once  begun,  and  no  lesion  of  syphilis  subse- 
quently appeared.  Fifteen  years  later  he  began  to  suffer  from  pains  to 
the  right  of  the  anus  and  in  the  right  tuberosity  of  the  ischium.  Very 
soon  the  symptoms  of  rectal  stricture  became  well  marked,  and  so 
extreme  was  the  intestinal  obstruction  that  large  fecal  tumors  formed, 
and  could  be  felt  through  the  abdominal  walls.  Upon  examining  the 
rectum  with  the  finger  smooth,  elastic  elevations  of  the  mucous  mem- 
brane were  felt,  rather  in  the  form  of  folds  than  of  condylomata  or  other 
adventitious  deposits.  Examination  with  the  speculum  showed  the 
mucous  membrane  hypertrophied,  uniformly  swollen,  and  slightly  mam- 
millated.  A  sound  could  readily  be  introduced  to  a  depth  of  11  centi- 
metres (4|  inches),  but  there  met  an  impassable  obstruction.  On  a 
second  examination  there  was  found  at  a  depth  of  4  centimetres  (l-j%- 
inches)  a  painless  swelling  the  size  of  a  hazelnut,  globular,  smooth,  and 

^  Vierteljahr.  fib-  Derm,  und  Syphilis,  1875,  pp.  1.S7  *t  seq. 

^  Ann.  univ.  di  Med.,  Milano,  ccxiii.,  1870;  also  Arch.  f.  Dermat.  u.  Syph.,  1871, 
p.  90. 


VARIOUS  RARE  AFFECTIONS.  765 

elastic,  which  was  situated  beneath  the  mucous  membrane  and  appeared 
not  to  adhere  to  the  latter.  The  diagnosis  lay  between  syphilis  and 
cancer.  Giving  the  patient  the  benefit  of  the  doubt,  he  was  placed 
upon  antisyphilitic  treatment,  consisting  of  large  doses  of  the  iodide  of 
potassium.  In  the  course  of  twelve  days  the  pain  disappeared,  the 
tumor  diminished  in  size,  natural  stools  took  place,  and  the  patient  was 
at  last  completely  restored  to  health. 

The  third  form  of  syphilitic  disease  of  the  rectum  is  that  of  annular 
fibroid  stricture,  and  it  is  not  due  to  an  essential  syphilitic  process,  but 
it  belongs  in  the  catagory  of  parasyphilitic  aifections,  in  which  this 
disease  shows  a  tendency  to  productive  and  cellular  inflammation.  This 
occurs  very  frequently  m  the  genitals  of  young,  and  particularly  of  old, 
syphilitic  women  long  after  the  activity  of  the  diathesis  has  ceased.  In 
some  cases  the  external  genitals  are  the  seat  of  the  hyperplasia,  and  in 
others  the  vaginal  w^alls  are  attacked.^ 

Either  synchronously  with  the  vulvar  or  vaginal  affection,  or  in  an 
uncomplicated  state,  this  affection  attacks  the  rectal  wall  and  runs  around 
it  in  ringed  form.  As  has  already  been  stated,  there  is  no  hypergemia 
and  there  are  no  exudative  products  :  there  is  simply  this  chronic  pro- 
ductive inflammation,  which  goes  slowly  and  persistently  on,  and  inevita- 
bly leads  to  the  formation  of  a  dense,  unyielding  ring  of  fibrous  tissue, 
which  may  in  the  end  thoroughly  occlude  the  gut.  Why  syphilis  should 
thus  lead  to  the  cellular  inflammation  localized  to  a  segment  of  the  rec- 
tum, from  three  to  six  inches  above  the  anus,  we  do  not  know.  Nor  do 
we  know  whether  any  traumatic  conditions  tend  to  thus  localize  this 
stenosing  process.  We  do  know,  however,  that  in  some  syphilitic  women 
a  periproctitis,  differing  in  no  particular  from  that  found  in  uninfected 
women,  occurs,  and  that  it  entails  long  suffering  and  may  lead  to  death. 


CHAPTEE  LXXVI. 

VARIOUS   RARE   AFFECTIONS. 

The  Parotid,  the  Sublingual  Gland,  the  Thyroid  Gland,  the  Pan- 
creas, the  Suprarenal  Capsules,  the  Pineal  Gland,  and  the 
Peritoneum. 

The  parotid  gland  may  very  exceptionally  be  attacked  in  the 
secondary  and  tertiary  stages  of  syphilis.  Neumann  ^  has  reported  four 
cases  in  which  this  gland  became  much  SAVollen  at  the  same  time  that 
other  manifestations  were  present  on  the  body.     The  parotid  infiltrations 

1  The  clinical  history  and  the  pathological  anntorav  of  the  morbid  process  are  fnilv 
given  in  my  essay  on  "  Chronic  Inflammation  of  the"  External  Genitals  in  Women,"" 
New  York  Med.  .Journ.,  June  4,  1890. 

^  Arch,  fur  Derm,  und  Syphilis,  1894,  vol.  xxix.  pp.  3  et  seq. 


76Q  SYPHILIS. 

were  cured  by  specific  treatment.  Lang^  has  also  reported  two  cases  of 
gummatous  infiltration  into  the  parotid  gland. 

The  sublingual  gland  may  be  attacked  early  and  late  in  the  course 
of  syphilis,  but  recorded  cases  are  very  rare.  Neumann^  has  also  re- 
ported a  case  in  which  a  woman,  syphilitic  four  years,  presented  a  swelling 
as  large  as  a  nut  of  the  sublingual  gland,  together  Avith  infiltration  of  the 
adjacent  mucous  membrane.  In  this  case  there  was  also  an  infiltration 
in  one  of  the  glands  of  Blandin-Nuhn,  which  are  deeply  seated  in  the 
tissue  of  the  tongue  near  its  tip  on  either  side  of  the  median  line. 
Fournier^  also  reported  the  case  of  a  man  who  in  the  eleventh  year  of 
syphilis  presented  a  swelling  of  the  sublingual  gland  which  underwent 
resolution  by  the  use  of  iodide  of  potassium  for  three  months. 

The  thyroid  gland  may  be  the  seat  of  gummatous  infiltrations,  but 
it  is  attacked  much  less  frequently  in  acquired  than  in  hereditary  syph- 
ilis. In  the  case  already  referred  to  and  reported  by  Frankel  (see  page 
754),  besides  syphilitic  infiltration  of  the  trachea  a  small  gummatous 
nodule  was  formed  in  the  right  lobe  of  the  gland.  Lang  also  speaks  of 
thp  case  of  a  man  who,  besides  general  early  manifestations,  had  a  rather 
painful  swelling  of  the  size  of  a  chestnut  in  the  thyroid  gland.  The 
case  of  PospelofF  *  is  interesting  and  unique.  It  was  that  of  a  man, 
syphilitic  six  years,  who  had  suffered  from  severe  gummatous  lesions  and 
profuse  diabetes  insipidus,  and  who  also  presented  cerebral  symptoms.  At 
this  time  gummatous  infiltration  into  the  testicles  developed,  and  an  elastic 
painless  tumor  of  the  size  of  a  nut  was  felt  at  the  upper  third  of  the 
thyroid  cartilage.  These  swellings  disappeared  under  the  influence  of 
treatment  in  three  months.  But  the  man  continued  in  bad  health.  He 
suffered  severely  with  cold  sensations,  his  hair  fell  out,  and  his  nails  be- 
came dry  and  brittle.  He  became  apathetic  and  lost  sexual  desire. 
Soon  the  face  assumed  a  waxy  hue  and  was  oedematous.  These  condi- 
tions, together  with  the  absence  of  sweating  for  two  years,  disturbances 
of  speech,  parsesthesia  of  the  extremities  and  of  the  back,  presented  a 
good  picture  of  myxoedema.  The  patient  was  ben-efited  by  antisyphilitic 
treatment  and  several  doses  of  thyroid  extract.  Pospeloff  is  disposed  to 
attribute  these  disorders  to  cirrhosis  of  the  thyroid  gland,  which  followed 
the  infiltration  process. 

The  pancreas,  alone  or  synchronously  with  visceral  lesions,  may  be 
attacked  by  gummatous  infiltration.  Such  cases  have  been  reported 
by  Rokitansky  and  Lancereaux.  Chvostek  ^  found  in  a  case  of  syph- 
ilis of  the  skin  and  viscera  cicatricial  condensation  of  the  tail  of  the 
pancreas. 

The  suprarenal  capsules  have  in  a  few  cases  been  found  to  be  the 
seat  of  connective-tissue  increase  and  gummatous  infiltration.  Gordon 
reports  a  case  in  which  during  life  the  morbid  conditions  of  Addison's 
disease  were  observed,  and  at  the  autopsy  Avhat  appeared  to  be  gum- 
matous degeneration  of  the  suprarenal  capsules  was  found.  (See  also 
page  641.) 

^  Wien.  med.  Wochenschrift,   1880.  No.  9,  and  Vorlesungen  iiber  Path,  und  Therap.   der 
Syphilis,  Wiesbaden,  1895  (first  part),  p.  295. 
^  Op.  cii. 

^  Annales  de  Derm,  et  de  Syph.,  vol.  vii.  pp.  81  et  seq. 
*  Medizinskoie  Obozrenie,  1 891:5,  No.  22. 
^  Wien.  med.  Wochenschrift,  1877,  No.  33. 


AFFECTIONS  OF  THE  MUSCLES,  ETC.  767 

The  pineal  gland  has  been  found  to  be  the  seat  of  gummatous  infil- 
tration by  Birch-Hirschfeld '  and  Weigert.^ 

The  Peritoneum. — Primary  syphilitic  changes  in  this  membrane  have 
not  been  found.  It  is  sometimes  the  seat  of  cellular  infiltration  by  the 
extension  of  the  syphilitic  processes,  which  attack  the  intestines  and 
viscera. 


CHAPTER    LXXVII. 

AFFECTIONS  OF  THE    MUSCLES,  OF  THE   TENDINOUS  SHEATHS, 
AND  OF  THE  APONEUROSES  AND  BURS^. 

Myositis. 

Myositis  is  sometimes  found  in  secondary  syphilis,  but  generally  in 
the  tertiary  stage.  It  occurs  in  three  principal  forms  :  first,  the  irritative 
or  hypersemic  ;  second,  the  chronic  infiltrative ;  and,  third,  in  the  form 
of  gummatous  nodules. 

Irritative  myositis  is  usually  seen  to  coexist  with  the  early  manifesta- 
tions, particularly  of  the  larger  joints  and  tendons,  and  it  is  attended 
with  rheumatoid  pain,  soreness,  and  perhaps  impairment  of  function. 
The  myalgias  produced  by  the  early  irritative  syphilitic  process  are,  as  a 
rule,  ephemeral  and  readily  yield  to  proper  treatment.  In  this  form  of 
myositis  no  permanent  structural  change  is  produced. 

Chronic  myositis  tends  to  more  or  less  permanent  contraction  of  the 
member  or  parts  on  or  in  which  the  muscle  is  situated.  It  occurs  in  two 
forms — the  localized  and  the  diifuse. 

According  to  Virchow,  this  lesion  is  analogous  to  that  produced  by 
rheumatic  inflammation.  "  In  the  interspaces  between  the  muscular 
fasciculi  a  connective  tissue  is  developed,  which  hardens  and  results  in 
atrophy,  and  finally  in  the  destruction  of  the  primitive  muscular  fibrils." 
We  thus  find  at  the  outset  the  presence  of  abnormal  nuclei,  cells,  and 
fibres  in  the  cellular  tissue,  and  afterward  a  secondary  degeneration  of 
this  new  formation,  resulting  in  atrophy  of  the  normal  elements,  contrac- 
tion of  the  muscle  itself,  and  in  some  instances  calcareous  and  bony  de- 
posits. This  lesion  usually  escapes  observation  until  the  contraction  of 
the  muscle,  interfering  with  motion  or  producing  flexion  of  the  limb, 
attracts  attention. 

One  or  more  muscles  may  be  attacked.  Those  most  frequently 
affected  are  the  flexors  of  the  upper  extremity,  and  especially  the  biceps. 
Notta  met  with  six  cases,  in  two  of  which  the  disease  was  confined  to  the 
biceps  ;  in  two  others,  to  the  biceps  and  supinator  longus  and ;  in  the  re- 
maining case  to  the  flexors  of  the  fingers.  The  biceps  has  been  affected 
with  the  same  frequency  in  the  cases  reported  by  other  observers. 

'  Lehrbuch  der  Path.  Anal.,  vol.  ii.,  1887,  p.  472. 
■■'  Archivfiir  Path.  Anat.,  vol.  Ixv.  p.  223. 


768  SYPHILIS. 

In  each  of  the  ten  cases  reported  by  Mauriac  ^  the  biceps  was  the  seat 
of  this  affection  ;  in  nine  it  was  the  only  muscle  involved,  while  in  one 
case  the  triceps  was  attacked  at  the  same  time.  In  seven  of  these  cases 
the  left  biceps  was  affected,  in  two  both  right  and  left,  and  in  only  one 
was  the  muscle  of  the  right  side  alone  affected.  When  both  biceps  and 
triceps  are  involved  muscular  ankylosis  of  the  elbow  results. 

The  contraction  comes  on  insidiously,  and  the  first  symptom  noticed 
by  the  patient  is  an  inability  to  extend  the  limb.  On  examining  the 
affected  muscle  no  change  is  perceptible  by  palpation  either  in  its  size  or 
texture  ;  its  power  of  contraction  is  normal ;  and  there  is  simply  a  dimi- 
nution in  length,  as  shown  by  its  tension  when  the  limb  is  forcibly  ex- 
tended. The  tendon  of  insertion  of  the  biceps  is  always  prominent  and 
tense,  and  the  muscle  itself  appears  to  be  in  a  state  of  partial  con- 
traction. 

Pouley^  has  reported  a  case  in  which  muscular  contraction  was  so 
severe  that  the  thighs  were  drawn  up  to  the  abdomen  and  the  legs  up  to 
the  thighs. 

In  neither  of  Notta's^  six  cases  was  the  fleshy  portion  of  the  muscle 
sensitive  to  pressure,  but  in  five  pain  was  excited  by  pressing  upon  one 
or  both  of  the  tendinous  insertions  and  by  forced  extension. 

According  to  Mauriac,  spontaneous  pain  was  absent  in  some  cases, 
while  in  others  the  muscle  was  the  seat  of  a  dull  aching  sensation  which 
was  subject  to  exacerbations.  In  other  instances  the  patients  suffered 
from  neuralgia  of  the  muscle  or  other  parts.  The  contraction  increases, 
slowly  in  most  cases,  but  rapidly  in  some,  up  to  a  certain  point,  when 
it  remains  stationary.  In  five  cases  in  which  the  biceps  was  affected,  the 
angle  formed  by  the  arm  and  forearm,  when  the  latter  was  extended  to 
the  utmost,  measured  160°,  135°,  130°  and  90°,  respectively.  In  an- 
other case  the  ring  and  little  fingers  were  completely  flexed  upon  the 
palm  of  the  hand. 

In  none  of  Notta's  cases  h:id  the  patients  ever  suffered  from  rheu- 
matism, which,  therefore,  could  have  had  no  part  in  producing  the  mus- 
cular contraction,  but  all  presented  unquestionable  syphilitic  symptoms, 
which  in  three  belonged  to  the  tertiary  period,  in  two  to  the  secondary, 
and  in  one  to  both  the  secondary  and  tertiary  periods. 

Mauriac,  however,  regards  this  as  a  precocious  rather  than  a  tertiary 
affection.  He  has  observed  it  as  earl}'-  as  the  second  and  as  late  as  the 
fifteenth  month  of  syphilis,  and  thinks  that  we  may  fix  upon  the  tenth 
month  as  the  average  date  of  its  appearance.  It  occurs  in  the  mild 
rather  than  in  the  severe  cases  of  syphilis.  He  thinks  that  rheumatism 
has  no  etiological  relation  to  this  affection, which  is  myo-neuropathic  in  its 
nature  ;  in  other  words,  syphilis  affects  the  peripheral  nerves  and  muscles. 
The  intensity  of  the  diathesis  has  slight  influence  upon  its  development ; 
of  nine  cases,  but  one  was  severe,  five  were  mild,  and  three  were  of  me- 
dium severity.  It  is  accompanied  by  non-ulcerative  more  frequently 
than  by  ulcerative  lesions. 

This    affection    may  last  months    or  years,  and,  while  it  yields    with 

^  Lemons  sur  les  Myopathies  syphilitiques,  Paris,  1878. 
^  Medical  Compend,  Jan.,  1890. 

"  "Memoire  sur  la  Retraction  musculaire,"  Arch.  gen.  de  Med.,  Dec,  1850,  pp.  413 
et  seq. 


AFFECTIONS  OF  THE  MUSCLES,  ETC.  769 

moderate  promptness  to  treatment,  it  is  capable  also  of  spontaneous 
cure.  Its  course  is  not  alwa_ys  uniform,  since  it  is  liable  to  remissions 
and  relapses. 

According  to  Neumann,^  the  sphincter  of  the  anus  is  more  frequently 
attacked  than  the  biceps.  This  affection,  he  says,  is  developed  earlier 
than  other  myosites,  and  is  seen  mostly  in  women.  The  symptoms  are 
pain  and  tenesmus  during  and  after  defecation.  The  totality  of  the 
muscle  is  not  involved,  since  some  fibres  may  be  spared.  Neumann  says 
that  the  lesion  begins  in  changes  in  the  vessels  of  the  perimysium,  and  it 
may  produce  serious  trouble. 


Gummatous  Tumors. 

These  tumors  begin  in  round-cell  infiltrations  around  the  vessels  of  the 
perimysium.  They  grow  slowly  and  usually  without  pain,  and  reach 
various  sizes,  and  sometimes,  as  in  Koehler's^  case,  they  involve  a  large 
mass  of  muscles.  In  this  case  the  tumor  extended  from  the  left  hypo- 
chondrium  to  the  inguinal  fold,  and  from  the  linea  alba  to  the  axillary 
line.  In  Netter's^  case  the  tumor  was  seated  in  the  sartorius  muscle,  was 
subaponeurotic,  and  was  five  inches  long  by  four  inches  wide.  These 
tumors  are  of  various  shapes,  globular,  fusiform,  flat,  or  irregular,  accord- 
ing to  the  nature  of  the  parts  in  which  they  are  seated.  When  superficial 
they  become  adherent  to  the  aponeurosis,  which  becomes  inflamed  and 
hypertrophied.  Being  frequently  developed  near  the  ends  of  the  muscles, 
the  tendons  are  sometimes  secondarily  involved. 

They  are  most  easily  detected  when  the  muscle  is  relaxed,  and  their 
independence  of  the  subjacent  bone  can  then  be  best  established.  They 
excite  little  or  no  pain,  unless  the  muscle  be  put  upon  the  stretch,  and 
their  chief  inconvenience  is  due  to  their  interference  with  motion.  They 
sometimes  produce  contraction  of  the  muscles,  but  this  is  not  a  necessary 
result. 

They  usually  appear  late  in  the  disease,  but  Mauriac  has  seen  them  in 
three  cases  as  early  as  three  and  five  months  after  infection,  and  I  have 
observed  a  tumor  in  the'  sterno-mastoid  muscle  in  the  fourteenth  month  of 
syphilis.  These  gummatous  tumors  of  the  muscles  may,  in  exceptional 
cases,  undergo  softening,  break  down,  and  form  deep  ulcers. 

They  are  very  often  accompanied  by  other  syphilitic  manifestations, 
such  as  nodes,  exostoses,  tubercles  of  the  cellular  tissues,  or  ulcerations 
of  the  fauces. 

Their  prognosis  is  good,  particularly  if  they  are  treated  early. 

The  dift'use  and  the  localized  myosites  are  rather  rarely  found  in  com- 
bination. Ostermeyer^  has  published  an  interesting  case  in  which  the 
triceps  muscle  Avas   thus   attacked,  and   in  which   suppuration   occurred. 

^  "  Beitrag  zur  Kenntniss  der  Myositis  syphilitica,"  Arch,  fur  Derm,  und  Syph.,   1886, 
pp.  19  et  seq 

_  2  Berl.  klin.  Wochenschrift,  No.  8,  1892,  pp.  162  et  seq.    Being  diagnosticated  as  sarcoma, 
this  mass,  with  part  of  the  diaphragm,  was  exsected.     When  it  was  found  tliat  this  lesion 
was  not  sarcomatous,  the  man  was  put  upon  antisyphilitic  treatment  and  cured.    The  left 
side  of  the  abdomen  was  only  covered  with  integument  after  the  operation. 
^  Archives  gen.  de  Med.,  1880,  pp.  218  et  seq. 

*  Arch,  fur  Derm,  und  Syphilis,  1892,  Ergiinzungsheft,  pp.  13  et  seq. 
49 


770  SYPHILIS. 

Affections  of  the  Tendinous  Sheaths  and  of  the  Tendons  and 

Aponeuroses. 

These  structures  are  sometimes  attacked  in  early  and  in  late  syphilis. 
In  the  early  stage,  and  in  the  second  and  third  years  of  syphilis,  these  parts 
may  be  the  seat  of  an  irritative  process  which  may  give  rise  to  effusion  or 
to  the  development  of  fibrous  tissue.  In  tertiary  syphilis  they  sometimes 
become  infiltrated  by  gummatous  deposits. 

We  sometimes  see  swellings  which  occur  on  the  backs  of  the  hands, 
and  which  follow  the  course  of  the  tendons,  but  never  extend  beyond  the 
dorsal  ligament ;  they  are  of  triangular  shape,  with  their  base  toward  the 
fingers.  They  are  due  to  effusion  and  yield  a  sensation  of  fluctuation ; 
they  cause  little,  if  any,  pain,  unless  of  unusually  large  size,  when  the 
skin  over  them  may  be  inflamed  and  painful.  They  occur  in  the  early 
years  of  syphilis  and  are  developed  rapidly. 

The  tendons  of  the  wrist,  ankle,  foot — in  fact,  any  tendon — may  be 
thus  attacked.  The  lesion  is  a  hypergemia  of  the  sheath  attended  by 
serous  eff"usion.  The  shape  of  the  resulting  tumors  varies  according  to 
the  conformation  of  the  parts. 

They  are  firm  and  elastic  and  sometimes  fluctuate.  The  overlying  skin 
is  frequently  reddened.  They  form  rapidly,  and  are  often  attended  with 
pain.  Fournier  believes  that  many  of  the  early  pains  of  syphilis  are  due 
to  hyperaemia  of  the  sheaths  of  the  tendons,  and  especially  that  the  pain 
sometimes  present  in  the  bend  of  the  elbow,  intensified  by  firm  pressure, 
is  due  to  inflammation  of  the  tendon  of  the  biceps. 

Tendons  may,  in  rare  cases,  be  the  seat  of  gummy  infiltrations,  which 
exist  in  the  form  of  small  subcutaneous  tumors,  usually  unattended  by 
spontaneous  pain.  After  remaining  indolent  for  a  long  time  they  may 
break  down  and  form  troublesome  ulcers.  Van  Oort  cites  a  case  of  gummy 
tumor  of  the  third  extensor  tendon  seated  over  the  middle  of  the  meta- 
carpal bone.  Such  a  tumor  might  be  mistaken  for  simple  ganglion. 
When  the  tendon  is  attacked  near  a  joint  the  latter  may  be  secondarily 
involved. 

The  tendons  are  also  subject  to  gummatous  changes  near  their  inser- 
tion and  in  their  thicker  portions.  The  larger  tendons  and  those  most 
constantly  in  use  are  most  frequently  involved.  Sabail  reports  a  case  of 
gummy  tumor  involving  the  tendo  Achillis  of  each  leg.  Nelaton  has 
twice  found  them  in  the  tendon  of  the  triceps  cruris,  and  cases  are  on 
record  in  which  the  ligamentum  patellae,  the  tendon  of  the  sterno-mastoid 
muscle,  the  anterior  tendon  of  the  thigh,  and  the  flexor  tendons  of  the 
legs  were  thus  affected.  Finally,  Bouisson  has  reported  a  case  of  strabis- 
mus due  to  a  gummy  tumor  in  the  tendon  of  one  of  the  orbital  muscles. 

The  aponeuroses  may  be  the  seat  of  localized  or  diffuse  fibroid  infil- 
tration. 

Affections  of  the  Bursse. 

The  burs?e  are  rather  infrequently  attacked  by  irritative  and  hyper- 
plastic processes  in  secondary  and  tertiary  syphilis. 

In  the  secondary  period,  sometimes  coincidently  with  the  onset  of 
general  manifestations,  one  or  more  bursas  are  affected.  As  a  result, 
we  find  decided  swellings — not,  however,  very  sharply  definable — under 
the  skin,  which  may  or  may  not  be  hyperaemic.     These  early  bursal 


AFFECTIONS  OF  THE  MUSCLES,  ETC.  Ill 

swellings  on  palpation  yield  a  fluctuating  or  a  doughy  sensation.  They 
are  sometimes  rather  sensitive,  but  not,  as  a  rule,  painful.  They  dis- 
appear promptly  under  specific  treatment,  provided  the  parts  on  which 
they  are  seated  are  put  at  rest  and  are  not  subjected  to  pressure.  Inter- 
esting cases  of  this  early  form  of  bursitis  have  been  reported  by  Trost ' 
and  Buechler.^  In  the  first  five  years  of  syphilis  hyperplasia  of  burs^e 
some^Yhat  rarely  occurs  in  the  form  of  quite  sharply-circumscribed, 
rather  firm  tumors,  which  run  an  indolent  and  painless  course  until 
affected  by  local  and  general  treatment.  This  variety  of  bursitis,  an 
interesting  case  of  which  I  have  reported,^  is,  I  am  led  to  think,  an 
intermediate  form  between  the  irritative  and  the  gummatous. 

In  the  tertiary  stage  affections  of  the  bursse  are  not  infrequent. 
The  bursffi  over  the  patellae  are  most  commonly  attacked.  The  lesion 
is  a  gummous  infiltration  with  formation  of  connective  tissue.  It 
begins  insidiously  and  without  pain ;  the  patient's  attention  is  first 
attracted  by  a  hard  movable  lump  beneath  the  skin.  It  varies  in  size 
and  shape  in  different  bursse.  Over  the  knee-joint  we  have  found 
tumors  as  large  as  a  walnut  or  as  an  egg.  The  tumor  may  remain 
indolent  for  a  long  time,  giving  very  slight  discomfort.  In  some  cases 
it  is  excessively  hard,  in  others  it  is  quite  elastic.  Sometimes  the  parts 
seem  to  be  infiltrated  with  fluid.  If  not  treated,  and  particularly  if 
subjected  to  irritation,  the  tumor  grows  and  becomes  adherent  to  the 
overlying  skin.  Inflammatory  symptoms  appear  and  the  integument 
over  the  bursse  ulcerates.  The  inflamed  and  infiltrated  bursa  may  some- 
times be  seen  at  the  base  of  the  ulcer.  Under  such  circumstances  the 
course  of  the  lesion  is  very  tedious.  In  other  cases,  even  of  very  large 
tumors,  treatment  causes  their  absorption  within  two  or  three  months. 
The  lesion  may  be  unilateral,  but  frequently  attacks  both  patellar  bursfe. 
In  many  cases  traumatism  is  an  important  exciting  cause ;  in  others  the 
bursse  are  secondarily  involved  by  the  extension  of  gummatous  infiltra- 
tion from  adjacent  parts.     Relapses  are  quite  frequent. 

Keyes  *  collected  the  histories  of  12  cases ;  in  3  the  bursas  of  both 
patellae  were  involved,  and  in  2  the  bursa  of  one  patella  only  was 
affected ;  that  over  the  tuberosity  of  the  tibia  once ;  that  between  the 
insertion  of  the  semi-tendinosus  and  the  lateral  ligament  of  the  knee, 
double  once  and  single  once.  In  the  other  4  cases  the  bursitis  was  uni- 
lateral— once  over  the  malleolus,  once  beneath  a  corn,  once  in  the  palm 
of  the  hand,  and  once  over  the  olecranon.  It  occurs  most  commonly  in 
women.  Gummatous  bursitis  appears  both  early  and  quite  late  in  ter- 
tiary syphilis. 

1  Wiener  med.  Wochemchrift,  1889,  p.  642. 

^  Medicin.  Monatshe/te  (]!sew  York),  Aug.,  1889. 

^  Journal  of  Cutaneous  and  Venereal  Diseases,  vol.  i.  p.  311. 

*  Am.  Journ.  Med.  Sciences,  1876,  pp.  349  et  seq. 


772  SYPHILIS. 

CHAPTER    LXXVIII. 

AFFECTIONS  OF  THE  BONES  AND  JOINTS. 

The  bones  are  sometimes  attacked  in  the  secondary  period  of  syphilis, 
but  osseous  affections  are  more  common  in  the  tertiary  stage.  While  the 
secondary  lesions  of  the  bones  are  usually  cured  very  readily,  those  of 
the  tertiary  period  are  very  persistent  and  prone  to  undergo  degenerative 
changes. 

According  to  Cornil,^  the  pathological  changes  in  bones  are  osteo- 
periostitis, rarefying  osteitis,  and  intense  rarefying  osteomyelitis  or 
gummatous  osteoperiostitis.  From  these  morbid  conditions  formative 
osteitis,  or  eburnation,  exostoses,  or  nodes,  necroses,  and  sequestra 
result. 

Syphilitic  osteoperiostitis  is  very  similar  to  the  simple  form.  It  is 
limited  to  the  superficial  layers  of  the  bone  and  to  the  periosteum,  and 
chiefly  attacks  the  long  bones  and  the  cranial  bones. 

The  affection  begins  in  the  connective  tissue  and  around  the  vessels 
of  the  Haversian  canals.  Thus  the  parts  are  infiltrated  with  numerous 
round  cells.  Besides  the  cell-infiltrations  into  the  periosteum,  the  mem- 
brane is  also  oedematous.  These  conditions  are  found  in  the  early  stages 
of  osteoperiostitis.  In  the  bones  the  Haversian  canals  become  enlarged 
and  filled  with  marrow,  which  is  either  red  or  embryonal  or  gray  and 
gelatinous.  In  the  stage  of  oedematous  infiltration  osteoperiostitis  may 
undergo  resolution  from  the  effect  of  specific  treatment. 

When  the  process  becomes  old  the  newly-formed  cells  act  as  osteo- 
blasts and  new  bone-tissue  is  formed.  As  a  result,  we  find  swellings  of 
the  bones,  which  are  called  exostoses  and  periostoses.  This  hyperplastic 
process  is  called  formative  osteitis  or  eburnation. 

In  ramifying  osteitis  the  subperiosteal  tissue  and  the  osseous  marrow 
contain  small  round  cells  and  transuded  red  corpuscles.  When  this 
exudation  of  cells  is  intense,  the  bone-tissue  becomes  eroded  and  de- 
stroyed upon  the  internal  surface  of  the  Haversian  canals.  The  osseous 
lamellge  are  destroyed,  and  replaced  by  inflamed  marrow.  Under  treat- 
ment this  process  may  be  stayed  and  cured. 

Gummatous  osteomyelitis  and  osteoperiostitis  are  more  advanced  con- 
ditions than  those  just  described :  the  subperiosteal  embryonal  tissue 
and  the  medullary  tissue  are  much  more  abundant,  and  these  structures 
become  arranged  like  that  of  gummata. 

Osteoperiostitis. 

The  bones  most  liable  to  be  attacked  by  osteoperiostitis  are  those 
Avhich  are  the  most  superficial,  as  the  tibia,  ulna,  clavicle,  sternum,  and 
cranium,  but  no  portion  of  the  skeleton  can  be  said  to  be  exempt.  The 
external  manifestation  of  this  affection  consists  in  ill-defined,  doughy 
tumors  of  variable  size,  shading  off  gradually  into  the  surrounding 
tissues,  adherent  to  the  osseous  structure  beneath,  but  independent  of 

1  Op.  cit.,  pp.  269  et  seq. 


AFFECTIONS  OF  THE  BONES  AND  JOINTS.  11^ 

the  overlying  integument,  usually  very  sensitive  to  pressure,  the  seat, 
at  certain  hours  in  the  twenty-four,  of  severe  pain,  and  bearing  the 
common  name  of  nodes.  A  striking  peculiarity  of  the  pains  produced 
by  nodules  is  their  marked  nocturnal  character.  They  are  generally 
absent  or  are  scarcely  felt  during  the  day,  but  return  at  night  with 
great  severity  after  the  patient  retires  to  bed,  and  only  abate  toward 
morning.  This  nocturnal  exacerbation  is  attributed  to  the  warmth  of 
the  bed  by  Ricord,  who  states  that  in  bakers  and  others,  who  are 
obliged  by  their  occupation  to  turn  day  into  night,  the  pains  are  chiefly 
diurnal.  This  explanation,  however,  does  not  appear  to  hold  good  in 
all  cases,  for  in  some  they  return  at  a  certain  hour  in  the  evening 
whether  the  patient  has  or  has  not  retired,  and  in  a  few  instances  they 
are  equally  as  severe  during  the  day  as  at  night.  These  pains  some- 
times exist  without  the  appearance  of  any  organic  lesion,  and  in  such 
instances  have  been  regarded  as  the  direct  effect  of  syphilis,  but  it  is 
extremely  probable  that  they  are  always  dependent  upon  changes,  how- 
ever slight,  in  the  periosteum  or  bone.  The  student  should  notice  the 
difference  between  these  pains  and  those  attending  early  secondary 
symptoms,  the  former  being  confined  to  certain  regions,  usually  the  con- 
tinuity of  the  long  bones  and  those  portions  of  the  skeleton  which 
approach  nearest  the  surface,  and  nocturnal  in  their  character,  while 
the  latter  affect  by  preference  the  neighborhood  of  the  joints,  and  rap- 
idly change  their  locality  from  one  part  of  the  body  to  another. 

The  swellings  produced  by  syphilitic  osteoperiostitis  are,  as  already 
stated,  called  nodes,  in  contradistinction  to  the  more  compactly-devel- 
oped exostoses. 

In  the  majority  of  cases  of  nodes  the  infiltration  is  absorbed  under 
appropriate  treatment  and  the  tumor  undergoes  resolution.  In  other 
cases  the  inflammation  is  more  acute ;  the  skin  becomes  adherent  to  the 
tumor,  is  reddened  and  thinned ;  degeneration  and  softening  take  place 
and  an  opening  is  formed ;  the  ulcer  shows  little  or  no  tendency  to  ex- 
tend, but  a  superficial  portion  of  the  bone  to  a  limited  extent  usually 
becomes  necrosed  and  comes  away,  and  an  adherent  cicatrix  is  the  final 
result. 

Exostoses. 

When  eburnation  of  the  bony  tissue  is  developed  the  result  is  an 
exostosis.  Such  new  growths  are  often,  for  a  time  at  least,  movable 
upon  the  bone  beneath,  and  are  then  called  einphysary  exostoses.  In 
this  form  they  are  due  rather  to  periostitis  than  ostitis ;  they  are  gener- 
ally of  small  size,  sometimes  thin  and  flat,  sometimes  hemispherical  or 
pedunculated,  and  at  times  annular.  They  acquire  greater  consistency 
with  time,  and  finally  present  an  eburnated  texture.  Arrived  at  this 
point,  resolution  is  no  longer  possible ;  the  tumor  remains  stationary, 
and  treatment  has  no  other  effect  than  to  quiet  the  osteocopic  pains. 
If  resolution  be  attained  at  an  early  period,  their  surface,  which  before 
was  smooth,  becomes  irregular,  indicating  partial  absorption.  Some- 
times this  absorption  continues  after  the  whole  of  the  tumor  has  dis- 
appeared, so  that  local  atrophy  of  the  bone  succeeds  the  exostosis.  In 
other  instances  syphilitic  exostosis  is  not  preceded  by  periostitis,  but  is 


774  SYPHILIS. 

the  result  of  osteitis  terminating  in  hypertrophy  of  the  normal  bony 
tissue,  in   which  case  it  is  denominated  parenchymatous  exostosis. 

An  exostosis  situated  externally  rarely  occasions  sufficient  inconve- 
nience or  deformity  to  necessitate  its  removal  by  an  operation  unless 
under  peculiar  circumstances. 

Exostosis  may  spring  from  the  internal  surface  of  the  cranial  bones, 
and  give  rise  to  symptoms  of  the  most  serious  character,  as  convulsions 
and  the  various  forms  of  paralysis.  The  frontal  bone  is  by  far  the 
most  frequently  affected  in  this  manner. 

Syphilitic  exostosis  of  the  vertebrae,  either  external  or  within  the 
spinal  canal,  is  rare. 

Syphilitic  exostoses  may  generally  be  distinguished  from  similar 
growths  due  to  other  causes  by  the  nocturnal  pains  attending  them,  by 
their  usually  occupying  the  continuity  of  the  more  superficial  bones,  by 
their  hemispherical  form,  and  by  the  fact  that  they  are  rarely  multiple 
or  symmetrical  on  opposite  sides  of  the  body. 

Gummatous  Osteoperiostitis  and  Osteomyelitis. 

The  bones  most  commonly  attacked  by  these  processes  are  the  long 
bones,  the  cranial  bones,  and  the  bones  of  the  fingers  and  toes. 

When  the  bones  of  the  skull  are  affected,  one  or  more  nodes  are  de- 
veloped. As  a  rule,  in  the  late  secondary  and  in  the  early  tertiary 
stages  we  find  several  or,  in  rare  cases,  as  many  as  twenty,  nodes  on 
the  cranial  bones,  whereas  at  late  periods  there  may  be  but  one  or  two. 
These  multiple  cranial  nodes  usually  make  their  appearance  by  crops  of 
one  or  more.  Single  nodes  run  a  slow  course,  and  one  may  be  followed 
by  its  successor  after  the  lapse  of  months  or  years. 

In  Fig.  222  multiple  gummatous  nodes  are  well  shown.  In  Fig. 
223  many  of  the  clinical  features  of  bone-syphilis  are  graphically  por- 
trayed. On  the  right  forehead  there  is  a  very  large  rounded  node, 
while  on  the  left  forehead  is  an  eroded  cicatrix  of  bone  which  followed 
a  gummatous  ulceration  which  developed  and  underwent  necrosis,  to- 
gether with  ulceration  of  the  overlying  skin.  To  the  left  of  this  ne- 
crotic patch  the  skin  may  be  seen  to  be  the  seat  of  a  pigmented  cicatrix, 
which  also  shows  the  site  of  a  broken-down  node.  These  cranial  nodes 
followed  each  other  at  intervals  of  one,  three,  and  five  years.  The 
sunken  nose  shows  that  necrosis  of  the  nasal  bones  had  also  taken 
place. 

The  bones  of  the  face,  particularly  the  malar  bones,  may  be  attacked 
by  gummatous  osteoperiostitis,  and  in  the  course  of  the  affection  mild  or 
severe  neuralgic  pain  may  be  felt. 

The  superior  maxillary  bone  is  not  infrequently  attacked.  The  first 
symptoms  are  local  swelling  and  pain,  and  later  on  the  cheeks  and  the 
tissues  around  the  eyes  become  red  and  oedematous.  Very  often  the  whole 
bone  is  destroyed.  In  some  cases  the  periosteum  is  left  intact  and  a  new 
bone  forms. 

The  inferior  maxillary  may  be  the  seat  of  nodes  on  its  external  surface 
or  lower  border.  According  to  Chabaud,^  rarefying  osteitis  may  occur  in 
this  bone  and  destroy  the  alveolar  arches.     Spontaneous  fracture  has  been 

1  These  de  Pari^,  1885. 


AFFECTIONS  OF  THE  BONES  AND  JOINTS. 


775 


observed  in  cases  of  gummatous  osteoperiostitis  of  the  inferior  maxillary 
bone. 

The  clavicle,  scapula,  and  ribs  are  not  uncommonly  the  seat  of  nodes 
of  varying  sizes.  Follet^  brings  out  the  fact  that  gummata  of  the  scapula 
may  be  mistaken  for  cold  abscess  and  osteosarcoma,  and  suggests  that  it 
is  always  well  to  think  of  syphilis  in  cases  of  swellings  on  this  bone. 


Fig.  222. 


Gummatous  osteoperiostitis  :  multiple  nodes  of  the  skull-bones. 

A  goodly  number  of  cases  of  gummatous  osteoperiostitis  of  the  verte- 
brae have  been  published.  In  these  cases  pain  caused  by  pressure  on  the 
nerves  was  complained  of,  and  in  some  cases  there  was  paralysis  of  the 
upper  or  lower  extremities. 

Jasinski^  has  reported  several  interesting  cases,  and  has  given  the 
bibliography  of  this  subject  up  to  1891. 

The  bodies  of  the  vertebrse  are  much  more  frequently  attacked  than 

1  Thhe  de  Pnrh,  1884. 

^"Ueber  Syphilitische  Ekrankungen  der  Wirbelsiiule,"  Arch,  fur  Demi,  und  Syph., 
vol.  xxiii.  pp.  409  et  seq. 


776  SYPHILIS. 

are  the  arches.  In  a  number  of  cases  of  syphilis  of  the  vertebrge  strik- 
ingly beneficial  results  have  followed  the  use  of  the  mixed  treatment. 

Fragility. — As  the  result  of  local  inflammation  and  cell-infiltration  in 
cases  of  rarefying  and  gummatous  osteoperiostitis  the  structure  of  bones 
sometimes  becomes  fragile,  and  they  may  be  fractured  by  muscular  con- 
traction or  mild  or  severe  traumatism. 

Provost  ^  has  carefully  studied,  both  clinically  and  microscopically,  the 

Fig.  223. 


Showing  a  large  cranial  node,  necrosis  of  skull,  and  cicatrix  of  skin. 

subjects  of  spontaneous  fracture  and  of  the  non-union  of  fractured  bones 
in  syphilitic  subjects.  He  concludes  that  non-union  is  either  due  to  a 
depraved  condition  or  to  the  fact  that  the  newly-formed  embryonal  tissues 
do  not  produce  an  ossifying  callus,  but,  on  the  contrary,  caseous,  fatty, 
and  sclerotic  tissues,  which  tend  to  produce  false  joints.  In  these  cases 
local  and  general  medication  and  good  hygiene  are  very  essential. 

Charpy^  in  chemical  examinations  of  fractured  syphilitic  bones  found 
all  the  constituents  in  normal  quantity  except  fluoride  of  lime,  w^hich  was 
markedly  deficient.     He  therefore  suggests  this  as  a  possible  cause. 

1  Thhe  de  Lille,  1886. 

^  Annates  de  Derm,  et  de  Syph.,  1885,  pp.  269  et  seq. 


AFFECTIONS  OF  THE  BONES  AND  JOINTS.  777 

Affections  of  the  Joints. 

The  joints  are  frequently  affected  by  syphilis  in  both  the  secondary 
and  tertiary  stages.  In  some  instances  the  morbid  process  begins  in  the 
joint-structures,  and  in  others  inflammation  of  the  articular  ends  of  the 
bones  and  of  the  large  tendons  inserted  near  the  joints  involves  the  latter 
secondarily. 

Synovitis  of  the  Late  Stage. — The  synovitis  which  occurs  late  in  the 
secondary  and  during  the  tertiary  stage  is  also  markedly  subacute.  It  is 
attended  with  the  same  symptoms,  and  is  mainly  distinguishable  from  that 
of  the  earlier  period  by  appreciable  lesions  of  the  joint-structures.  The 
attention  of  the  patient  is  called  to  the  affection  by  slight  pain  and 
impairment  of  motion,  and  the  joint  is  then  found  somewhat  enlarged. 
The  effusion  into  its  cavity  takes  place  slowly  and  perhaps  intermittingly, 
so  that  in  many  cases  several  months  elapse  before  the  joint  is  very 
decidedly  enlarged.  When  the  affection  is  fully  developed  we  find  evi- 
dence of  intra-articular  effusion  and  general  thickening  of  the  fibrous 
coverings  and  of  the  synovial  membrane.  The  affection  has  been  called 
by  Richet,^  who  first  described  it  as  "syphilitic  white  swelling,"  and  it 
was  said  by  him  to  be  due  to  gummy  infiltration  into  the  subsynovial  con- 
nective tissue  and  into  the  reflections  of  the  membrane  which  lines  the 
joints. 

It  is  probable  that  this  is  the  chief  focus  of  the  lesion,  but  in  some 
cases  there  is  a  coexisting  hyperplasia  of  the  fibrous  structures  of  the 
parts.  This  affection  may  remain  in  an  indolent  condition  for  years  with- 
out undergoing  any  further  changes.  There  is  little  tendency  to  complete 
ankylosis,  though  quite  frequently  there  is  more  or  less  erosion  of  the 
articular  cartilages,  as  shown  by  the  crepitation  on  motion.  We  seldom 
find  sinuses  near  the  joints,  and  the  stationary  character  of  the  affection 
is  in  marked  contrast  to  the  tendency  to  degeneration  which  is  such  a 
prominent  feature  of  the  strumous  affections  of  these  parts.  The  knee- 
joint  is  the  one  most  commonly  attacked. 

Late  syphilitic  synovitis  may  be  complicated  by  tuberculosis,  and  the 
mixed  condition  then  produced  is  very  rebellious  to  treatment,  which  is 
sometimes  signally  efficacious  in  the  true  syphilitic  affection. 

In  many  cases  a  history  of  syphilis  points  to  the  nature  of  the  affec- 
tion. Then  in  tuberculosis  this  morbid  process  usually  exists  elsewhere, 
particularly  in  the  lungs.  In  the  mixed  form  of  synovitis  it  is  often 
impossible  to  make  a  sharp  diagnosis. 

The  prognosis  of  this  affection  is  rather  more  serious  than  that  of  the 
earlier  form.  If  it  is  submitted  to  treatment  early,  it  is  in  general  cur- 
able, but  if  it  is  neglected,  permanent  thickening  occurs,  and  consequently 
more  or  less  impairment  of  motion. 

The  constitutional  treatment  consists  in  the  administration  of  the 
iodide  of  potassium  and  of  mercury.  Locally,  frictions  with  mercurial 
ointment  may  be  used. 

In  some  cases  in  which  there  is  a  syphilitic  affection  of  the  tendons 
inserted  near  a  joint  there  is  a  coincident  effusion  into  the  cavity  of  the 
latter.  This  occurs  slowly  and  painlessly,  and  disappears  on  the  subsidence 
of  the  disease  of  the  tendon. 

'  "De  la  Tumeur  blanche,"  Memoires  de  I' Acad,  de  Med.,  Paris,  t.  xvii.,  1853,  pp. 
249  et  seq. 


778  SYPHILIS. 

CHAPTER    LXXIX. 

AFFECTIONS  OF  THE  FINGERS  AND  TOES. 

Besides  being  the  seat  of  primary  and  secondary  lesions,  the  fingers 
and  toes  are,  in  the  tertiary  period,  attacked  by  gummy  deposit  in  their 
subcutaneous  connective  tissue  and  by  infiltration  and  inflammation  of 
their  bones.  This  affection  was  formerly  called  syphilitic  panaris.  I 
use  the  term  dactylitis,  derived  from  the  Greek  daxzuXo^,  a  digit  or 
finger,  as  being  more  correct  and  expressive.^ 

The  affection  is  caused  both  by  acquired  and  by  hereditary  syphilis. 
The  cases  due  to  the  former  are  much  less  numerous,  there  being  under 
four  dozen  reported  up  to  the  present  time,  whereas  hereditary  dactylitis 
is  by  no  means  uncommon.  In  this  section  the  acquired  form  will  be 
described.  Of  this  there  are  two  varieties  :  First,  that  in  which  the  sub- 
cutaneous connective  tissue  and  the  fibrous  structures  of  the  joints  are 
involved ;  second,  that  in  which  the  morbid  process  begins  in  the  bones 

Fig.  224. 


Dactylitis  sypliilitica. 


and  periosteum,  secondarily  implicating  the  joints,  and  perhaps  accom- 
panied by  deposit  in  the  subdermal  connective  tissues.  These  varieties 
are  constantly  found,  and  their  adoption  will  simplify  description.  The 
size  of  the  affected  member  is  materially  increased  and  its  mobility  is  more 
or  less  interfered  with.  The  lesion  comes  on  slowly,  and  first  attracts  the 
patient's  attention  by  the  slight  enlargement  of  one  or  more  fingers  or 
toes.  The  swelling  gradually  increases  and  the  member  becomes  hard 
and  firm.  When  the  toes  are  affected,  their  whole  length  is  generally 
1  "On  Dactylitis  Syphilitica,"  Am.  Journ.  of  Derm,  and  Syph.,  1871,  pp.  1  et  seq. 


AFFECTIONS  OF  THE  FINGERS  AND   TOES.  779 

included ;  but  when  a  finger  is  attacked,  the  lesion  may  be  quite  sharply 
limited  to  one  phalanx,  almost  invariably  the  proximal  one,  or  the  adja- 
cent phalanx  may  be  involved  to  a  less  degree.  (See  Fig.  224.)  The 
distal  phalanges  and  the  metacarpal  bones  may  also  be  attacked  (see  Fig. 
225),  or,  finally,  the  whole  finger  may  be  affected.  Fig.  224  shows  this 
infiltration  into  the  first  and  second  phalanges  of  the  left  hand. 

A  finger  or  a  toe  thus  attacked  presents  a  reddish,  violaceous  appear- 
ance, and  to  the  touch  is  quite  resistant  and  tense,  the  normal  lines  of 
the  integument  being  effaced.     Unlike  gummy  tumors  developed  where 

Fig.  225. 


r#"' 


Dactylitis  syphilitica. 


the  connective  tissue  is  plentiful,  and  which  are  isolable  and  movable, 
these  infiltrations  of  the  fingers  and  toes  are  firmly  attached  to  the  skin, 
the  process  apparently  involving  the  corium  even  to  its  papillary  layer. 
In  most  cases  the  thickening  is  greatest  on  the  dorsal  aspect,  very  rarely 
being  equally  copious  on  the  palmar  or  plantar  surface.  The  swelling,  as 
a  rule,  ends  abruptly  at  the  metacarpo-phalangeal  joint. 

These  swellings  are  usually  developed  slowly  and  painlessly,  but  in 
some  cases  a  dull  aching  pain  is  present.  When  the  infiltration  is  com- 
plete it  is  impossible,  on  account  of  the  density  of  the  tissues,  to  determine 
accurately  the  condition  of  the  bones,  although  they  seem  to  be  thickened. 
As  the  affection  subsides  the  bones  and  joint-structures  can  be  more  thor- 
oughly examined,  and  we  then  find  more  or  less  periosteal  thickening.  In 
most  cases,  however,  the  bones  are  quite  superficially  involved,  whereas 
in  the  second  form  of  dactylitis  they  are  profoundly  attacked.  It  is  im- 
possible to  say  whether  the  morbid  process  begins  in  the  periosteum  or  in 
the  connective  tissue  over  it;  it  is  certain  that  the  lesion  is  sometimes 
sharply  limited  to  the  tissues  over  one  or  more  phalanges,  and,  again,  it 
may  involve  the  whole  member. 

Within  a  few  weeks  after  the  development  of  the  affection  symptoms 
of  joint-implication  appear.  At  first  flexion  of  the  joints  is  impaired  by 
the  swelling.  In  the  course  of  one  or  two  months,  if  no  treatment  is 
followed,  the  joints  become  flaccid  and  unnaturally  mobile.  Sometimes 
in  this  variety  of  dactylitis  there  is  slight  hydrarthrosis  and  often  crepita- 
tion in  the  metacarpo-phalangeal  joint  or  between  the  articular  surfaces 


780  SYPHILIS. 

of  two  phalanges.     This  will  be  again  referred  to  in  speaking  of  the 
second  form  of  dactylitis,  next  to  be  described. 

This  gummous  infiltration  of  the  integument  and  periosteum  of  the 
fingers  and  toes  may  be  limited  to  one  of  these  members  or  may  involve 
several.  A  single  hand  or  foot,  or  both,  may  be  involved,  one  or  more 
fingers  and  toes  being  attacked  simultaneously  or  in  succession.  (See  Fig. 
226.)  The  lesion,  being  a  late  manifestation,  very  often  follows  or  accom- 
panies gummous  infiltration  elsewhere.  It  runs  a  chronic  course,  and  in 
its  early  stage  is  amenable  to  treatment.  The  fact  that  gummy  tumors 
of  these  parts  are  not  prone  to  ulcerate  is  incapable  of  positive  explana- 

Fig.  226. 


Dactylitis  of  the  second  phalanx  with  gummatous  deposit  in  the  skin,  which  has  ulcerated. 

tion.  The  character  of  the  deposit  is  certainly  not  peculiar,  but  it  may 
be  that  the  vascularity  and  density  of  the  tissues  modify  the  course  of  the 
lesion.  The  wonderful  reparative  power  of  the  fingers  after  injury  is  well 
recognized.  This  form  of  dactylitis  generally  results  in  restoration  of  the 
affected  members,  but  in  neglected  cases  the  joints  may  be  rendered  per- 
manently useless  and  the  bones  may  remain  enlarged.  The  nails  either 
escape  or,  in  very  chronic  cases,  present  minute  transverse  furrows,  indica- 
tive of  impaired  nutrition. 

The  first  form  of  dactylitis  is  sharply  limited  to  the  bone,  and  is 
due  either  to  specific  periostitis  or  osteomyelitis.  The  aff"ection  may 
progress  rapidly,  slowly,  or  with  intermissions.  The  earlier  after  the 
infection  the  lesion  occurs,  the  more  acute  is  its  course.  The  degree  of 
its  induration  is  generally  in  proportion  to  the  chronicity  of  its  develop- 
ment ;  a  rapidly-formed  swelling  may  be  so  soft  as  to  be  susceptible  of 
indentation  by  firm  pressure.  The  afi"ection  may  be  speedily  cured  by 
energetic  and  early  treatment,  but  if  unchecked  it  may  progress  to  an 
extreme  degree.  It  seems  to  be  the  rule  that  when  only  one  bone  is 
aifected  the  swelling  is  greater  than  when  several  are.  The  shape  of  the 
swelling  depends  upon  the  phalanx  attacked.  When  the  first  is  involved 
it  may  assume  an  acorn-shape  or  the  appearance  of  a  balloon ;  the  second 
and  third  phalanges  may  be  fusiform  or  cylindrical.  In  most  cases  the 
whole  bone  is  involved.  The  disease  may  be  limited  to  the  extremity 
of  a  phalanx  adjacent  to  one  already  the  seat  of  dactylitis. 

The  proximal  phalanx  is  most  frequently,  the  distal  phalanx  least 
frequently,  involved.  I  have  seen  in  four  instances  enlargement  of  the 
second  phalanx  only,  and  of  the  third  in  one  case.     In  hereditary  syph- 


AFFECTIONS  OF  THE  FINGERS  AND  TOES. 


781 


ills  it  is  not  uncommon  to  find  swelling  of  the  second  and  even  of  the 
third  phalanges. 

The  fingers  are  attacked  more  commonly  than  the  toes ;  in  a  few  cases 
they  have  been  involved  simultaneously.  More  than  one  phalanx  of  the 
same  finger  may  be  aifected,  as  Avell  as  several  fingers,  either  unilaterally 
or  symmetrically.  In  the  latter  case  swelling  of  one  or  more  toes  is 
likely  to  occur  at  the  same  time.  Other  osseous  lesions  may  coexist,  and 
articular  affections  and  gummous  infiltrations  of  the  skin  may  be  associated 
with  these  lesions  of  the  fingers. 

The  metacarpal,  and  less  frequently  the  metatarsal,  bones  become 
swollen  coincidently  with  dactylitis,  or  they  alone  may  be  affected.  (See 
Fig.  227.)  The  extremity  joining  the  phalanx  or  the  opposite  extremity 
may  be  involved. 


Fig.  227. 


Enlargement  of  the  metacarpal  bone  of  the  index  finger. 


The  mode  of  invasion  and  the  course  of  these  swellings  are  similar  in 
the  metacarpal  bones  and  in  the  bones  of  the  fingers.  The  metacarpal 
bones  of  the  thumb  and  index  fingers  are  those  most  frequently  the  seat 
of  dactylitis.     (See  little  finger  in  Fig.  225.) 

The  integument  is  rarely  infiltrated  in  this  form  of  dactylitis,  gum- 
mous deposit  having  been  found  in  the  subcutaneous  tissues  in  but  two 
cases  of  primary  lesion  of  the  bones.  The  skin  may  undergo  very  little 
change,  unless  the  swelling  is  excessive,  when  it  becomes  tense  and  thinned 
and  the  normal  furrows  are  effaced.  When  the  process  is  rapid  the  skin 
becomes  red  and  inflamed ;  when  the  growth  of  the  lesion  is  slow  the  skin 
accommodates  itself,  and  very  slight  if  any  inflammation  occurs.  In  some 
cases  ulceration  takes  place  or  an  incision  is  required  to  relieve  the  ten- 
sion. The  inflammatory  focus  is  always  on  the  sides  of  the  fingers.  In 
case  an  opening  forms  or  is  made,  a  soft  cheesy  detritus  mixed  with  pus 
comes  away.  Necrosis  may  occur,  but  the  destruction  of  bone-tissue  is 
usually  limited,  and  after  a  short  time  the  fistula  closes.  In  the  majority 
of  cases  resolution  of  the  bony  swelling  takes  place. 

The  joint-structures  are  generally  much  thickened.  After  the  dacty- 
litis has  existed  about  a  month  crepitation  may  be  detected  from  friction 
of  the  articular  surfaces.     This  is   undoubtedly  due  to  erosion  of  the 


782 


SYPHILIS. 


articular  cartilages  in  consequence  of  impaired  nutrition.  In  some  cases 
an  effusion  into  the  joint-cavity  takes  place,  slowly  and  without  pain. 
This  condition  of  hydrarthrosis  varies  in  degree,  and  may  be  due  either 
to  infiltration  or  simple  congestion  of  the  synovial  membrane.  This  com- 
plication is  not  serious,  and  generally  ends  in  absorption.  The  thicken- 
ing of  the  ligaments  and  joint-structures  results  in  impairing  the  motion 
of  the  joints  or  in  rendering  them  preternaturally  mobile. 

These  bony  swellings  may  remain  in  an  indolent  condition  for  a  long 
time,  and  finally  the  gummy  deposit  may  be  absorbed,  or  it  may  soften 
and  be  discharged  through  a  sinus.  The  shaft  of  the  bone  may  resume 
its  normal  size,  or  it  may  be  rendered  much  thinner  and  lighter.  Some- 
times it  is  shortened,  and  in  other  cases,  again,  it  is  slightly  longer  than 
normal.  The  bone  may  be  left  in  a  condition  of  eburnation,  being  de- 
cidedly thickened. 

The  process  of  involution  may  be  slow  or  quite  rapid,  and  seems  to  be 
in  proportion  to  the  rapidity  of  the  development  of  the  lesion.  In  most 
cases  the  deformity  is  not  very  marked ;  in  some  cases  of  necrosis  a  less 
fortunate  result  is  obtained  (Fig.  228).  The  illustration,  taken  from  my 
paper  on  the  subject,  shows  deformity  and  shortening  of  the  index  finger, 

Fig.  228. 


Showing  shortening  of  the  index  finger  from  absorption  of  part  of  the  phalanx  and  of  .the  meta- 
carpal hone. 

SO  that  its  extremity  scarcely  reaches  the  first  phalangeal  joint  of  the 
middle  finger.  In  this  case  the  greater  part  of  the  first  phalanx  and  the 
distal  extremity  of  the  metacarpal  bone  had  been  absorbed,  and  the  rem- 
nants of  the  two  bones  were  connected  by  fibrous  tissue.  In  a  similar 
manner  the  second  phalanx  of  the  ring  finger  had  been  reduced  to  about 
one-fourth  of  its  original  length.  After  the  process  of  absorption  is 
complete  the  contiguous  bones  are  always  united  by  a  ligamentous  band, 
which  serves  as  a  joint.  The  function  of  a  finger  in  such  a  condition  is 
of  course  greatly  impaired,  and  excessive  deformity  may  result.  The 
manner  in  which  the  soft  parts  adapt  themselves  to  the  altered  condition 
is  very  remarkable,  their  contraction  being  of  great  service  in  giving 
steadiness  and  solidity  to  the  fiilse  joints. 


LESIONS  OF  THE  KIDNEYS,  ETC.  783 

In  spite  of  the  extent  of  the  osseous  lesions  pain  is  either  very  slight 
or  altogether  absent.  In  no  case  have  the  tendons  or  their  sheaths  been 
found  implicated.  The  absorption  of  the  bones  is  unaccompanied  by 
ulceration  of  the  soft  parts. 

This  affection  is  one  of  the  late  manifestations  of  syphilis,  occurring 
usually  between  the  fifth  and  fifteenth  years.  The  average  age  of  its 
subjects  has  been  about  forty  years.  Exceptionally  it  appears  early,  I 
havino-  seen  one  case  in  which  it  occurred  eighteen  months  after  infection. 

The  early  recognition  of  these  two  forms  of  dactylitis  is  important  in 
order  to  prevent  destruction  of  tissue  and  deformity.  The  subcutaneous 
variety  in  its  early  stage  may  be  mistaken  for  perinychia,  but  the  absence 
of  acute  inflammatory  symptoms,  especially  pain,  establishes  the  diagnosis. 
Dactylitis  of  the  great  toe  might  be  mistaken  for  gout  but  for  the  sub- 
acute character  of  the  former.  When  several  fingers  and  toes  are  at- 
tacked, particularly  if  there  is  a  coincident  affection  of  one  of  the  larger 
joints,  the  case  may  be  regarded  as  one  of  rheumatoid  arthritis ;  but  the 
latter  is  essentially  a  joint  affection,  and  is  quite  painful ;  it  attacks  the 
metacarpo-phalangeal  (and  rarely  the  metatarso-phalangeal)  joints  more 
frequently  than  the  phalanges,  and  generally  involves  the  sheaths  of  the 
tendons ;  sometimes  tophi  are  deposited  in  the  tendons,  especially  of  the 
flexors,  and  elsewhere,  as  in  the  cartilages  of  the  ear :  deformity  begins 
early,  and  there  is  a  tendency  of  the  fingers  to  be  drawn  to  the  ulnar  side 
of  the  hand  and  to  be  flexed  and  extended  at  various  angles.  Dactylitis 
syphilitica  may  be  confounded  with  enchondroma  or  exostosis,  but  in 
each  of  the  latter  the  swelling  is  more  localized,  being  limited  to  a  portion 
of  the  circumference  of  the  bone. 

The  prognosis  depends  in  a  measure  upon  the  period  at  which  the 
lesion  is  recognized.  When  the  swelling  is  developed  quickly  rapid  in- 
volution follows  the  use  of  energetic  treatment.  The  longer  it  has  per- 
sisted the  less  amenable  to  treatment  it  becomes. 

The  treatment  is  that  of  late  syphilis,  a  combination  of  the  iodide  of 
potash  with  a  mercurial ;    locally,  mercurial  ointment  or  plaster  applied 
with  pressure  is  beneficial.     Sometimes  an  incision  is  required  in  case  of 
the  breaking  down  of  gummatous  infiltration. 


CHAPTEK    LXXX. 

LESIONS  OF  THE  KIDNEYS,  LATE  GLYCOSURIA,  AND  DIABETES 

INSIPIDUS. 

Kidney  disease  in  late  syphilis  is  of  rather  uncommon,  but  not  of 
rare,  occurrence.  In  9000  autopsies  Wagner  ^  found  63  cases  of  syphilis 
of  the  kidneys ;  of  these,  8  were  cases  of  acute  Bright's  disease,  4  of 
chronic,  7  of  granular  kidney,  6  of  atrophy  of  one  kidney,  35  of  amyloid 

^  "  Die  Constitutionelle  Syphilis  und  die  davon  abhiingigen  Nieren  Krankheiten," 
Deut.  Arch.fiir  klin.  Med.,  vol.  xxviii.,  1880,  pp.  94  et  seq. 


784  SYPHILIS. 

degeneration,  and  3  of  syphiloma  or  gummata.  Bamberger  found  49 
cases  of  syphilis  of  the  kidney  in  2340  cases  of  acute  and  chronic  Bright's 
disease.  Wagner  follows  Beer's  *  division  of  the  pathological  changes  of 
the  kidneys  in  syphilis.  These  are — 1.  Small  circumscribed  nodular 
formations  (gummatous  tumors)  in  otherwise  normal  or  differently  dis- 
eased kidneys ;  2.  Simple  interstitial  hyperplasia,  mostly  irregular,  with 
the  formation  of  cicatrices  in  otherwise  normal  kidneys ;  3.  Diffuse  cel- 
lular hyperplasia  of  the  interstitial  tissues,  mostly  with  degeneration  of 
the  vessels  and  atrophy  of  the  new  formation,  as  well  as  peculiar  paren- 
chymatous changes.  These  latter  were  particularly  small  fatty  deposits, 
lardaceous  degeneration  being  common  in  this  form ;  4.  Purely  paren- 
chymatous changes.  According  to  Wagner  and  Beer,  only  the  first  and 
third  forms  are  absolutely  characteristic  of  syphilis. 

There  are  no  pathognomonic  signs  or  symptoms  of  tertiary  syphilis  of 
the  kidneys.  The  symptoms  are  emaciation  and  various  forms  of  dropsy, 
together  with  the  presence  of  albumin  in  the  urine. 

Glycosuria  and  Syphilis. 

The  question  of  the  relation  betw-een  syphilis  and  glycosuria,  or  dia- 
betes, has  of  late  been  much  studied,  but  still  there  is  much  to  be  learned. 

Patients  suffering  from  diabetes,  who  later  on  contract  syphilis,  usually 
present  a  severe  order  of  primary  and  secondary  manifestations,  due  to  the 
hybrid  morbid  condition.  In  many  instances  the  initial  lesion  in  these 
subjects  is  rpore  exuberant  and  shows  decided  tendency  to  ulceration. 
With  the  onset  of  syphilis,  which  is  usually  very  rapid,  diabetes  seems  to 
induce  a  condition  of  deep  cachexia,  and  as  a  result  the  course  of  the  dis- 
ease is  more  severe  and  less  amenable  to  treatment.  In  these  cases  mer- 
cury should  be  used  very  guardedly.  In  general,  the  mixed  treatment 
works  well  toward  the  end  of  the  first  year.  Several  writers  have  stated 
that  sugar  seems  to  leave  the  urine  more  rapidly  in  syphilitic  than  in 
other  patients.  This  view  is  entertained  by  Arnaud,^  who  has  studied 
the  subject  exhaustively.  Several  instances  are  known  in  which  sugar 
disappeared  at  the  breaking  out  of  specific  manifestations,  and  reappeared 
on  the  cessation.  In  diabetes  and  syphilis  there  is  frequently  observed  a 
fermentation  of  the  sugar  in  the  mouth,  which  produces  severe  and  rebel- 
lious ulcerative  lesions.  Though  this  morbid  combination  tends  to  induce 
great  deterioration  of  nutrition,  the  consoling  fact  remains  that  in  some 
syphilitics  sugar  disappears  more  permanently  than  in  those  uninfected. 

That  syphilis,  therefore,  may  in  some  mysterious  manner  cause  diabetes 
there  can  no  longer  be  any  doubt.  So  many  cases  have  been  reported  in 
which  no  other  pathogenic  cause  than  syphilis  could  be  ascertained  that 
the  conclusion  is  warranted  that  diabetes  may  result  from  the  effects  of 
this  far-reaching  infection,  either  by  its  disturbance  of  the  liver  and  of 
the  blood-making  function,  or  by  reason  of  some  change  in  the  fourth 
ventricle  or  in  its  vicinity. 

Diabetes  may  occur  within  the  first  few  months  of  infection,  within  one 
or  several  weeks,  and  it  may  occur  in  the  tertiary  stage. 

'  Die  Eingeweide  Syphilis,  Tubingen,  1867. 

^  "  De  ri'nflnence  rdciproque  du  Diab^te  sur  la  Syphilis,  et  la  Syphilis  sur  le  Dia- 
b4te,"  These  de  Paris,  1886. 


AFFECTIONS  OF  THE  PENIS,  ETC.  785 

Diabetes  Insipidus. 

In  the  course  of  sypliititic  disease  of  the  brain,  particularly  when 
seated  at  or  near  the  floor  of  the  fourth  ventricle,  diabetes  or  polyuria  is 
sometimes  observed.  It  has  no  distinguishing  characteristics,  and  its 
chief  symptoms  are  inordinate  thirst  and  the  discharge  of  large  quantities 
of  pale  urine  of  very  low  specific  gravity,  in  which  neither  sugar  nor 
albumin  is  found. 

A  number  of  interesting  cases  are  to  be  found  in  literature.  L^corch^ 
and  Talamon^  have  reported  the  case  of  a  thirty-four-year-old  syphilitic 
man  who  had  been  infected  fourteen  years  before,  and  who  for  six  years 
had  passed  nine  to  ten  litres  of  urine  daily.  Under  treatment  the  quan- 
tity Avas  reduced  to  five  litres. 

Sourouktchy^  has  reported  the  case  of  a  twenty-five-year-old  man  who, 
when  seven  months  syphilitic,  was  aff"ected  with  great  thirst,  and  passed 
large  quantities  of  urine  free  from  sugar  and  albumin.  He  was  promptly 
cured  by  the  use  of  mercurial  inunctions  and  of  iodide  of  potassium 
internally.  The  reporter  of  the  case  thought  that  there  was  a  syphilitic 
aifection  of  the  ependyma  in  the  floor  of  the  fourth  ventricle. 

In  a  case  reported  by  Buttersack,^  in  which  the  woman  suffered  from 
vertigo,  neuralgic  pains,  and  pains  in  the  head,  and  who  voided  a  large 
amount  of  characteristic  urine,  on  post-mortem  examination  chronic 
descending  leptomeningitis,  with  implication  of  the  trigeminal  and  spinal 
nerves,  was  found. 


CHAPTER    LXXXL 

AFFECTIONS  OF   THE   PENIS,  OS   UTERI,  UTERUS,  AND  VAGINA. 

In  somewhat  rare  cases  a  diff"use  gummatous  infiltration  occurs  in  the 
submucous  connective  tissue  of  the  glans  penis,  either  in  a  localized  or 
general  form.  This  new  tissue  may  break  down,  and  as  a  result  we  some- 
times see  deep  ulcers,  which  are  indistinguishable  from  chancroids  in  their 
appearance.  In  exceptional  cases  more  or  less  of  the  glans  itself  may  be 
the  seat  of  gummatous  infiltration. 

It  is  necessary  also  to  remember  that  relapsing  indurations  occur  rather 
early  and  late  in  syphilis,  and  that  they  are  found  in  the  glans,  prepuce, 
at  the  meatus,  and  in  the  urethra.     (See  page  548.) 

Nodes  in  the  Corpora  Cavernosa. 

In  some  cases  small  or  large  nodules,  varying  in  size  between  that  of 
a  pea  and  a  nutmeg,  may  be  found  in  the  meshes  of  the  corpus  caverno- 
sum.     These  tumors  are  usually  round.      They  can  be   quite  sharply 

'  Ln  Merlecine  mnrhrne,  .Tan.  26,  1890. 
2  VracK  No.  1,  1891,  p.  1. 

^  "Zur  Lehre  von  syphilitischeErkrangungen  des  Centralnervensystems  nebst  einigen 
Bemerknngen  iiber  Polyurie  und  Polydipsie,"  Inaug.  Dissert.,  Heidelberg,  1886. 
50 


786  SYPHILIS. 

defined,  and  have  a  moderately  firm  consistence,  and  they  may  even 
present  cartilaginous  hardness. 

These  lesions  develop  very  insidiously,  and  in  speaking  of  them 
patients  usually  say  they  knew  of  no  trouble  until  they  found  the  lump 
in  the  penis.  As  a  result  of  these  tumors  the  penis  becomes  curved  when 
erect  in  various  ways,  laterally,  upward,  and  backward  and  downward. 
If  these  swellings  of  the  cavernous  bodies  are  allowed  to  become  chronic, 
they  produce  much  structural  deformity  of  the  penis.  They  very  rarely 
soften  and  break  down.  They  are  promptly  influenced  for  the  better  by 
antisyphilitic  treatment. 

Infiltrations  of  the  size  of  a  pea  or  of  a  hazelnut  are  somewhat  rarely 
found  in  the  corpus  spongiosum,  and  which  may  extend  to  the  parts 
beyond.  They  run  an  indolent  course,  rarely  break  down,  but  become 
sclerotic  and  produce  very  dense   and  intractable  urethral  strictures. 

In  this  connection  it  is  well  to  describe  a  condition  of  the  corpora 
cavernosa  not  caused  by  syphilis,  in  which  hard,  firm,  laminated  masses 
develop  in  the  superficial  portion  of  the  tissues.  It  is  called  chronic  cir- 
cumscribed inflammation  of  the  corpora  cavernosa — a  very  objectionable 
name,  since  there  are  no  inflammatory  symptoms  observed  during  the 
whole  course.  The  process  is  really  a  sclerous  infiltration  of  fibrous 
tissue.  This  afi"ection  is  free  from  pain  and  progresses  slowly,  until  the 
patient  notices  a  small  lump  which  is  painful  on  erection  of  the  penis. 
Upon  examination  we  find  a  hard,  firm  plate  of  tissue,  a  line  or  two  in 
thickness,  situated  in  the  superficial  portion  of  the  corpus  cavernosum. 
Its  margins  are  sharply  defined  and  regular,  or  they  may  be  uneven, 
slightly  nodulated,  and  perhaps  thickened.  The  deeper  parts  seem  to  be 
free  from  disease.  The  induration  of  the  plate  is  variable,  in  some  cases 
being  cartilaginous. 

EXULCERATIVE  HYPERTROPHY  OF  THE  NeCK  OF  THE  UtERUS. 

Our  knowledge  of  this  aff"ection  is  derived  chiefly  from  the  writings  of 
Aime  Martin,  De  Fourcauld,^  Mesnard,  Doleris,  and  Blanc.  It  consists 
in  a  total  or  partial  enlargement  and  hardening  of  the  os,  which  appears 
congested  and  is  more  or  less  superficially  ulcerated ;  its  surface  is  granu- 
lar or  often  presents  a  varnished  aspect.  The  hypertrophy  is  greatest  in 
the  transverse  diameter,  and  is  but  slight  in  the  antero-posterior.  The 
parts  are  indurated  and  resistant,  or  sometimes  doughy,  and  generally  are 
not  sensitive  to  manipulation.  In  most  of  the  cases  there  were  no  symjD- 
toms  referable  to  the  utero-ovarian  system  ;  in  others  the  patients  com- 
plained merely  of  certain  unpleasant  sensations,  such  as  pain  in  the  loins, 
back,  and  thighs,  and  a  bearing-down  feeling.  The  secretion  from  the 
ulcer  is  scanty  and  muco-purulent,  and  is  infectious  like  the  secretion 
from  other  secondary  lesions.  The  affection  may  be  accompanied  by 
various  displacements  of  the  womb. 

According  to  A.  Martin,  this  lesion  occurs  in  48  per  cent,  of  syphilitic 
women,  beginning  on  an  average  in  fifty-eight  days  after  infection,  while 
in  reported  cases  it  was  developed  in  the  second,  eighth,  and  ninth  years 
of  syphilis.  According  to  Martin,  it  is  frequently  preceded  by  fever,  and 
in  31  cases  out  of  47  it  coexisted  with  hypertrophy  of  the  tonsils.     It  runs 

1  Th'^se  de  Paris,  1877. 


AFFECTIONS  OF  THE  PENIS,  ETC.  787 

a  chronic  course,  but  yields  readily  to  internal  treatment  alone.  Martin, 
who  observed  its  cure  in  from  four  to  five  weeks,  considers  local  treatment 
of  merely  secondary  importance. 

Mesnard^  reports  the  case  of  a  woman  in  whom  abortion  occurred  at 
the  end  of  the  second  month  of  pregnancy,  and  who  was  then  found  to  be 
syphilitic.  In  eighteen  months  she  again  became  pregnant,  and  at  delivery 
a  number  of  hard  nodules  were  found  around  the  os  uteri  which  so 
impeded  dilatation  that  it  was  necessary  to  make  four  incisions. 

An  essay  from  the  standpoint  of  the  gynecologist  as  to  the  efi"ect  of 
syphilitic  stenosis  of  the  os  uteri  has  been  published  by  Dol6ris.^ 

Mesnard,^  in  microscopical  studies  of  rigidity  of  the  os  uteri  due  to 
syphilis,  found  that  the  process  consists  in  the  development  of  a  dense, 
compact  fibrous-tissue  infiltration,  together  with  lymphoid  cells.  It  is, 
therefore,  a  chronic  inflammation  of  the  cellular  tissue  with  chronic  lymph- 
itis.  As  the  process  grows  old  the  new  tissue  takes  the  place  of  the  mus- 
cular fibres. 

Blanc*  has  reported  a  case  in  which  dystocia  was  due  to  stenosis 
which  followed  the  initial  lesion.  He  thinks  that  deep  incisions  are  neces- 
sary in  such  cases. 

Affections  of  the  Ovaries,  Fallopian  Tubes,  Uterus,  and  Vagina. 

Syphilitic  affections  of  the  ovaries  are  rarely  met  with.  According 
to  Lancereaux,  they  present  a  close  analogy  to  syphilitic  affections  of  the 
testicle,  and  are  either  diffuse  or  circumscribed.  This  author  has  only 
met  with  the  diffuse  form  after  it  has  arrived  at  the  stage  of  atrophy ;  the 
ovaries  Avere  of  the  usual  size  or  smaller  than  natural,  fibrous  in  their 
structure,  with  scattered  cicatrices,  and  destitute  of  Graafian  vesicles, 
although  the  patients  had  not  yet  arrived  at  the  usual  age  for  the  cessa- 
tion of  the  menses.  Lancereaux  gives  a  representation  of  a  case  furnished 
by  Dr.  Richet,  in  which  there  was  a  circumscribed  deposit  of  gummy 
material,   similar  to  that  found  in  syphilitic  orchitis. 

The  symptoms  of  these  affections  are  said  to  be  a  slight,  dull  pain  in 
the  region  of  the  ovaries,  possibly  at  the  outset  some  increase  in  the  size 
of  these  organs,  perceptible  on  abdominal  and  vaginal  palpation,  a  loss 
of  sexual  passion,  and  sterility.  It  is  evident  that  these  signs,  taken  in 
connection  with  the  history  of  the  case,  can  only  furnish  a  probability  of 
the  nature  of  the  disease,  which  may  be  further  increased  by  the  success 
of  antisyphilitic  treatment. 

No  instance  is  known  in  which  the  Fallopian  tubes  have  been  affected 
with  syphilis. 

Certain  cases  in  which  uterine  tumors  in  syphilitic  subjects  have  yielded 
to  the  internal  administration  of  iodide  of  potassium  and  mercurials  ren- 
der it  probable  that  this  organ  is  not  exempt  from  the  late  manifestations 
of  syphilis,  but  nothing  more  definite  is  known  upon  the  subject,  since 
post-mortem  investigation  has  been  wanting.  The  vagina  is  in  rare  cases 
the  seat  of  localized  gummatous  infiltration. 

1  Arch,  (h  Tocologie,  etc.,  Jan.,  1891,  p.  19. 

*  "  Etude  sur  la  Eigidit^  du  Col  d'Origine  syphilitique,"  ibid.,  vol,  xii.,  April,  1885, 
pp.  805  et  seq. 

3  Thise  de  Paris,  1884. 

*  Lyon  medical,  March  29,  1891,  p.  440. 


788  SYPHILIS. 


CHAPTER    LXXXII. 

AFFECTIONS  OF  THE  EPIDIDYMIS  AND  TESTIS. 

Like  all  organs  and  structures  rich  in  connective  tissue,  the  testicle 
and  its  appendages  are  frequently  attacked  both  early  and  late  in  the 
course  of  syphilis. 

The  Epididymis. 

In  somewhat  rare  cases  the  epididymis  is  the  seat  of  an  irritative  pro- 
cess at  the  date  of  the  general  manifestations.  Sometimes  one  and  then 
again  both,  may  be  very  slightly  enlarged,  sensitive,  and  even  mildly 
painful.  This  ephemeral  condition  promptly  yields  to  treatment.  It  may 
occur  in  patients  who  have  suffered  from  gonorrhoea  and  its  epididymitis, 
and  in  those  who  have  never  been  thus  affected. 

In  some  cases  syphilitic  epididymitis  begins  insidiously,  and  is  not 
recognized  until  "  a  lump  "  is  felt  by  the  patient ;  in  others  a  slight  un- 
easiness attends  its  formation.  Upon  examination  we  find  a  small,  round, 
or  oval  tumor  just  above  the  testis,  the  scrotum  itself  being  unaffected. 
It  usually  has  a  smooth  surface  and  is  of  a  decidedly  firm  consistency. 
Its  size  varies  from  that  of  a  pea  to  a  lima  bean.  It  may  exist  in  one 
epididymis  only,  but  frequently  both  are  affected.  Such  tumors  remain 
in  an  indolent  condition  without  showing  any  tendency  to  degeneration, 
and  they  always  promptly  disappear  under  mercurial  treatment.  Other 
portions  of  the  epididymis  or  the  testicle  itself  are  commonly  not  attacked 
simultaneously.  I  have,  however,  seen  two  instances,  and  Fournier  has 
met  with  such,  in  which  the  globus  minor  was  involved  shortly  after  the 
globus  major.  I  have  also  found  similar  tumors  developed  in  the  vas 
deferens  subsequent  to  the  appearance  in  the  epididymis,  and  others 
again  in  which  sarcocele  coexisted. 

This  affection  is  usually  a  somewhat  precocious  manifestation  of  syph- 
ilis, occurring  in  most  cases  within  the  first  six  months,  and  sometimes  as 
early  as  the  second  month,  or,  again,  as  late  as  the  fifth  year,  after  infec- 
tion. It  is  more  commonly  unilateral  when  it  occurs  at  a  later  period. 
In  opposition  to  the  view  that  it  is  the  result  of  acute  or  chronic  urethral 
inflammation,  it  is  only  necessary  to  say  that  it  occurs  in  syphilitic  sub- 
jects, some  of  whom  have  never  had  any  urethral  trouble,  and  that  it  is 
quickly  cured  by  antisyphilitic  treatment.  An  important  point  in  the 
diagnosis  of  this  affection  is  that,  as  a  rule,  it  attacks  the  globus  major, 
whereas  in  gonorrhoeal  epididymitis  the  globus  minor  is  most  commonly 
involved  alone. 

Late  in  the  secondary  and  in  the  tertiary  stages  the  epididymis  may 
be  attacked.  The  resulting  affection  is  of  sIoav  and  usually  painless 
growth,  and,  as  a  rule,  patients  are  ignorant  of  the  presence  of  any  testic- 
ular trouble  until  they  discover  a  lump  on  the  organ.  The  epididymis, 
in  part  or  in  whole,  is  then  found  to  be  swollen  and  hard,  and  perhaps  a 
little  sensitive  on  pressure. 


AFFECTIONS  OF  THE  EPIDIDYMIS  AND  TESTIS.  789 

No  sharply-drawn  description  can  be  given  of  the  condition  of  the 
epididymis  when  the  seat  of  change  in  tertiary  syphilis.  This  appendage 
may  be  quite  uniformly  and  evenly  swollen,  and  it  may  be  the  seat  of 
bulbous  expansions,  and  it  may  be  slightly,  even  markedly,  nodular.  In 
uncomplicated  cases,  particularly  if  seen  quite  early,  more  or  less  prompt 
resolution  of  the  hyperplasia  may  follow  on  active  internal  and  local 
treatment.  When  seen  late  treatment  has  a  limited  effect,  for  the  reason 
that  dense  fibrous  tissue  or  caseated  gummatous  tissue  has  been  produced, 
and  much  disorganization  has  resulted.  In  general,  even  after  what  may 
be  called  good  results  have  been  produced,  more  or  less  firmness  and 
rigidity  of  the   parts   is   left. 

Diagnosis. — The  early  form  of  epididymitis  is  generally  easy  of  recog- 
nition, since  it  usually  coexists  with  or  rapidly  follows  general  manifesta- 
tions.    In  many  cases  a  clear  history  of  syphilis  is  readily  obtained. 

In  the  later  syphilitic  epididymitis  it  is  often  very  difiicult  to  arrive  at 
a  satisfactory  diagnosis.  In  a  given  case  we  must  bear  in  mind  that  an 
antecedent  inflammation,  caused  by  gonorrhoea  or  some  other  infectious 
disease,  may  have  been  the  underlying  cause  of  the  swelling.  In  cases 
of  chronic  posterior  urethritis  it  is  not  at  all  uncommon  to  find  a  chronic 
fibroid  epididymitis,  which  may  develop  acutely  and  then  run  a  chronic 
and  nearly  painless  course,  or  it  may  begin  insidiously  and  run  on  in  a 
sluggish  manner,  or  there  may  be  exacerbations  of  acuity.  When  in 
these  cases  a  history  of  syphilis  is  also  obtainable,  it  is  often  impossible 
to  determine  whether  that  diathesis  has  any  influence  upon  the  morbid 
process. 

Chronic  epididymitis  may  result  from  trauma,  but  usually  a  clear  his- 
tory may  be  obtained. 

In  many  cases  of  late  syphilitic  epididymitis,  there  is  a  symbiosis  with 
tuberculosis,  and  in  this  case  it  is  utterly  impossible  to  make  a  sharply- 
drawn  diagnosis.  The  physical  signs  are  sometimes  very  similar  and 
even  identical,  and  our  reliance  is  then  to  be  placed  on  the  results  which 
follow  active  local  and  general  antisyphilitic  treatment.  Syphilitic  con- 
ditions are  thereby  more  or  less  benefited,  while  in  tuberculosis  at  the 
best  only  a  moderate  improvement  may  sometimes  follow  the  use  of  the 
iodide  of  potassium.  On  this  subject  C.  W.  Allen  ^  has  published  an 
interesting  clinical  essay. 

It  is  always  well  in  cases  of  chronic  epididymitis,  even  if  nodulation 
is  present,  not  to  jump  too  hastily  to  the  conclusion  that  tuberculosis  is 
the  cause,  which  now-a-days  is  so  frequently  done.  The  surgeon  should 
bear  in  mind,  in  considering  these  cases,  chronic  posterior  urethritis, 
trauma,  antecedent  infectious  processes,  syphilis,  tuberculosis,  and  the 
tuberculo-syphilitic  symbiosis. 

In  some  cases  of  early  and  late  syphilitic  epididymitis  the  juxta-tes- 
ticular  part  of  the  vas  deferens  is  the  seat  of  irritative,  hyperplastic,  or 
gummatous  changes. 

The  Testis. 

In  tertiary  syphilis  the  body  of  the  testis  and  the  tunica  vaginalis  may 
be  attacked  by  chronic  hyperplastic  processes  peculiar  to  that  period.     In 

^  American  Jouni.  Med.  Sciences,  April,  1894. 


790  SYPHILIS. 

general,  the  body  of  the  testis  is  alone  attacked,  and  exceptionally  there 
is  coincident  involvement  of  its  serous  tunic. 

Tertiary  lesions  of  the  testis  begin  in  a  painless  and  insidious  manner, 
without  any  of  the  ordinary  signs  of  inflammation.  Some  patients  com- 
plain of  an  uneasy  sensation  in  the  organ,  but,  as  a  general  rule,  no  atten- 
tion is  paid  to  the  progressing  affection  until  the  weight  of  the  swelling 
produces  a  moderate  pain  in  the  loins  and  the  inguinal  region.  When 
seen  early,  a  case  of  syphilitic  orchitis  or  sarcocele  presents  no  very  well- 
marked  features.  The  organ  is  found  to  be  uniformly  swollen,  and  quite 
hard  and  firm  in  consistence,  and  it  is  less  sensitive  than  in  a  normal 
state.  In  some  cases  a  small  portion  of  the  apparent  swelling  is  depend- 
ent upon  hydrocele,  since  in  nearly  every  instance  of  syphilitic  orchitis 
there  is  a  slight  effusion  into  the  tunica  vaginalis.  When  the  amount  of 
fluid  is  considerable,  it  may  be  necessary  to  evacuate  it  by  puncture  before 
a  satisfactory  examination  can  be  made ;  but  in  most  cases  we  may  by 
firm  pressure  sufficiently  displace  the  fluid  to  reach  the  body  of  the  testi- 
cle and  determine  its  condition  by  palpation.  At  an  early  stage  of  the 
disease  the  testicle  may  in  a  minority  of  cases  be  found  to  contain  one  or 
more  distinct  masses  of  induration,  which  form  slight  projections  upon 
the  surface  of  the  size  of  the  head  of  a  pin,  pea,  or  even  an  almond,  but 
which  are  never  so  prominent  as  to  change  the  general  contour  of  the 
organ.  These  projections  are  due  to  an  effusion  of  plastic  material,  of 
the  same  nature  as  gummy  tumors,  upon  the  surface  of  the  tunica  albu- 
ginea.  As  the  disease  progresses  the  distinct  masses  of  induration  coalesce 
and  form  a  hard,  resistant  tumor,  which  still  preserves  to  a  great  extent 
the  normal  shape  of  the  testicle. 

As  a  rule,  the  tumor  is  smooth  throughout  its  whole  course,  while  the 
other  symptoms  remain  the  same. 

Testicular  tumors  of  late  syphilis  may  be  of  the  size  of  a  small  egg 
or  even  as  large  as  a  fist.  They  are  ovoid  or  globular,  smooth,  firm 
usually  as  a  billiard-ball,  and  when  elevated  in  the  palm  of  the  hand 
they  feel  very  heavy.  As  a  rule,  no  pain  is  present,  and  much  pressure 
can  be  borne  without  discomfort  to  the  patient. 

In  somewhat  rare  cases,  particularly  when  the  gummatous  infiltration 
is  localized  in  nodules  and  masses,  the  morbid  tissue  may  break  down  and 
an  abscess-cavity  is  left.  In  rare  cases  this  leads  to  the  excessive  pro- 
liferation of  the  tissues,  and  a  fungus  of  the  testicle  is  produced. 

The  course  of  this  affection  is  exceedingly  slow  and  chronic,  frequently 
lasting  for  several  years.  The  sexual  desires  are  not  changed  unless  the 
disease  has  made  great  progress  in  both  testicles. 

When  recognized  at  a  sufficiently  early  period,  syphilitic  orchitis  may 
almost  invariably  be  arrested  and  the  organ  restored  to  its  original  in- 
tegrity. If  left  to  itself,  it  most  frequently  terminates  in  obliteration  of 
the  seminiferous  tubes  and  complete  or  partial  atrophy  corresponding  to 
the  extent  of  the  adventitious  deposit ;  or,  again,  the  parenchyma  of  the 
gland  may  degenerate  into  fibrous,  cartilaginous,  or  even  osseous  tissue. 

The  pathological  changes  in  tertiary  syphilitic  orchitis  consist  of  intersti- 
tial sclerosis,  gummatous  infiltration,  and  sclero-gummatous  degenerations.^ 

^  For  the  pathology  of  syphilis  of  the  testicles  and  epididymis  the  reader  is  re- 
ferred to  Monod  and  Terrillon,  op.  cit.,  pp.  429  et  seq.,  and  to  Reclus,  De  la  Syphilis  dv, 
Testicule,  Paris,  1882. 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  791 

Diagnosis. — The  smooth,  hard,  and  heavy  syphilitic  orchitis  is  gener- 
ally easily  recognized.  In  a  given  case  it  is  well  to  bear  in  mind  that  a 
very  firm  hydrocele  tumor  with  thick  walls  may  be  mistaken  for  syphilis, 
and  that  cystic  sarcoma,  villous  cancer,  and  carcinoma,  and  exceptionally 
tuberculosis  of  the  testis,  may  exist  in  the  shape  of  smooth,  round,  ovoid, 
and  pear-shaped  swellings,  which,  at  the  period  of  development  and  before 
degenerative  changes  have  taken  place,  may  in  every  particular  resemble 
the  syphilitic  testicle. 

Localized  nodular  gummatous  infiltration  may  be  mistaken  for  tuber- 
culosis. In  many  cases  of  syphilis  no  history  can  be  obtained,  and  in 
cases  of  malignant  disease  it  also  may  be  absent.  It  is  well,  therefore, 
in  all  cases  of  chronically  enlarged  testis  where  the  history  is  doubtful, 
to  cause  the  patient  to  undergo  a  carefully  watched  but  sufficiently  vigor- 
ous local  and  general  antisyphilitic  treatment.  If  syphilis  exists,  more 
or  less  improvement  will  soon  be  noted,  and  in  most  cases  a  brilliant 
cure  will  be  obtained.  When,  after  a  thorough  tentative  antisyphilitic 
treatment,  the  testicular  swelling  remains  uninfluenced  or  increases  in 
size,  the  surgeon  may  quite  confidently  conclude  that  the  case  is  one  of 
malignant  disease  or  of  tuberculosis.  In  malignant  disease  there  is  no 
enlargement  of  the  inguinal  ganglia  until  the  process  has  extended  to  the 
scrotum,  and  in  late  syphilis  the  condition  is  similar.  In  many  cases  of 
syphilitic  sarcocele  there  is  no  evidence  of  ill-health,  which  will  generally 
be  noted  in  the  other  classes  of  cases  just  mentioned. 

We  have  no  precise  knowledge  of  the  effects  of  syphilis  upon  the 
prostate,  seminal  vesicles,  and  the  bladder. 


CHAPTER    LXXXIII. 

AFFECTIONS  OF  THE  NERVOUS  SYSTEM. 

So  minute  and  extensive  is  our  present  knowledge  of  the  anatomy 
and  structure  of  the  cerebro-spinal  system,  and  so  much  detail  and  elabo- 
ration has  been  expended  upon  the  infinitude  of  morbid  conditions  of 
these  parts  due  to  syphilis,  that  for  their  description  a  portly  volume 
would  be  required.  It  is  only  intended  here  to  present  such  a  succinct 
account  of  nervous  phenomena  as  is  required  in  general  practice. 

Syphilitic  nervous  affections  may  be  developed  as  early  as  the  sixth 
month  and  as  late  as  the  twentieth  year  after  infection.  They  are  seen 
more  frequently  in  men  than  in  women,  and  are  most  common  between 
the  ages  of  twenty  and  thirty,  simply  because  syphilis  is  most  likely  to 
be  contracted  at  this  period  of  life.  It  seems  to  be  an  established  fact 
that  nervous  phenomena  are  likely  to  follow  a  course  of  syphilis  in  which 
the  external  manifestations  have  been  insijinificant  or  so  sliffht  as  to  have 
been  entirely  overlooked. 

Syphilis  does  not  primarily  attack  nervous  tissue,  but  begins  in  the 


792  SYPHILIS. 

vessels  and  connective  tissues  of  these  structures.  The  brain  is  more 
frequently  attacked  than  the  spinal  cord.  Our  knowledge  of  the  efiect 
of  syphilis  upon  the  cerebellum  is  as  yet  rather  limited. 

The  prominence  and  constancy  of  some  of  the  nervous  phenomena  of 
syphilis  enable  us  to  recognize  them  as  distinct  affections — namely,  sub- 
acute meningitis,  hemiplegia,  epilepsy,  paraplegia,  and  aphasia,  and  cer- 
tain others  of  minor  importance. 

Predisposing  Causes  of  Syphilis  of  the  Nervous  System. 

Nervous  symptoms  are  especially  likely  to  appear  in  persons  of  a 
neurotic  or  neuropathic  constitution,  which  may  be  hereditary  or  acquired. 
Chorea,  migraine,  apoplexy,  melancholia,  and  neuralgia  are  common  fea- 
tures in  the  family  history  of  such  individuals.  Those  who  have  pre- 
viously had  some  simple  nervous  affection  are  particularly  liable,  when 
infected  by  syphilis,  to  the  development  of  specific  nervous  symptoms. 
Protracted  mental  anxiety,  depressing  emotions,  sexual  excesses,  the 
abuse  of  alcohol  and  of  narcotics,  have  been  known  to  act  as  predisposing 
causes.  Of  diseases,  those  accompanied  or  followed  by  cerebral  conges- 
tion, also  malaria  and  other  conditions  producing  cachexia,  may  act  indi- 
rectly. Sunstroke  and  injuries  of  the  skull  may  be  included,  as  well  as 
the  gouty  diathesis,  particularly  in  elderly  persons  and  in  those  in  whom 
gouty  cerebral  symptoms  have  been  prominent. 

The  inadequacy  or  the  absence  of  treatment  in  relation  to  the  invasion 
of  the  nerve-centres  by  syphilis  should  be  observed.  In  reading  the 
histories  of  cases  thus  far  reported  it  is  found  that  in  many  no  treatment 
at  all  had  been  attempted,  in  some  the  treatment  had  been  insufiicient, 
while  in  very  few  had  it  been  carried  to  the  extent  which  we  deem  neces- 
sary in  even  the  slightest  cases. 

The  nervous  phenomena  of  syphilis  generally  originate  in  lesions  de- 
veloped in  one  or  more  of  the  following  structures  :  the  cranial  bones  and 
vertebrae,  the  dura  mater,  the  arachnoid  and  pia  mater,  the  brain  and 
cord,  and  the  arteries,  the  nerves. 

The  Bones. 

Any  lesion  seated  on  the  inner  surface  of  the  cranium  or  vertebrae 
may  excite  inflammation  of  the  membranes,  and  may  finally  lead  to 
morbid  changes  in  the  brain  itself  and  in  the  spinal  cord.  The  most 
frequent  lesions  are  nodes,  exostoses,  caries,  and  necrosis. 

Although  nodes  may  occur  early  in  the  course  of  syphilis,  these  are 
generally  considered  tertiary  lesions.  In  one  instance  I  have  seen  mul- 
tiple nodes  developed  on  the  external  surface  of  the  cranium  ten  months 
after  syphilitic  infection ;  the  presumption  is  that  similar  growths  may 
appear  as  early  on  the  inner  surface.  We  may,  therefore,  expect  grave 
disturbance  of  the  nervous  system  during  the  first  year  and  as  late  as  the 
twentieth,  since  syphilitic  osseous  lesions  are  known  to  be  developed  even 
at  this  advanced  period.  The  phenomena  may  be  referred  to  pressure 
or  to  inflammation  of  the  brain-substance,  and  are  of  the  most  varied 
character,  including  paralyses,  convulsions,  ataxic  symptoms,  and  mental 
disturbances.     Many  cases  have  been  observed,  in  which  extensive   de- 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  793 

struction  of  the  skull-bones  has  occurred,  even  with  partial  loss  of  the 
dura  mater,  without  the  production  of  cerebral  symptoms. 

A  remarkable  case  reported  by  Gama,  in  which  there  was  destruction 
of  the  bones  of  the  face,  including  the  ethmoid,  caries  of  the  frontal 
bone,  erosion  of  the  dura  mater,  disorganization  of  the  arachnoid,  and 
localized  superficial  softening  of  the  anterior  hemispheres,  which  were 
bathed  in  pus,  presented  as  the  single  nervous  symptom  severe  pain  in 
the  head. 

It  is  interesting  to  notice  that  large  portions  of  the  cerebral  mass  in 
the  anterior  basal  region,  which  was  the  part  involved  in  the  foregoing 
case,  have  been  removed  in  surgical  operations  for  injury  without  pro- 
ducing any  bad  symptoms. 

The  membranes  of  the  brain  may  be  the  seat  of  hypersemia,  which 
produces  no  permanent  alteration,  or  the  process  may  become  chronic 
and  result  in  structural  changes. 

The  Dura  Mater. 

The  dura  mater,  being  a  fibrous  membrane,  is  peculiarly  susceptible 
to  the  syphilitic  influence.  The  changes,  which  usually  consist  of  thick- 
ening due  to  increased  cell-growth,  roughening  of  the  inner  surface  of  the 
membrane,  and  abnormal  vascularity,  are  generally  not  striking.  In  some 
cases  the  membrane  has  a  brownish-red  color  and  gelatinous  appearance, 
yet  its  structure  remains  firm. 

The  extent  of  the  structure  involved  and  the  amount  of  thickening 
vary,  but  are  generally  considerable. 

The  dura  mater  may  be  exclusively  affected,  or  the  disease  may  invade 
the  inner  table  of  the  skull  and  the  arachnoid,  or  the  dura  mater  may  be 
secondarily  affected  by  processes  beginning  in  the  arachnoid  and  pia 
mater.  In  the  case  of  nodes  of  the  inner  table  the  dura  mater  is  found 
thickened  and  abnormally  adherent. 

The  syphiloma  may  form  a  circumscribed  tumor  or  may  be  diffused 
over  a  large  area. 

In  his  atlas  Lancereaux^  gives  an  excellent  illustration  of  gummatous 
infiltration  into  the  dura  mater. 

The  portion  of  the  membranes  enveloping  the  brain  is  more  often 
involved  than  that  covering  other  parts.  There  may  be  but  one  focus  of 
disease  or  several ;  in  the  latter  case  they  are,  as  a  rule,  unsymmetrical. 

Syphilomata  of  the  spinal  dura  mater  have  an  origin  and  pursue  a 
course  similar  to  those  of  the  cerebral. 

The  Arachnoid  and  Pia  Mater. 

In  simple  hypertemia  of  the  pia  mater  the  arachnoid  may  not  be 
involved,  but  when  the  process  advances  to  cell-proliferation  it  is  impos- 
sible to  demonstrate  a  line  of  demarcation  between  the  two  membranes. 

In  most  cases  the  affection  of  these  membranes  consists  of  congestion 
and  visible  enlargement  of  the  vessels,  followed  by  increase  of  connective 
tissue  and  consequent  thickening  ;  but  sometimes  gummatous  infiltration 
supervenes,  constituting  a  gummous  meningitis. 

^  Atlas  d'Anatomie  paiholor/ique,  pi.  41,  Paris,  1874. 


794  SYPHILIS. 

More  or  less  change  in  the  subjacent  nervous  tissue  always  follows,  and 
the  lesion  may  involve  the  dura  mater  and  the  cranial  bones. 

This  is  perhaps  the  most  frequent  syphilitic  nervous  lesion.  It  is  found 
in  single  or  multiple  patches,  distinctly  circumscribed,  of  round  or  oval 
shape  and  of  various  sizes. 

When  multiple,  the  patches  are  scattered  irregularly,  most  frequently 
at  the  base,  in  the  anterior  and  middle  foss?e,  less  frequently  on  the  con- 
vexity of  the  brain,  seldom  on  the  cord  and  medulla,  and  exceptionally 
on  the  cerebellum. 

The  Brain  and  Cord. 

The  changes  in  the  brain  and  cord  are  always  secondary  to  lesions  of 
the  bones,  of  the  meninges,  or  of  the  vessels,  and  consist  of  two  kinds  of 
softening,  the  red  and  the  white,  which  are  similar  to  these  lesions  when 
non-specific. 

The  softening  is  likely  to  be  more  superficial  when  the  lesion  begins  in 
the  meninges  than  when  it  originates  in  the  bones. 

A  primary  vascular  lesion  on  the  basal  surface  will  produce  much  more 
serious  and  extensive  structural  change  in  the  brain  than  one  at  the  vor- 
tex, for  the  reason  that  in  the  latter  situation  the  vessels  anastomose 
freely,  whereas  in  the  former  each  vessel  is  distributed  to  a  region  which 
has  no  other  source  of  nutrition. 

The  Arteries. 

Although  the  effect  of  syphilis  upon  the  cerebral  arteries  has  been 
referred  to  by  several  English  authors,  our  knowledge  of  the  subject  was 
meagre  and  unsatisfactory  until  the  appearance  of  the  excellent  mono- 
graph by  Heubner,  in  which  he  gives  a  minute  description  of  the  various 
morbid  changes. 

These  changes,  which  are  chiefly  subendothelial,  consist  of  thickening 
of  the  lamella  of  the  endothelium,  between  which  and  the  membrana 
fenestrata  is  soon  deposited  a  finely  granular  substance,  with  a  few  nuclei, 
some  in  process  of  division,  as  well  as  a  few  nucleated  spindle-shaped  and 
stellate  cells.  In  the  normal  condition  this  part  is  nearly  free  from  cells 
and  nuclei. 

Subdivision  and  fresh  proliferation  of  cells  constitute  the  subsequent 
changes.  An  important  point  of  distinction  between  atheroma  and  the 
syphilitic  process  is  that  in  the  latter  the  development  of  cells  is  more 
active  than  that  of  intercellular  substance. 

As  the  process  continues  the  endothelium  becomes  separated  from  the 
membrana  fenestrata  ;  the  interposed  cells  beconae  compressed  and  flattened, 
and  by  their  fusion  probably  result  in  the  formation  of  giant-cells.  The 
endothelium  becomes  thickened  and  encroaches  on  the  lumen  of  the  vessel. 
Owing  to  the  irritation  produced,  small  round  cells,  perhaps  derived  from 
the  vasa  vasorum,  are  observed.  While  the  essential  lesion  is  limited  to 
the  locality  mentioned,  adjacent  parts  may  become  secondarily  involved, 
and  these  small  round  cells  may  be  seen  in  the  meshes  of  the  tunica  media 
and  tunica  adventitia.  The  new  growth  gradually  becomes  organized,  and 
is  supplied  with  nutrition  by  newly-formed  capillaries,  most  clearly  seen 
in  a  transverse  section. 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  795 

The  subsequent  morbid  process  is  a  subdivision  into  layers  of  the  new 
tissue  between  the  membrana  fenestrata  and  the  endothelium.  At  the 
same  time  a  new  membrana  fenestrata  is  formed  beneath  the  endothelium, 
which  is  regarded  by  Heubner  not  as  an  essential  part  of  the  syphilitic 
process,  but  as  due  to  increased  activity  of  the  endothelium. 

In  the  early  stage  of  this  lesion  very  slight  impediment  to  the  blood- 
current  results,  but  as  contraction  of  the  lumen  of  the  artery  goes  on 
white  blood-corpuscles  are  deposited  along  its  inner  wall  until  a  perfect 
thrombus  may  be  formed.  Occasionally  the  vessel  still  remains  slightly 
permeable. 

There  are  several  points  of  distinction  between  atheroma  and  this 
syphilitic  lesion.  The  latter  is  much  more  rapid  in  its  course,  and  usually 
occurs  much  earlier  in  life.  In  atheroma  the  calibre  of  the  vessel  is  sel- 
dom diminished,  while  in  syphilitic  endarteritis  complete  stenosis  may 
result.  Atheroma  generally  involves  more  extensive  surfaces  and  a 
larger  number  of  vessels  than  the  syphilitic  lesion,  and,  moreover,  in  the 
latter  there  is  no  tendency  to  calcific  degeneration,  so  common  in 
atheroma,  which,  unlike  the  product  of  the  syphilitic  process,  is  in- 
curable. 

This  process  is  not  at  all  specific  m  its  nature,  since  the  cells  are 
similar  in  structure  and  arrangement  to  those  of  certain  sarcomata  and 
gliomata.  The  syphilitic  virus  seems  to  excite  irritation  of  the  endo- 
thelium, which  results  in  the  conditions  previously  described.  The 
resemblance  of  this  lesion  to  gummata  or  granulation  tissue  is  very 
marked.  I  have  observed  an  instance  in  which  it  existed  in  the  left 
Sylvian  artery,  continuous  with  a  gumma  completely  encircling  that 
vessel. 

Although  this  arterial  lesion  may  occur  as  early  as  the  first  year  of 
syphilis,  it  is  usually  developed  much  later,  having  generally  been  found 
associated  with  nodes  and  gummata  of  the  liver  and  testes.  As  a  rule,  it 
is  to  be  expected  at  about  the  third  year  of  syphilis,  but  may  occur  as 
late  as  the  twentieth. 

The  arteries  most  frequently  involved  are  the  large  vessels  at  the 
base  of  the  brain,  and,  for  reasons  already  given,  the  danger  to  an  exten- 
sive portion  of  the  cerebral  mass  from  defective  nutrition  is  much  greater 
than  in  disease  of  arteries  distributed  to  the  convexity. 

The  morbid  change  is  rarely  confined  to  a  segment  of  the  artery,  but 
usually  involves  its  entire  circumference,  and  generally  from  an  inch  to  an 
inch  and  a  half  of  its  continuity.  Several  vessels  may  be  involved  in 
different  stages  of  the  lesion  or  only  one  may  be  affected. 

In  advanced  stages  of  the  morbid  process  the  vessel  is  found  to  be 
thickened,  rigid,  and  slightly  compressible,  and  may  even  have  a  nodu- 
lated appearance,  due  to  excessive  cellular  development  and  invasion  of 
the  outer  tunics  at  certain  points.  A  thickened  arter^^  of  small  size  may 
present  several  rounded  expansions  within  the  limit  of  an  inch. 

Longitudinal  sections  of  an  artery  which  is  affected  to  an  extreme  de- 
gree shows  roughening  of  its  inner  surface,  which  has  lost  its  normal 
gloss  and  color,  being  dull  gray  Avhere  the  lesion  is  recent  and  brownish 
where  it  is  older. 

Thrombi,  with  or  without  distinct  laminre,  are  found,  some  very  thin 
and  friable,  others  firm  and  fully  occluding  the  vessel. 


796  SYPHILIS. 

Friedlander  and  Koster  believe  that  the  cellular  infiltration  of  the 
tunica  intima,  and,  in  proportion  to  the  intensity  of  the  process,  of  the 
other  coats  of  the  artery,  is  not  peculiar  to  syphilis,  but  is  found  in  in- 
flammatory, tubercular,  carcinomatous,  and  other  growths.  They  com- 
pare the  process  to  that  of  organization  of  a  thrombus,  and  conclude 
that  the  new  cells  of  the  intima  are  derived  from  the  vasa  vasorum. 

While  Heubner  admits  that  the  cellular  infiltration  of  the  outer  coat  is 
derived  from  the  vasa  vasorum,  he  is  positive  in  his  opinion  that  the  cells 
found  in  the  inner  coat  are  furnished  by  proliferation  of  the  epithelial 
lining  of  the  vessel  due  to  irritation  by  the  syphilitic  poison.  He  thinks 
that  it  is  a  gummatous  affection  beginning  in  the  intima,  independently  of 
inflammatory  processes  without  the  vessel. 

Baumgarten  of  Kbnigsberg  has  studied  the  subject  carefully,  and, 
though  agreeing  in  the  main  Avith  the  former  observers,  he  thinks  that 
Heubner  is  right  in  his  belief  that  the  infiltrating  cells  have  two  sources. 
The  growth  in  the  outer  coats  he  considers  gummatous  and  peculiar  to 
syphilis,  while  that  in  the  inner  coat  he  thinks  is  non-specific  ;  in  other 
words,  the  cells  from  the  vasa  vasorum  form  a  gumma,  while  those  de- 
rived from  the  endothelium  form  a  tissue  resembling  ordinary  granulation 
tissue. 

In  the  thesis  of  Rabot  another  variety  of  syphilitic  arteritis  is  de- 
scribed on  the  authority  of  M,  Charcot,  who  calls  it  "syphilitic  peri- 
arteritis." The  details  are  given  of  an  autopsy  made  upon  a  syphilitic 
woman,  thirty  years  of  age,  at  which,  among  other  lesions,  was  found 
upon  the  trunk  of  the  left  Sylvian  artery,  near  its  origin,  a  nodosity  as 
large  as  a  haricot  bean,  whitish  in  color,  irregular  in  form,  and  appearing 
to  involve  the  external  tunics  of  the  vessel.  Similar  lesions  were  found 
on  other  arteries,  but  they  were  much  more  numerous  on  those  of  the 
base  than  on  those  of  the  convexity.  Microscopic  examination  of  these 
tumors  showed  that  they  were  the  result  of  an  acute  arteritis,  producing 
thickening  of  the  internal  coat,  with  infiltration  of  connective-tissue  cells 
into  the  tunica  media.  The  new  tissue  consisted  of  fusiform  cells  in  the 
midst  of  a  finely  granular  fibrillated  substance.  The  internal  elastic 
tunic  was  intact,  while  the  tunica  muscularis  was  infiltrated  with  round 
embryonic  cells  and  permeated  by  capillaries.  Similar  young  cells  were 
found  throughout  the  external  coat,  chiefly  around  the  vasa  vasorum, 
which  were  much  enlarged.  Contraction  of  their  walls  and  the  formation 
of  thrombi  had  produced  occlusion  of  the  vessels. 

Charcot  leans  to  the  opinion  that  this  is  a  true  syphilitic  periarteritis, 
but  refrains  from  a  positive  statement  until  he  has  made  further  ob- 
servations. 

The  Nerves. 

The  cerebrospinal  nerves  may  be  involved  in  the  various  affections  of 
the  meninges  ;  they  may  be  encircled  by  gummy  tumors  or  they  may  be 
compressed  by  swellings'^ of  the  bony  foramina.  The  resulting  symptoms 
are  anaesthesia,  hypergesthesia,  analgesia,  neuralgia,  paralysis,  or  disturb- 
ances of  the  special  senses. 

Syphilitic  lesions  being  most  frequent  in  the  neighborhood  of  the  inter- 
peduncular space,  the  nerves  near  this  lesion  are  most  commonly  involved. 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  797 

The  third  pair  are  perhaps  most  often  affected,  the  first,  second,  fourth,  and 
sixth  quite  frequently,  while  syphilitic  changes  of  the  seventh  pair,  or 
facial  nerves,  are  rather  exceptional. 

The  syphilitic  lesions  of  the  optic  nerve  have  been  studied  by  Barbar, 
Arcoleo,  and  Hulke,  but  more  recently  by  Schott,  who  describes  them 
very  accurately  and  illustrates  them  copiously  with  lithographic  plates. 
This  observer  confirms  the  view  of  Virchow,  that  there  may  be  both 
neuritis  and  perineuritis.  In  two  cases  he  found  free  proliferation  of 
young,  round,  nucleated  cells  in  the  connective-tissue  sheath,  with  some 
increase  of  the  spindle-shaped  cells.  He  found  similar  cells,  in  rows  and 
solitary,  in  the  nerve-tissue  itself  and  around  the  nutrient  vessels  of  the 
nerves.  The  nerve-bundles  were  separated  and  thinned  by  the  pressure. 
In  one  case  the  process  was  limited  to  a  portion  of  one  optic  nerve,  and 
was  more  pronounced  near  its  origin.  In  the  other  case,  though  both 
nerves  were  involved,  the  left  was  more  markedly  affected. 

Other  cranial  nerves  and  the  spinal  nerves  may  be  altered  in  a  similar 
manner,  with  or  without  coincident  lesions  of  adjacent  parts.  Heubner 
states  that  a  nerve  has  been  found  to  pass  through  a  syphilitic  new  growth 
and  yet  remain  normal. 

We  know,  as  yet,  little  of  the  morbid  changes  caused  by  syphilis  in 
the  peripheral  nerves,  but  certain  clinical  facts  indicate  that  neuritis  and 
multiple  neuritis  occur  in  the  course  of  syphilis,  as  they  do  in  that  of 
other  infectious  diseases.  A  number  of  writers  describe  the  gross  appear- 
ances as  follows :  In  the  early  stage  they  lose  their  rounded  shape  and 
become  swollen ;  they  assume  a  reddish-yellow  color  and  a  soft  ancl  pulpy 
consistency ;  at  the  same  time  the  swelling  may  give  them  a  bulbous  ap- 
pearance ;  subsequently  they  become  atrophied  into  yellowish-white  car- 
tilaginous cords.  This,  like  all  other  syphilitic  lesions,  is  limited  to 
certain  portions,  and  never  attacks  the  entire  length  of  a  nerve.  We 
are  wholly  ignorant  of  any  primary  changes  in  the  nerve-fibres  and 
axis-cylinder. 

The  sympatlietio  nerves  may  undergo  two  varieties  of  changes — one 
afi'ecting  the  nerve-cells  and  characterized  by  pigmentary  and  colloid 
degeneration ;  the  other  consisting  of  a  connective-tissue  proliferation. 
These  conditions  were  found  by  Dr.  Petrow,  on  microscopic  examination 
both  of  fresh  specimens  and  of  those  hardened  in  chromic  acid,  in  the 
cervical,  thoracic,  and  solar  plexuses  of  syphilitic  subjects.  He  draws  the 
following  conclusions  from  his  studies :  The  syphilitic  diathesis  affects  the 
sympathetic  nerves,  determining  very  distinct  alterations.  The  nerve- 
cells  may  undergo  change  independently  of  the  connective  tissue,  con- 
sisting of  pigmentary  and,  less  frequently,  of  colloid  degeneration.  The 
connective  tissue  may  undergo,  as  elsewhere,  sclerosis  and  cause  atrophy 
of  the  nervous  elements.  The  membrane  covering  the  nerve-cells  may 
be  involved,  at  first  by  hypertrophy  from  cell-infiltration,  which  may 
afterward  undergo  fatty  degeneration. 

Syphilitic  Tumors  of  the  Nervous  System. 

Two  forms  of  syphiloma,  or  syphilitic  tumor,  are  found  in  the  cranio- 
vertebral  cavity  which  differ  widely  in  gross  appearances,  but  are  com- 
posed of  similar  structural  elements.     These  tumors  are  usually  connected 


798  SYPHILIS. 

with  the  cerebrum  ;  they  have  rarely  been  found  in  the  medulla  oblongata 
or  in  the  cord,  and  we  are  not  aware  of  any  having  been  observed  either 
upon  or  within  the  cerebellum. 

The  first  form  is  of  a  grayish-red  color  and  is  extremely  vascular, 
most  of  the  vessels  being  very  minute,  while  some  are  plainly  visible  to 
the  naked  eye.  When  developed  exclusively  in  the  pia  mater  and  arach- 
noid the  tumor  is  soft  and  slightly  fibrous  ;  but  if  it  is  formed  only  in  the 
dura  mater,  its  consistence  is  quite  firm,  owing  to  the  abundance  of 
fibrous  tissue. 

Under  hio-h  powers  of  the  microscope  the  tumor  is  found  to  consist  of 
small  round  cells,  arranged  regularly  or  Avithout  order  in  a  very  delicate 
alveolar  stroma  of  connective  tissue.  The  walls  of  the  newly-formed 
vessels  are  usually  much  thickened  by  cell-increase. 

The  second  form  of  tumor,  which  is  harder  and  of  a  yellowish  color, 
is  merely  a  late  and  degenerating  stage  of  the  first  variety.  Excess  of 
fibrous  tissue  renders  its  structure  more  dense  and  its  boundaries  more 
clearly  defined.  The  blood-vessels  are  few,  and,  while  permeable  at  the 
periphery,  at  the  centre  of  the  tumor  they  are  converted  into  fibrous 
cords.  On  section  the  tumor  is  slightly  resistant  to  the  knife  and  appears 
more  or  less  desiccated.  Microscopic  examination  shows  a  distinctly 
fibrous  stroma,  in  which  is  imbedded  a  large  quantity  of  withered  cells, 
granular  and  fatty  matter,  and  blood-crystals. 

These  tumors  Vary  greatly  in  number  and  in  size ;  there  may  be  a 
single  one  or  the  surface  of  the  hemisphere  may  be  studded  with  large 
numbers  of  them,  resembling  the  condition  in  miliary  tuberculosis ;  they 
may  be  of  the  size  of  a  pea  or  of  a  small  walnut.  They  are  usually  round 
or  oval,  but  in  some  situations  they  become  flattened.  They  have  been 
found  encircling  an  artery,  and  it  is  probable  that  their  origin  is  always 
around  some  vessel,  particularly  one  traversing  the  large  fissure  of  the 
brain.  In  rare  instances  the  soft  form  of  tumor  has  been  found  in  large 
patches,  involving  chiefly  the  vascular  cerebral  membranes,  and  having  a 
thickness  of  from  a  quarter  to  half  an  inch,  and  constituting  in  reality 
a  gummatous  meningitis. 

These  tumors  are  found  chiefly  on  the  inferior  surface  of  the  brain,  in 
the  region  of  the  fissure  of  Sylvius.  Great  care  must  be  employed  in 
examining  the  hemispheres,  since  such  growths  may  exist  in  any  recess 
of  the  brain  into  which  the  vascular  membranes  are  reflected.  Heubner 
says  that  frequently,  after  having,  as  he  supposed,  finished  an  autopsy,  he 
has  run  across  minute  tumors  hidden  in  such  situations. 

Hemiplegia. 

One  of  the  most  frequent  phenomena  of  cerebral  syphilis  is  hemi- 
plegia, which  may  occur  as  early  as  the  third  month  or  as  late  as  twenty 
years  after  infection.  The  interference  with  the  motor  function  may  be 
slio-ht  or  there  may  be  complete  loss  of  power.  It  is  generally  preceded 
by  a  stage  in  which  a  prominent  symptom  is  localized  headache,  often 
associated  with  many  of  the  other  symptoms  already  mentioned,  such  as 
mental  disturbance,  hebetude,  vertigo,  and  convulsions,  which  are  often 
immediately  followed  by  the  paralytic  stroke. 

In  some  cases  muscular  spasm,  a  form  of  preparalytic  chorea,  has  been 


AFFECTIOXS  OF  THE  NERVOUS  SYSTEM.  799 

observed  in  the  limbs  afterward  paralyzed.  For  instance,  the  arm  may 
be  jerked  in  various  directions,  or  the  patient  may  find  it  impossible  to 
place  the  foot  firmly  on  the  ground,  the  leg  being  pulled  suddenly  from 
under  him  when  he  attempts  to  stand.  In  other  cases  darting  pains  are 
felt  in  the  leg  or  arm,  or  constant  neuralgic  pain  may  exist  in  some  part 
of  the  limb,  or  there  may  be  numbness  or  tingling  in  the  hands  and  feet, 
with  patches  of  hypertesthesia  or  anesthesia. 

In  cases  of  gradual  invasion  total  paralysis  seldom  occurs.  The 
patient  first  notices  that  he  is  losing  strength,  perhaps  in  his  fingers,  so 
that  he  finds  himself  unable  to  button  his  clothing  or  to  hold  a  pen 
firmly.  This  condition  may  continue  until  paralysis  comes  on,  or  it  may 
be  intermittent,  the  normal  strength  returning  at  intervals.  When  the 
leg  is  thus  affected  the  patient  naturally  has  more  or  less  difficulty  in 
walking.  Complete  hemiplegia  has  been  seen  to  come  on  in  this  gradual 
manner,  but  is  generally  sudden.  Sometimes  the  leg  is  affected  several 
hours  before  power  is  lost  in  the  arm.  The  reverse,  however,  is  infre- 
quent. Patients  are  usually  attacked  with  hemiplegia  when  engaged  in 
some  act  of  muscular  effort,  such  as  pulling  on  the  boots,  walking  briskly, 
reaching  for  some  object,  or  on  the  point  of  shooting  at  game.  On  the 
contrary,  the  attack  may  happen  during  the  night,  and  the  patient  be 
unable  to  rise  from  the  bed  in  the  morning. 

The  course  and  duration  of  hemiplegia  vary  greatly.  When  partial 
the  paralysis  may  gradually  improve,  and  even  disappear  spontaneously 
in  a  few  days ;  or,  as  improvement  takes  place,  the  opposite  side  may 
be  similarly  affected,  followed  by  recurrence  of  the  paral3^sis  on  the 
side  first  involved.  These  cases  are  accompanied  by  excessive  mental 
impairment,  and,  as  a  rule,  have  an  early  fatal  termination.  Syphilitic 
hemiplegia  is  caused  by  lesions  of  the  arteries,  and  in  cases  of  the 
latter  class  just  mentioned  the  vessels  of  each  side  of  the  brain  are 
implicated. 

Disturbance  of  general  sensation  is  usually  limited,  but  instances  of 
slight  loss  of  motor  power,  with  complete  loss  of  the  sensory  function, 
have  been  reported.  In  exceptional  cases  there  may  be  total  loss  of  both 
motion  and  sensation. 

A  great  variety  of  phenomena,  depending  upon  the  extent  and  situa- 
tion of  the  lesions,  may  accompany  syphilitic  hemiplegia,  such  as  paraly- 
sis of  various  nerves,  aphasia,  mydriasis,  optic  neuritis,  and  epilepsy. 
Mental  depression  seems  to  be  constant,  and  most  patients  either  display 
a  condition  of  complete  hebetude  or  are  excessively  emotional. 

Early  and  energetic  treatment  may  accomplish  the  relief  and  even  the 
cure  of  hemiplegia,  but  the  prognosis  is  greatly  influenced  by  the  age 
and  extent  of  the  lesion.  The  arteries  arising  from  the  circle  of  Willis 
supply  the  most  important  regions  of  the  brain,  and  are  most  frequently 
affected  by  syphilis  ;  obviously,  if  but  one  is  involved  the  prognosis  may 
be  more  favorable  than  if  many  are.  The  number  and  gravity  of  the 
symptoms  will  usually  give  an  idea  of  the  extent  of  the  lesion.  In  a 
simple  case  of  hemiplegia  probably  only  one  or  two  vessels  are  affected, 
and  complete  recovery  may  take  place,  but  when  other  symptoms,  indica- 
tive of  extensive  disorganization  of  the  brain,  are  exhibited,  the  progno- 
sis must  be  less  favorable.  As  a  rule,  perfect  health  is  in  no  case  re- 
stored, although  the  patient  may  present  no  conspicuous  abnormality. 


800  SYPHILIS. 

We  may  say,  however,  that  the  prognosis  in  syphilitic  hemiplegia  is  better 
than  in  the  simple  form. 

Diagnosis. — Syphilitic  hemiplegia  usually  occurs  much  earlier  in  life 
than  the  simple  variety,  which  is  not  commonly  seen  before  the  age  of 
forty  years.  In  diagnosis,  therefore,  it  should  be  remembered  that 
syphilis  is  the  cause  of  most  of  the  cases  of  hemiplegia  in  the  young 
and  middle-aged.  The  fact  that  a  patient  rarely  loses  consciousness 
when  attacked  by  syphilitic  hemiplegia  is  an  additional  diagnostic  point 
of  importance. 

Epilepsy. 

This  is  of  frequent  occurrence  iu  cerebral  syphilis,  and,  like  non- 
specific epilepsy,  presents  two  forms,  the  grand  mal  and  the  j^^^  ^^f-^^- 
Headache,  increasing  in  severity,  always  precedes  an  attack.  The  S3'mp- 
toms  of  the  severe  form  are  similar  to  those  of  the  non-specific  variety, 
consisting  of  sudden  loss  of  consciousness,  tonic  followed  by  clonic  spasms, 
facial  distortion,  foaming  at  the  mouth,  and  stertorous  respiration.  Ac- 
cording to  some  authors,  the  epileptic  aura  and  cry  are  absent.  Such 
convulsions  generally  occur  at  short  intervals,  and  frequently,  with  dis- 
tinct regularity,  every  ten  days  or  once  a  month.  Instances  of  their  reg- 
ular occurrence  in  the  evening  and  at  night  have  been  reported,  but,  as  a 
rule,  they  come  on  at  no  definite  time.  In  some  cases  consciousness 
returns  in  a  few  minutes ;  in  others  the  patient  remains  in  a  stupid  condi- 
tion for  hours,  and  may  not  be  fully  restored  for  several  days.  After  the 
seizure  the  headache  may  be  much  less  severe  for  a  time,  but  unless  treat- 
ment is  followed  its  intensity  soon  returns. 

The  course  of  syphilitic  epilepsy  is  uncertain,  and  may  be  greatly 
modified  by  treatment. 

When  convulsions  follow  a  long  prodromal  stage  in  which  symptoms 
of  mental  disturbance  have  been  particularly  severe,  the  prognosis  must 
be  rather  unfavorable;  cases  in  which  they  follow  a  short  period  of  head- 
ache generally  yield  to  proper  treatment,  as  we  have  several  times 
observed.  Tonic  spasms  may  precede  or  follow  an  attack  of  hemiplegia, 
and  are  often  seen  in  connection  with  permanent  or  intermittent  aphasia. 
They  are  generally  caused  by  pachymeningitis,  though  probably,  in  some 
cases,  as  claimed  by  Jackson,  irritation  from  a  tumor  is  the  exciting 
cause. 

The  intervals  of  syphilitic  epilepsy,  unlike  those  of  apparent  health  in 
the  simple  form,  are  marked  by  symptoms  of  mental  disturbance,  which 
tend  to  increase,  and  may  finally  end  in  dementia. 

The  mild  form,  called  by  Charcot  partial  syphilitic  epilepsy,  may  exist 
independently  or  combined  with  the  severe  form.  The  paroxysm  may 
begin  either  with  a  twitching  of  one  side  of  the  face,  a  turning  of  the 
tongue  to  one  side,  a  tendency  on  the  part  of  the  patient  to  whirl  around, 
extreme  giddiness,  general  trembling,  or  great  weakness,  or  cramps  of  the 
extremities,  which  are  followed  by  loss  of  consciousness  and  a  convulsion 
consisting  either  of  slight  muscular  tremor  or  of  general  tonic  spasm. 
The  seizure  may  be  limited  to  a  single  limb  or  to  one  side  of  the  body, 
and  in  some  cases  amounts  to  nothing  more  than  slight  rigidity.  The 
severity  and  length  of  the  attack  are  much  less  than  in  the  grand  mal. 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  801 

Frequently  there  is  no  convulsion  at  all,  but  the  patient,  while  talking 
or  in  performing  any  act,  becomes  unconscious  and  is  seen  to  stare 
vacantly.  If  sitting,  he  becomes  motionless ;  if  walking,  he  does  not 
fall,  but  proceeds  m  an  uncertain,  aimless  manner;  and  if  in  the  midst  of 
conversation,  he  suddenly  becomes  obtuse  and  fails  to  comprehend  any 
question  addressed  to  him.  While  in  this  condition,  which  may  last  only 
a  few  seconds  or  even  twenty  minutes,  he  may  perform  rational  acts,  such 
as  paying  properly  for  a  purchased  article,  or  he  may  even  walk  along 
without  staggering,  and  when  his  senses  are  restored  he  may  recall  indis- 
tinctly or  not  at  all  what  he  has  said  or  done. 

Dr.  Hughlings  Jackson  has  described  a  form  of  seizure  which  he  has 
found  to  be  caused  by  syphilis,  and  to  be  accompanied  or  followed  by 
optic  neuritis.  It  begins  unilaterally  as  a  mere  twitch,  a  slight  rigidity, 
or  a  violent  convulsion,  in  most  cases  in  the  thumb  and  fore  finger.  It 
may  be  limited  to  the  arm,  along  which  it  extends,  or  it  may  also  involve 
the  face  of  the  same  side  ;  it  may  reach  the  leg  and  constitute  a  hemispasm, 
or  finally  it  may  proceed  to  general  convulsion.  During  the  intervals, 
which  vary  in  length,  a  course  of  symptoms  similar  to  those  of  the  grand 
mal,  though  perhaps  of  milder  character,  may  be  observed. 

The  diagnostic  points  of  syphilitic  epilepsy  are — 1,  the  history  of  the 
patient ;  2,  the  paroxysmal  headache ;  3,  the  frequency  of  mental  dis- 
turbance; 4,  the  frequent  coexistence  of  optic  neuritis,  hemiplegia,  aphasia, 
and  paralyses  of  various  nerves ;  5,  the  age  of  the  patient ;  6,  the  result 
of  treatment. 

Simple  epilepsy  is  usually  developed  before  puberty,  whereas  that 
caused  by  syphilis  generally  occurs  between  the  ages  of  twenty  and  thirty, 
the  period  when  syphilis  is  most  frequently  contracted.  The  former  is 
either  uninfluenced  or  aggravated  by  the  iodide  of  potassium  and  mer- 
curials, whereas  their  influence  on  the  latter  is  favorable  and  in  some  cases 
curative. 

Paraplegia. 

Though  the  spinal  cord  is  attacked  by  syphilis  less  frequently  than 
the  brain,  at  least  one-half  the  cases  of  paraplegia  are  of  syphilitic  origin. 

The  symptoms  are  not  strongly  marked.  The  patient,  who  may  or 
may  not  suffer  from  pain  in  the  back,  notices  slight  weakness  of  the  lower 
extremities,  and  may  also  complain  of  one  or  more  of  the  following  symp- 
toms :  Darting  pains  and  spasms  in  the  legs,  numbness,  tickling,  or  aching 
pains  in  the  feet,  hyperaesthesia,  anaesthesia,  dermatalgia,  and  formication. 
Loss  of  co-ordinating  power  may  be  observed.  There  is  usually  progres- 
sive weakness  in  the  expulsive  power  of  the  rectum  and  bladder.  This 
condition  may  remain  stationary  for  a  long  time  or  it  may  improve  tem^ 
porarily,  but  unless  treatment  is  adopted  complete  paralysis  of  both  legs 
finally  ensues.  On  the  other  hand,  the  development  of  paraplegia  may  be 
much  more  rapid. 

General  sensation  may  be  preserved  slightly  impaired  or  wholly  lost. 
Exceptionally  it  is  destroyed,  while  the  motor  function  remains  perfect. 
After  the  establishment  of  full  paralysis  there  may  be  short  intervals  of 
slightly  restored  power  or  there  ma)^  be  jerking  of  the  muscles. 

Paraplegia  may  be  the  only  manifestation  of  syphilis  existing  at  this 
time,  but  frequently  there  are  evidences  of  lesions  in  the  brain,  such  as 

51 


802  SYPHILIS. 

headache,  vertigo,  mental  impairment,  paralysis  of  one  or  more  cranial 
nerves,  particularly  those  supplying  the  muscles  of  the  eyes,  or  optic 
neuritis.  Mydriasis  has  also  been  observed.  The  presence  of  any  of 
these  latter  symptoms  confirms  the  diagnosis  of  syphilis,  which  is  ordi- 
narily less  clear  in  this  than  in  other  nervous  affections  of  specific 
origin.  Careful  inquiry  into  the  history  and  age  of  the  patient  is  de- 
manded. Simple  idiopathic  paraplegia  generally  occurs  later  in  life 
than  the  syphilitic  form,  and  the  latter,  like  all  specific  nervous  affec- 
tions, is  greatly  influenced  and  frequently  cured  by  treatment,  which 
should  be  adopted  early  in  all  cases,  even  in  those  of  doubtful  character. 

The  prognosis,  unless  treatment  has  been  long  delayed,  is  favorable. 

The  causes  of  syphilitic  paraplegia  are  lesions  of  the  vertebrae,  of 
the  spinal  meninges,  and  tumors,  which  by  pressure  on  the  cord  lead  to 
myelitis  and  softening. 

Cases  thus  far  observed  indicate  that  paraplegia  is  a  later  manifesta- 
tion of  syphilis  than  hemiplegia  and  epilepsy,  though  probably  the 
lesions  which  cause  it  may  be  developed  as  early  as  within  the  first  year 
of  syphilis.  In  the  majority  of  recorded  cases  its  invasion  has  occurred 
after  the  sixth  year  of  infection.  It  may  of  course  occur  very  much 
later. 

Aphasia. 

Various  disturbances  of  speech,  included  under  the  term  "aphasia," 
frequently  occur  in  the  course  of  syphilis  of  the  nervous  system.  These 
may  consist  merely  of  hesitation  in  speaking,  called  emharras  de  parole, 
or  of  inability  to  remember  certain  words  in  writing  and  in  speaking,  or 
of  the  use  of  utterly  inappropriate  words  on  all  occasions. 

A^an  Buren  and  Keyes  have  reported  an  interesting  case  of  a  man 
who,  prior  to  an  attack  of  syphilitic  hemiplegia,  spoke  English  and 
French,  besides  German,  his  native  language,  but  during  recovery  he 
could  only  speak  French. 

Syphilitic  aphasia  may  be  continuous  or  intermittent,  and  always 
accompanies  other  symptoms,  which  determine  its  origin,  since  it  pre- 
sents in  itself  no  diagnostic  features. 

The  prognosis  depends  to  a  great  extent  upon  the  early  adoption  of 
antisyphilitic  treatment. 

Locomotor  Ataxia. 

Investigations  made  within  fifteen  years  very  clearly  show  that  in 
60  or  70  per  cent,  of  cases  of  locomotor  ataxia  the  patients  had  suffered 
more  or  less  remotely  from  syphilis.  This  affection  is  due  to  connec- 
tive-tissue increase  in  the  neuroglia,  which  is  so  commonly  caused  by 
syphilis. 

The  syphilitic  form  of  this  disorder  is  similar  in  its  clinical  history 
to,  and  is  as  rebellious  to  treatment  as,  the  simple  form. 

Chorea. 

The  spasmodic  muscular  movements  caused  by  syphilis  are  irregular 
and  occasional,  and  never  constitute   complete  chorea.      Preparalytic 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  803 

chorea,  characterized  by  spasmodic  contractions  without  loss  of  con- 
sciousness, preceding  an  attack  of  hemiplegia  or  paraplegia,  has  been 
already  referred  to  ;  similar  contractions  not  infrequently  follow  these 
paralyses,  and  the  condition  is  then  called  post-paralytic  chorea. 

The  spasms  vary  in  intensity  from  a  mere  twitch  to  a  decided  con- 
vulsion, and  may  be  limited  to  an  arm,  or  may  at  the  same  time  include 
the  face,  or  they  may  occur  unilaterally  in  the  arm  and  the  leg.  They 
do  not,  as  a  rule,  become  general,  and  always  coexist  with  other  symp- 
toms of  graver  importance. 

Pseudo -general  Paralysis  or  Dementia. 

The  relation  of  syphilis  to  general  paralysis  of  the  insane  has  been 
until  recently  a  disputed  question.  While  some  authorities  claimed 
that  the  latter  affection  was  in  a  measure  due  to  syphilis,  others  believed 
that  its  occurrence  in  a  syphilitic  subject  was  a  mere  coincidence.  The 
subject  has  lately  been  carefully  studied  by  Mickle  and  Fournier,  who 
have  arrived  at  the  conclusion  that  syphilis  produces  an  affection  re- 
sembling in  certain  respects  the  general  paralysis  of  the  insane,  but 
that  the  two  diseases  are  not  identical. 

This  affection,  to  which  Fournier  gives  the  name  pseudo-general 
paralysis  of  syphilitic  origin.,  consists  of  an  association  of  intellectual, 
sensory,  and  motor  disturbances,  evidenced  by  numerous  and  complex 
symptoms.  The  intellectual  disorder  is  indicated  by  cerebral  excite- 
ment and  exaltation  of  ideas  with  incoherence,  and  by  gayness  of  spirits 
alternating  with  hebetude,  together  with  delirium  and  even  mania.  The 
motor  disturbances  are  well  marked,  and  consist  of  uncertain  movements 
without  paralysis,  trembling,  and  imperfect  prehensile  power  of  the 
hands,  sudden  loss  of  equilibrium,  imperfect  co-ordination,  staggering 
gait,  and  hesitating  speech.  Besides  these,  there  are  frequently  special 
a,ffections,  such  as  trembling  of  muscles  and  partial  paralysis,  ephemeral 
or  persistent,  and  also  certain  symptoms  of  cerebral  congestion ;  of  the 
latter  may  be  mentioned  a  sense  of  weight  and  pain  in  the  head,  dizzi- 
ness, sudden  dazzling  sensations,  vertigo,  and  various  impairments  of 
sight  and  hearing ;  to  these  should  be  added  epileptic  and  epileptiform 
convulsions  and  sudden  seizures  of  an  apoplectic  character.  Of  course 
we  never  meet  with  all  the  above  symptoms  combined,  but  in  all  cases 
many  of  them  are  associated. 

The  peculiarities  of  this  syphilitic  affection  are  that  the  paralytic 
symptoms  predominate ;  that  symptoms  appear  in  a  capricious  and 
irregular  manner,  fibrillary  contractions  of  the  facial  and  lingual  muscles 
being  absent ;  that  there  are  no  well-defined  exalted  ideas ;  and  that  be- 
hind all  there  is  generally  a  syphilitic  cachexia. 

After  considering  the  subject  exhaustively  and  criticising  the  loose 
manner  in  wliich  the  terra  "syphilitic  insanity"  is  used,  Mickle  gives 
the  following  points  of  differential  diagnosis  between  true  general  paraly- 
sis and  the  pseudo-general  paralysis  of  syphilis : 

1.  Distinct  history  or  symptoms  of  syphilis. 

2.  Preceding  cranial  pains,  nocturnal  and  intense. 

3.  Exaltation  less  marked,  less  persistent,  and  perhaps  less  associated 
with  general  maniacal  restlessness  and  excitement. 


804  SYPHILIS. 

4.  Sometimes  complicated  by  palsies  of  one  or  more  cranial  nerves,  or 
by  hemiplegia,  paraplegia,  etc.,  having  the  character  and  course  of  syph- 
ilitic palsies. 

5.  The  greater  frequency  of  optic  neuritis,  early  amaurosis,  deafness, 
local  anaesthesia,  vertigo,  and  local  rigid  contraction. 

6.  The  affection  of  the  articulation  is  paralytic  rather  than  paretic, 
and  usually  speech  is  not  accompanied  by  any  facial  or  labial  tremors. 

7.  Cerebral  or  spinal  meningitis  or  pachymeningitis. 

8.  Great  variety  of  motor  and  sensory  symptoms,  their  capricious  asso- 
ciation or  succession,  and  their  transitory  character,  and  the  absence  of 
general  progressive  muscular  paresis. 

9.  Effect  of  antisyphilitic  treatment. 

Mickle  adds  that  in  the  simple  affection  the  faradic  contractility  of 
the  muscles  of  the  extremities  becomes  considerably  and  progressively 
lessened,  while  in  syphilis  it  is  normal  or  but  slightly  impaired.  This 
condition  originates  in  connective-tissue  infiltration  and  in  perivascular 
changes. 

Multiple  Neuritis. 

Our  knowledge  of  multiple  neuritis  may  be  said  to  have  been  formu- 
lated and  systematized  ivithin  the  past  five  or  six  years,  though  of  course 
the  observations  and  studies  of  many  physicians  over  a  long  stretch  of 
years  laid  a  good  foundation.  It  is  a  subject  of  congratulation  that 
American  observers  have  played  no  small  part  in  the  study  of  this  subject 
and  have  aided  materially  in  its  partial  elaboration.  As  it  stands  to- 
day, the  subject  of  multiple  neuritis  is  imperfect  in  the  direction  of 
etiology  and  pathological  anatomy,  but  hopeful  signs  are  to  be  seen  on  all 
sides,  and  as  time  goes  on  anomalous  facts  will  be  reconciled  and  hiati  be 
filled. 

In  the  year  1879,  Buzzard  ^  published  a  lecture  in  which  was  detailed 
a  case  of  sciatica  with  muscular  wasting  and  Aveakness  of  the  limbs, 
which  that  author  considered  to  be  caused  by  syphilis.  In  1881, 
Ormerod^  presented  to  the  Pathological  Society  of  London  a  case  of 
painful  enlargement  of  the  median  nerve  of  the  upper  extremity,  which 
he  thought  was  the  result  of  hereditary  syphilis.  This  communication 
was  followed  by  a  second  consideration  of  this  subject  by  Buzzard,^  who 
detailed  the  history  of  a  case  in  which  there  Avas  paralysis  of  the  muscles 
of  the  face  and  of  both  the  upper  and  lower  extremities  and  of  the  trunk, 
with  disseminated  anaesthesia. 

The  next  paper  on  this  subject  was  by  Ehrmann*  in  1886,  and  it  was 
followed  by  a  communication  by  C.  K.  Mills  ^  before  the  American  Neur- 
ological Association.     Then,  in  1888,  Laschkewitch®  published  a  clinical 

1  "  Clinical  Lecture  on  Cases  of  Neuritis,  Syphilitic  and  Kheuraatic,"  Lancet,  March 
1,  1879. 

2  British  Med.  Journal,  1881,  vol.  i.  p.  88. 

^  "  Harveian  Lectures  on  Some  Forms  of  Paralysis  dependent  upon  Peripheral  Neur- 
itis," Lancet,  Nov.  28  and  Dec.  1,  1885. 

*  "  Ein  Fall  von  halbseitiger  Neuritis  spinaler  Aeste  bei  recenter  Lues,"  Wiener  med. 
Blatter,  1886,  Nos.  46  and  47. 

5  "  Notes  of  Some  Cases  of  Multiple  Neuritis  for  Myelitis)  of  Syphilitic  Origin,  with 
remarks  on  the  difficulty  of  diagnosticating  multiple  neuritis  from  some  forms  of  myeli- 
tis," Medical  Neivs,  Aug.  20,  1887,  and  N.  Y.  Medical  Journal,  July  3,  1887. 

®  "  Neuritis  multiplex  chronica  luetica,"  Russ.  Med.,  St.  Petersburg,  1888,  vol.  i.  pp.  87 
to  90. 


AFFECTIONS  OF  THE  NERVOUS  SYSTEM.  805 

lecture  upon  this  subject,  which  is  very  unsatisfactory,  for  the  reason  that 
the  history  of  syphilis  in  the  case  was  not  well  established.  In  this  same 
year  Leyden  ^  published  two  lectures  on  inflammation  of  peripheral  nerves, 
in  which  he  speaks  of  a  case  in  Avhich  he  thought  the  nerve  aff'ection  was 
caused  by  syphilis.  Finally,  in  the  recent  excellent  compendium  of 
Bowlby^  we  find  a  section  upon  neuritis  of  syphilitic  origin.  , 

An  important  case  of  multiple  neuritis,  with  analgesia  of  the  hands  and 
arms,  legs  and  toes,  was  published  by  me  some  years  ago.^ 

Two  very  interesting  cases  of  neuritis  of  the  ulnar  nerve  have  been 
published  by  Gaucher  and  Barbe.* 

Treatment. — It  may  be  well  here  to  emphasize  the  point  that  in  the 
treatment  of  syphilitic  nervous  affections,  particularly  those  occurring 
within  the  early  years  of  the  infection,  we  must  not  place  our  whole 
trust  in  the  iodide  of  potassium  and  ignore  mercury.  This  latter  agent 
is  sometimes  invaluable  in  these  cases.  By  its  use,  together  with  that 
of  the  iodide,  it  will  in  many  cases  not  be  necessary  to  give  the  latter 
drug  in  such  very  large  doses  as  we  sometimes  do.  Mercurial-ointment 
inunctions  and  hypodermic  injections  of  the  bichloride  of  mercury  are 
in  many  cases  of  signal  benefit.  Iodide  of  potassium  internally  and 
mercury  locally  applied  should  not  be  forgotten  in  brain,  medullary, 
and  neuritic  syphilis.  It  is  important  in  the  treatment  of  cases  of  cere- 
bral syphilis  that  the  mercurial  ointment  should  be  rubbed,  if  possible, 
upon  the  neck  or  upper  portions  of  the  body,  in  order  to  act  upon  the 
lymphatic  system  as  near  as  possible  to  the  brain.  With  care  and  atten- 
tion to  the  local  reaction  which  the  inunctions  may  induce  (but  not 
necessarily),  the  region  of  the  neck,  and  even  the  scalp,  may  be  util- 
ized for  sufficiently  long  periods  to  ensure  amelioration  of  the  case. 

Not  only  in  cases  of  syphilitic  meningeal  lesions,  but  also  in  those 
of  arterial  degeneration,  of  extensive  and  localized  paralyses,  epilepsy, 
dementia,  and  of  the  various  syphilitic  neuralgias,  will  this  combination 
treatment  prove  beneficial,  and  very  often  be  followed  by  the  most  prompt 
and  brilliant  results,  as  I  have  so  often  seen.  The  regional  use  of  the 
inunctions  is,  in  my  judgment,  a  great  aid  in  promptness  of  cure. 

(For  further  information  see  chapter  on  the  Treatment  of  Syphilis.) 


Syphilophobia. 

Sypliilophohia  is  sometimes  included  among  the  manifestations  of 
syphilis,  but  I  do  not  believe  that  it  is  directly  due  to  this  disease. 
It  is  quite  as  often  met  Avith  in  patients  affected  only  Avith  gleet,  prosta- 
torrhoea,  or  who  have  nothing  in  the  world  the  matter  with  them  except 
their  own  disordered  imaginations.  Moreover,  in  truly  syphilitic  cases 
the  fear  of  syphilis  often  increases  in  proportion  as  the  specific  symp- 
toms disappear. 

Syphilitic  patients  will  sometimes  state  that  they  have  resolved  to 

'  Die  Entziindung  der  peripheren  Nerven,  deren  Pathologic  und  Behandlung,  Berlin,  1888, 
p.  26. 

^  Injuries  and  Diseases  of  Nerves  and  their  Surgical  Treatment,  Philadelphia,  1890,  pp.  4G0 
et  seq. 

^  New  York  Med.  Journal,  July  5,  1890. 

*  Annales  de  Derm,  et  de  Syph.,  p.  26  and  p.  .310,  1895. 


806  SYPHILIS. 

give  up  their  business  and  devote  their  time  to  the  cure  of  their  disease. 
Such  a  course  should  always  be  discouraged,  since  it  favors  mental 
depression,  interferes  with  the  general  health,  and  thus  retards  the  effect 
of  remedies,  and  may  lead  to  confirmed  hypochondria  or  syphilophobia. 


CHAPTER    LXXXIV. 

THE  ABORTIVE  TREATMENT,  AND  TREATMENT  OF  CHANCRES. 

The  Abortive  Treatment. 

The  idea  of  preventing  syphilis  by  the  destruction  of  the  chancre  is  a 
very  old  one,  dating  as  far  back  as  the  end  of  the  fifteenth  century.  It 
was  brought  into  prominence  by  the  writings  of  Bell  and  Hunter  toward 
the  end  of  the  last  century.  These  famous  surgeons  taught  that  the 
chancre  was  always  local,  and  that  general  infection  did  not  occur  imme- 
diately, but  that  it  followed  as  an  accident  consecutive  to  the  chancre. 
In  spite  of  such  strong  statements,  which  by  implication  recommended  the 
excision  of  chancre  as  a  cure  for  syphilis,  no  clinical  evidence  of  its  use 
early  in  this  century  is  at  hand.  The  era  of  this  prophylactic  treatment 
may  be  said  to  begin  with  the  publication  of  a  paper  by  Hiiter^  in  1867, 
which,  though  sadly  incomplete  in  many  details,  claimed  the  cure  of  two 
cases  of  syphilis  out  of  seven  in  which  the  chancre  had  been  excised. 
This  paper  may  be  said  to  have  led  the  way  to  the  generalization  of 
excision  of  chancre  as  a  means  of  attenuating,  emasculating,  delaying, 
suppressing,  or  aborting  syphilis  in  its  early  stage.  The  theory  of  its 
action  may  be  briefly  stated  to  be  based  upon  the  supposed  local  character 
of  the  initial  lesion  which  was  thought  to  exist  for  a  short  time  after  its 
appearance.  The  opposite  theory,  of  the  immediate  infection  of  the  sys- 
tem, presupposed  the  entry  of  the  virus  through  the  lymphatic  system 
into  the  general  circulation  and  its  return  to  the  point  of  infection,  where 
it  underwent  a  slow  process  of  germination,  and  then  again  became  gen- 
eralized. This  view  was  not  supported  by  the  facts  offered  by  the  evolu- 
tion of  syphilis  nor  by  the  clinical  features  of  the  hard  chancre  itself; 
therefore,  this  theory  failing,  the  doctrine  of  early  localization  was  quite 
generally  accepted. 

The  opinions  very  generally  held  by  advanced  students  and  authorities 
in  syphilis  as  to  Avhat  takes  place  in  the  early  stages  of  infection  may  be 
concisely  stated  as  follows  :  That  the  virus  is  localized  at  its  point  of  entry, 
and  that  the  first  stage  of  syphilis,  or  rather  its  first  period  of  incubation 
(which  means  the  interval  between  the  date  of  the  infecting  contamination 
and  the  appearance  of  the  chancre),  is  occupied  by  the  processes  Avhich  go 
toward  the  development  of  the  chancre,  and  that  this  lesion  is  then  the 

1  "  Excision  der  Ulcus  Induratiim,"  Bed.  klin,  Wochenschrift,  No.  27,  1867  ;  and  "  Zur 
Geschichte  der  Excision  der  Ulcus  Induratum,"  Centralblatt  fur  Chirurgic,  Nos.  23  and 
24,  1879. 


ABORTIVE  TREATMENT,  AND   TREATMENT  OF  CHANCRES.      807 

sole  expression  of  the  disease.  The  virus  is  then  supposed  to  be  limited 
to  the  chancre  for  some  time — let  us  say  from  one  to  eight  or  ten  days — 
and  in  this  period  annihilation  of  the  disease  is  possible.  Lang's^  idea  of 
the  chancre  is  sharply  stated,  and  conveys  in  a  few  -words  the  prevailing 
sentiment  of  the  past  twenty  years  at  least.  He  says  that  a  morbid  focus 
is  developed,  and  at  its  periphery  a  cell-wall  is  formed  which  acts  as  a 
temporary  barrier  or  blockade.  In  due  time  (during  which  the  syphilitic 
virus  is  germinating  and  maturing)  this  melts  away  or  disappears,  and 
then  the  virus  is  carried  into  the  surrounding  parts  by  the  lymphatics  and 
the  blood-vessels  and  by  slow  contiguous  tissue-infection.  In  this  connec- 
tion it  must  be  mentioned  that  the  experiment  of  Cohnheim  had  much  to 
do  with  fortifying  the  view  of  the  local  nature  of  the  young  chancre. 
This  observer  threw  into  the  anterior  chamber  of  the  eye  of  a  rabbit,  by 
means  of  a  hypodermic  syringe,  a  small  quantity  of  tuberculous  matter. 
For  eight  days  no  change  whatever  was  observed,  but  after  that  time 
liquefaction  and  absorption  took  place,  and  in  due  time  the  infection  of 
the  whole  organism  followed.  Under  these  conditions  it  is  not  strange 
that  the  belief  in  the  prophylactic  benefit  of  excision  of  chancre  is  exten- 
sively held,  though  it  must  be  confessed  that  there  are  not  a  few  who 
scouted  the  idea  and  claimed  syphilis  as  a  constitutional  disease  from  the 
first. 

Huter's  paper,  already  mentioned,  while  it  marks  an  era,  was  not 
productive  of  great  results  in  the  utilization  of  this  method,  and  it  was 
not  until  the  appearance  of  two  essays  by  Auspitz^  and  Unna  in  1877 
that  excision  of  chancre  was  extensively  tried.  These  observers  reported 
33  cases  in  which  chancres  were  excised,  of  which  in  14  success  was 
claimed,  in  10  failure  was  conceded,  and  in  the  balance  the  records  of 
essential  facts  Avere  so  incomplete  that  they  were  thrown  out.  The 
results  here  obtained,  fortified  by  the  high  reputation  of  Auspitz,  made 
a  decided  impression  upon  the  medical  world,  and  from  this  date 
excision  of  chancre  was  largely  practised  in  Germany,  and  to  a  less 
degree  in  Italy  and  France.  In  America  and  England  syphilographers 
looked  coldly  upon  the  procedure,  which,  it  may  appear  strange  to  say, 
in  their  hands  gave  uniformly  barren  results.  Auspitz  and  Unna's 
paper  was  followed  by  a  second  one  by  Auspitz^  alone,  in  which  he 
took  the  ground  in  an  unqualified  manner  that  the  initial  sclerosis 
should  be  looked  upon  as  a  symptom  local  in  character.  This  assertion 
had  certainly  the  greatest  weight  in  causing  the  quite  general  adoption 
of  excision  of  chancre  as  a  prophylactic  for  syphilis.  It  had  much  to 
do  with  clinching  in  the  minds  of  physicians  the  impression  that  at 
first  the  syphilitic  process  is  a  strictly  localized  one.  The  chancre 
came  to  be  regarded  as  the  concentrated  effect  of  the  virus,  and  that 
for  contamination  of  the  system  to  occur  the  changes  inherent  in  it 
must  go  on  to  maturity  before  its  poisonous  elements  could  be  scattered 
generally  throughout  the  system.     Auspitz  and  Unna  were  the  first  to 

'  "  Wege  und  Wandlungen  des  Syphiliscontagiums,  etc.,"  Mltlheilungen  der  Wien.  med. 
Doetoren  Coll.eginm.%  xiv.  and  xv.  Band,  1888-89. 

^  "  Ueber  die  Excision  der  Syphilitischen  Initial  Sclerose,"  and  "  Die  Anatomie 
der  Syphilitischen  Initial  Sclerose,"  Vierteljahresschrift  fib-  Dermal,  und  Syphilis,  1877, 
pp.  107  and  200. 

^  "  Ueber  die  Excision  der  Hunter'schen  Induration,"  Wiener  med.  Presse,  Nos.  50 
and  51,  1878. 


808  SYPHILIS. 

bring  out  clearly  the  invasion  of  the  vessels  in  the  early  stages  of 
syphilitic  infection.  They,  however,  evidently  reached  the  conclusion 
that  the  vessel-changes  were  limited  to  the  area  of  the  chancre,  and 
that  they  only  extended  slowly  beyond  that  circumscribed  region  during 
the  latter  part  of  the  secondary  period  of  incubation.  Cornil's^  views 
are  also  interesting.  He  says :  "  We  cannot  state  it  in  an  absolute 
manner,  but  we  may  venture  the  hypothesis  that  the  syphilitic  virus 
when  deposited  in  the  skin  remains  at  first  only  locally  active,  but  that 
it  gradually  affects  cells  in  close  contiguity,  and  prepares  them  for  the 
hyperplasia  which  soon  forms  the  chancre."  It  Avill  therefore  be  seen 
that  the  prevailing  ideas  of  the  mode  of  syphilitic  infection  favored 
the  view  that  the  disease  might  be  aborted.  In  the  light  of  facts  to  be 
presented  later  on  it  would  be  a  Avaste  of  time  and  space  to  give  a 
general  survey  of  the  literature  of  excision  of  chancre.  Any  person 
desiring  further  information  on  this  subject  may  consult  the  papers 
mentioned  in  the  foot-note,^  as  well  as  those  already  referred  to.  The 
facts  are  briefly  these :  There  have  been  reported  about  460  cases  in 
which  excision  has  been  performed,  and  in  about  110  success  has  been 
claimed.  I  have  not  the  slightest  hesitation  in  saying  that  I  do  not 
believe  that  a  single  case  of  syphilis  was  ever  aborted  or  annihilated  by 
early  radical  procedures  of  any  kind.  Many  of  the  cases  reported  as 
cured  have  undoubtedly  been  those  of  soft  chancre  which  for  some 
reason  had  become  the  seat  of  oedematous  hyperplasia ;  and  others  were 
undoubtedly  cases  of  relapsing  chancres  in  situ  (the  pseudo-chancre, 
indure  of  Fournier),  which  are  often  seen  late  in  syphilis,  and  com- 
monly are  not  followed  by  any  other  lesions  ;  while  still  others  were  in 
all  probability  instances  of  irritated  herpes,  which  so  often  puzzle  even 
the  elect.  I  have  several  times  seen  acarian  nodules  upon  the  penis, 
and  also  on  the  outer  female  genitals,  which  had  been  pronounced  even 
by  intelligent  physicians  to  be  syphilitic  neoplasms. 

Then,  again,  besides  the  probable  manifold  errors  in  diagnosis  of  the 
excised  lesions,  in  very  many  instances  the  cases  were  examined  too 
cursorily  and  for  too  short  a  period,  or  at  too  long  or  too  frequent  inter- 
vals. Auspitz  himself  stated  that  four  months'  observation  was  suf- 
ficient. It  may  be  that  some  of  my  readers,  even  in  spite  of  what  is 
said  in  this  work,  may  think  fit  to  try  excision  of  chancre  as  a  prophy- 
lactic in  syphilis.  If  so,  it  is  well  for  them  to  follow  the  requirements 
laid  down  by  Fournier^  in  the  study  of  this  subject,  which  are  as  fol- 
lows :  "  1.  The  man  whose  chancre  is  to  be  removed  (and  it  must  always 
be  remembered  that  in  these  very  early  lesions  the  appearances  are  not 
sharply  cast  and  a  diagnosis  is  often  diflftcult  even  for  the  expert)  must 
be  confronted  with  the  woman  from  whom  he  derived  his  lesion,  and 
she  must  be  proven  to  be  syphilitic.  2.  A  precise  and  clear  period  of 
incubation  of  from  two  to  four  weeks  must  be  made  out.  3.  The  obser- 
vation of  the  case  must  be  complete  and  well  analyzed,  and  it  must  be 
proved  [by  microscopical  examination — R.  W.  T.]  that  the  excised 
lesion  is  a  syphilitic  chancre,  and  that  the  patient  had  not  previously 

]  Op.  ciU  Paris,  1879,  p.  15. 

"^  The  reader  is  referred  to  an  article  by  Leloir,  Annates  de  Derm,  ef  de  Sj/ph.,  vol.  ii., 
1881,  p.  69,  and  to  Kaposi's  Path.  und.  Therap.  der  Syphilis,  p.  419,  for  a  full  bibliography. 
^  "Traitement  abortif  de  la  Syphilis,"  Gazelle  des  Hopitaux;  No.  116,  p.  1071  et  seq. 


ABORTIVE  TREATMENT,  AND   TREATMENT  OF  CHANCRES.      809 

teen  syphilitic.  4.  The  patient  must  be  carefully  and  at  short  inter- 
vals examined  for  a  period  of  at  least  six  months."  Further  than  this, 
I  may  add  that  it  must  be  proved  conclusively  that  the  patient  has  not 
taken  mercury  surreptitiously,  for  I  can  well  understand  that  a  man 
might  seemingly  consent  to  excision  as  a  possible  cure,  and  yet  not  care 
to  take  its  chances,  and  for  that  reason  take  mercury  on  the  sly. 

The  study  of  the  question  of  the  abortive  treatment  of  syphilis  will 
not  be  complete  without  the  consideration  of  the  bearing  upon  it  of  a 
number  of  cases  recently  reported  showing  an  unusual  mode  of  evolu- 
tion of  the  disease.  The  following  case,  reported  by  Dubois  Havenith,^ 
will  serve  as  a  good  specimen :  A  man  sixty  years  old  had  coitus  in  the 
first  days  of  July.  Toward  August  1st  an  erosion  appeared  on  the  pre- 
puce which  soon  became  indurated  and  caused  phimosis.  The  diagnosis 
of  infecting  chancre  of  the  prepuce  was  made.  As  the  ganglia  were  not 
perceptibly  affected,  Havenith  entertained  the  idea  of  circumcision  as  a 
means  of  aborting  the  syphilis.  He  sent  the  patient  to  Leloir,  who 
confirmed  the  diagnosis  and  advised  waiting  until  secondary  manifesta- 
tions appeared.  Havenith  has  examined  the  man  for  a  year  every  five 
days,  and  has  seen  no  syphilitic  manifestations.  In  the  discussion  of 
this  case  both  Barthelemy  ^  and  Aubert  stated  that  they  had  seen  seem- 
ingly typical  indurated  chancres  which  were  not  followed  by  syphilis. 
In  like  manner,  Burnett^  reports  a  very  striking  case  of  a  seemingly 
typical  indurated  chancre  and  inguinal  adenopathy,  both  of  which 
gradually  disappeared  without  any  treatment.  Though  carefully  looked 
for  at  short  intervals  during  a  period  of  sixteen  months,  no  evidences  of 
syphilis  were  observed.  Burnett  quotes  a  similar  case  reported  to  him 
by  Bryson,  and  also  a  case  of  similar  import  reported  by  Kaposi.*  A 
further  case,  reported  by  Ehlers^  of  Copenhagen,  occurring  in  the  prac- 
tice of  Professor  Haslund,  is  also  reported,  in  which  examination  for 
one  year  failed  to  reveal  secondary  manifestations.  These  facts  are 
certainly  very  striking,  and  open  up  a  subject  as  yet  very  obscure  to  us. 
I  have  seen  several  cases  similar  to  those  just  reported,  and,  although 
the  objective  features  of  syphilitic  infection  were  complete,  I  have  been 
disposed  to  look  upon  them  as  anomalous  instances  of  simple  localized 
hyperplasia.  Perhaps,  however,  I  am  wrong.  Burnett  thinks  these 
cases  are  instances  in  which  syphilis  became  inert — as  Barthelemy  says, 
aborted — in  the  primary  stage  through  influences  which  we  do  not 
understand,  due  to  conditions  of  the  organism  or  to  a  modification  of 
the  virus  itself.  Besnier,^  however,  is  confident  that  some  individuals, 
though  inoculated  with  syphilis,  do  not  become  syphilitic,  and  he  offers 
the  following  hypothesis:  "When  we  consider  the  extraordinary  immu- 
nity to  syphilis  presented  by  the  entire  animal  kingdom,  it  occurs  to  us 
that  some  individuals,  like  animals,  have  in  their  physical  condition,  in 

'  Comples  Rendus  du  Congrh  international  de  Dermat.  et  de  Syph.,  tenu  a  Paris  en  1889, 
Paris,  1890,  pp.  474  et  seq. 

"  "Sur  les  Auto-inoculiitions  du  Chancre  syphilitique,"  Annates  de  Derm,  etde  Syph., 
1885,  pp.  200  et  seq. 

^  "  Induration  of  Venereal  Sores  not  always  an  Indication  that  Constitutional  Syphilis 
will  Follow,"  Journal  of  Cutaneons  and  Oenito-urinary  Diseases^,  1889,  pp.  325  et  seq. 

*  Syphilis  der  haul  und  der  Angrenzenden  Schlei7nh(iulf',\iennn,  1S73,  Liefcrung  1,  p.  22. 

*"('as  de  Chancre  indur^  non  suivi  d' Accidents  secondaires,"  Bidletin  de  la  Societe 
Franr/mc  de  Dermat.  et  de  Syph.,  1890,  pp.  3G5  et  seq. 

6  Ibid.,  p.  367. 


810  SYPHILIS. 

an  elementary  condition  of  their  solids  and  their  fluids,  something  which 
is  antagonistic  to  the  germination  of  the  syphilitic  virus.  The  occur- 
rence of  such  cases  as  these  suggests  the  possibility  that  some  of  the 
reported  successful  cases  of  chancre  excision  were  really  instances  in 
which  syphilis  aborted  in  its  first  stage.  Then,  again,  the  thought  is 
suggested  to  the  mind  that  if  syphilis  may  really  abort  in  its  primary 
stage — in  other  words,  if  the  patient's  tissues  are  immune  to  its  influ- 
ence— have  we  not  here  another  reason  why  it  is  well  to  withhold 
mercurial  treatment  until  the  general  manifestations  teach  us  that  we 
have  a  case  of  syphilis  on  our  hands  ?"  This  point  will  come  up  again 
later  on. 

In  a  report  to  the  French  Academy  of  Medicine,^  Cornil,  having 
gone  carefully  over  the  literature  of  the  subject,  pronounces  excision 
of  chancre  futile,  and  he  calls  attention  to  the  fact  that  its  use  may 
be  dangerous,  for  the  reason  that  a  mercurial  treatment  may  not  be 
instituted  and  the  disease  will  then  run  on  unchecked. 

The  negative  evidence  as  to  the  value  of  excision  of  chancre  is  very 
strong,  and  is  off"ered  by  a  number  of  observers.  The  classical  case  of 
Berkely  Hill,  in  which  he  unsuccessfully  cauterized  a  tear  upon  the 
penis  within  twelve  hours  after  infection,  is  Avell  known.  Further  than 
this,  cases  are  reported  by  Razori,  Coulson,  Gibier,  Mauriac,  Thiry, 
Meyer,  Zeissl,  Zarewicz,  Krowcynski,  Bumstead  and  Taylor,  and  others, 
in  which  excision  was  practised  at  periods  of  twelve  to  thirty-six  and 
forty-eight  hours  after  the  appearance  of  the  chancre,  in  Avhich  syphilis 
developed  in. its  usual  way.  I  have  several  times  removed  hard  chancres 
within  the  first  day  of  appearance,  and  in  each  instance  failed  to  abort 
syphilis.  The  following  personal  case  well  illustrates  the  average  of 
cases  of  chancre-excision  and  its  results :  A  gentleman,  aged  thirty,  came 
to  me  early  in  1889  in  great  distress  of  mind  concerning  a  lesion  on  his 
penis  which  he  had  noticed  for  the  first  time  the  night  before  while 
taking  a  hot  bath.  The  reason  of  his  fear  and  worry  was  that  a  friend 
had  a  few  days  before  informed  him  that  he  had  contracted  a  hard  chan- 
cre from  a  woman  with  whom  he  had  learned  that  he  (my  patient)  had 
had  intercourse.  Upon  examination  I  found  on  the  dorsum  of  the  penis 
a  very  minute  (one-tenth  of  an  inch  long)  fissure  of  a  dull  violaceous 
color.  I  could  discover  no  change  in  the  inguinal  ganglia.  At  his  urgent 
request  I  examined  the  woman,  and  found  just  within  the  vagina,  in  the 
sulcus  on  the  right  of  the  urethra,  a  red  and  inflamed  patch,  the  seat  of 
considerable  thickening.  In  the  light  of  what  I  found  besides  I  diagnos- 
ticated it  as  a  declining  hard  chancre,  of  which  I  had  seen  many  similar 
before.  There  was  marked  inguinal  adenitis  and  a  very  faint  disappear- 
ing roseola,  a  mucous  patch  on  the  right  pillar  of  the  fauces,  and  slight 
fall  of  hair.  The  certainty  of  the  syphilitic  nature  of  the  sore  on  the 
patient's  penis,  which  appeared  seventeen  days  after  coitus,  being  so  con- 
vincing, its  probable  character  was  announced  to  him.  The  condition  of 
the  skin  of  the  penis  was  such  that  the  little  fissure  could  be  cut  aAvay  by 
means  of  a  very  liberal  elliptical  incision,  and  no  harm  would  be  done  to 
the  integrity  of   the   organ.      Under  the   most   careful   technique,   with 

^  "Rapport  sur  la  Memoire  address^  en  response  a  la  question  suivante:  Precises 
sur  une  serie  d'observations  s'il  exist  nn  traitement  abortif  de  la  Syphilis  confirmee," 
Annates  de  Dermat.  el  de  Syph.,  1887,  p.  60. 


ABORTIVE  TREATMENT,  AND  TREATMENT  OF  CHANCRES.      811 

thorough  antisepsis,  I  excised  a  piece  of  skin  half  an  inch  wide  and 
three-quai'ters  of  an  inch  long  on  the  evening  of  the  day  on  which  the 
fissure  was  first  noticed  and  seventeen  days  after  the  infecting  coitus. 
Examination  of  the  patient  was  made  almost  daily.  The  wound  healed 
kindly  under  iodoform  gauze,  and  was  not  followed  by  any  induration  in 
the  minute  scar  which  was  formed.  It  was  fully  twenty  days  after  the 
operation  that  well-marked  inguinal  adenopathy  could  be  made  out.  In 
fifty-two  days  after  the  first  appearance  of  the  chancre  well-marked  sec- 
ondary manifestations  were  observed. 

A  very  similar  case  has  already  been  reported  by  me.  Prior  to  June, 
1891,  therefore,  Avhile  the  majority  of  syphilographers  believed  in  the 
absolute  futility  of  chancre-excision  as  a  means  of  aborting  syphilis,  a 
few  still  believed  in  its  efficacy  in  some  rather  exceptional  cases. 

In  Chapter  LI.  it  is  shown  that  from  the  very  earliest  hours  of  infec- 
tion the  morbid  process  runs  rapidly  down  the  vessels,  and  that  in  a  few 
days  parts  far  beyond  are  attacked ;  consequently,  after  excision  of  the 
chancre  the  infection  is  rapidly  diffusing  itself  by  means  of  the  vessels 
throughout  the  entire  system.     (See  page  533  and  Figs.  192  and  193.) 

These  clinical  and  pathological  observations  therefore  show  why  syph- 
ilis is  not  aborted  by  early  excision  or  destruction  of  its  initial  lesion, 
even  including  a  liberal  slice  of  the  surrounding  parts.  The  reason, 
succinctly  stated,  is,  that  (contrary  to  the  prevailing  views)  the  syphilitic 
infective  process  is  from  the  very  start  a  quite  rapid  one.  The  poison 
strikes  directly  for  the  blood-vessels,  and,  causing  there  its  peculiar 
changes,  runs  along  them  with  astonishing  rapidity.  Thus  it  gains  a 
foothold  in  parts  beyond  the  reach  of  the  knife,  caustics,  or  electrolysis. 
In  fact,  the  tissues  of  the  whole  penis  in  very  early  syphilis  are,  we  may 
say,  honeycombed  by  these  infected  vessels.  These  observations,  sup- 
ported by  the  evidence  of  the  failure  in  chancre-excision,  go  to  show  that 
beyond  the  chancre  there  is  sufficient  syphilitic  poison  to  infect  the  whole 
system,  and  that  the  initial  lesion,  through  the  visible  and  exuberant  evi- 
dence of  syphilitic  infection,  may  be  removed  without  in  any  way  altering 
or  modifying  the  course  of  the  disease. 

In  my  judgment,  therefore,  irrefragable  proof  has  been  offered  which 
clearly  shoAvs  the  absolute  futility  of  excision  of  chancre  as  a  prophy- 
lactic of  syphilis.  It  is  necessary,  however,  as  a  matter  of  history,  to 
record  here  in  a  brief  manner  the  further  and  more  radical  operations 
which  have  been  proposed  for  the  extinction  of  syphilis.  The  recital 
will  certainly  act  as  a  warning  to  future  experimenters  and  theorizers, 
particularly  if  they  will  read  what  has  just  been  said  of  the  early  stage 
of  syphilitic  infection.  In  1871,  Vogt^  proposed  that  in  addition  to  the 
extirpation  of  the  chancre  a  like  operation  should  be  performed  upon 
the  inguinal  ganglia.  In  the  year  1872,  Hardaway^  in  an  elaborate 
paper  showed  that,  according  to  existing  views,  syphilitic  infection  took 
place  through  the  lymphatics,  and  arrived  at  the  logical  conclusion  that 
extirpation  of  the  ganglia,  in  connection  witli  the  chancre,  offered  a 
reasonable  chance  of  aborting  the  disease.     He  simply  made  the  sug- 

^  Berliner  klininche  Wocheniichrijt,  1871,  No.  38. 

^  "The  Pathology  of  Early  Syphilis,"  St.  Louis  Medical  and  Surcjiecd  Journal,  May, 
1872;  also  "The  Lymphatic  Theory  of  Syphilitic  Infection,  etc.,"  N.  Y.  Med.  Journal, 
vol.  xxvi.,  1877;  and  "The  Radical  Treatment  of  Syphilit;,"  ibid.,  Sept.  26,  1885. 


812  SYPHILIS. 

gestion,  unsupported  by  clinical  evidence.  Bumm,^  however,  in  an 
article  advocating  chancre-excision,  detailed  seven  cases  in  which  the 
ganglia  were  extirpated,  and  in  two  of  which  he  claimed  that  he  had 
aborted  syphilis.  The  next  noticeable  article  on  the  subject  was  by 
Leuf,^  who  in  an  essay  based  on  theoretical  grounds  regarded  excision 
of  chancre  as  only  a  halfway  measure,  and  advocated  the  extirpation  of 
the  lymphatics  of  the  penis  and  also  of  the  lymphatic  ganglia. 

In  this  connection  it  may  be  interesting  to  remember  that  Neumann  ^ 
recently  showed  a  case  of  a  man  in  whom  he  removed  the  chancre  and 
the  inguinal  ganglia  on  the  thirty-first  day  after  the  infection.  Sec- 
ondary lesions  promptly  appeared,  followed  later  on  by  tertiary  man- 
ifestations, which  Neumann   exhibited  to  the  Vienna  Medical  Society. 

This  operation,  if  performed,  occurs  at  an  epoch  in  the  patient's  life- 
time in  which  every  effort  should  be  made  to  place  him  in  a  position  of 
superior  mental  and  physical  health,  and  when  anything  which  may  act 
as  a  shock  or  drain  upon  his  system  must  be  most  sedulously  avoided. 
For  these  reasons  alone  it  is  to  be  shunned.  The  operation  is  based 
upon  false  ideas  of  the  pathology  of  syphilis.  In  the  first  place,  it  as- 
sumes that  the  virus  of  syphilis  is  in  a  fluid  form,  germinated  and  devel- 
oped in  the  initial  lesion ;  and  in  the  second  place,  that  this  fluid  virus 
runs  up  the  lymphatic  vessels  of  the  penis  without  exudation  or  leaking, 
as  Croton  water  runs  from  the  reservoir  to  our  houses.  Now,  the  truth 
is,  that  the  syphilitic  virus  or  poison  is  an  entity,  and  while  it  may,  and 
perhaps  does,  contain  a  fluid  plasma,  undoubtedly,  as  shown  by  the 
microscope,  it  is  made  up  of  peculiar  infecting  cells,  and  the  process  of 
systemic  invasion  depends  upon  the  peripheral  increase  of  the  original 
infected  area.  Secondly,  this  invading  poison,  whatever  it  may  be, 
does  not  infect  the  system  through  two  or  more  closed  channels  or  pipes 
(lymphatics),  but,  like  an  army  with  the  skirmish-line  thrown  out,  fol- 
lowed by  the  invading  body,  is  powerful  along  its  Avhole  line  of  advance. 
In  this  way  the  whole  system  becomes  infected,  and  the  culmination  is 
reached  at  the  period  of  generalized  manifestations. 

Extirpation  of  the  ganglia,  therefore,  is  not  in  any  way  indicated 
by  the  pathology  of  syphilis,  and  it  may  be  classed  with  many  other 
surgical  vandalisms  which  unfortunately  to-day  are  too  frequently  per- 
petrated. 

It  may  be  stated,  however,  that  in  some  cases,  where  the  anatomical 
arrangement  of  the  parts  warrants  it,  excision  of  chancre  may  be  per- 
formed with  benefit,  thus  removing  a  conglomerate  mass  of  infection 
and  a  lesion  in  many  instances  slow  to  disappear. 

We  come  now  to  the  question  :  Cao  we  by  a  general  preventive  treat- 
ment suppress,  abort,  favorably  attenuate,  or  modify  syphilis  ?  Within 
a  few  years  a  method  of  treatment  has  been  advocated  which  has  for  its 
purpose  the  eradication  of  syphilis  by  the  prompt  and  vigorous  use  of 
mercury  as  early  as  possible  in  the  primary  stage.  This  treatment  is 
really    not    new,  since    it    is   the    same  as   that  advocated  by  Fournier, 

1  "Zur  Frage  der  Schanker-excision,"  Vierteljahr.  fur  Derm,  und  Syphilis,  1882,  pp. 

259  et  seq.  .     ,  ,r         »  ht  tr 

•■^  "  On  the  Eradiction  of  Syphilis  during  the  First  Stage  by  Surgical  Means,     J\.  X. 

Med.  Journal,  July  11,  1885.  ^       ,    „'       •  •  ,   ,^  ,    r 

3  "On  the  Excision  of  Primary  Sores  and  Enlarged  Glands,"  British  Med.  Journal, 
May  19,  1890. 


ABORTIVE  TREATMENT,  AND  TREATMENT  OF  CHANCRES.      813 

Baumler,  Mauriac,  and  others,  who  give  mercury  just  as  soon  as  the 
diagnosis  of  syphilis  is  made.  If  there  is  any  difference  between  it  and 
other  methods,  it  is  that  the  advocates  of  a  general  preventive  treatment 
put  a  little  more  energy  in  their  words,  if  they  do  not  in  their  mercurial, 
and  support  their  method  by  pleasing  (to  some)  sentimental  talk.  That 
eminent  surgeon,  Mr.  Jonathan  Hutchinson,  has  within  a  few  years  pub- 
lished a  very  interesting  paper  on  this  subject,  which  does  for  it  all  that 
ingenuity  of  argument  can  do.  Mr.  Hutchinson  '  says  that  "  if  a  scheme 
of  treatment,  begun  in  the  primary  stage,  is  planned  to  prevent  the 
secondary  phenomena,  and  generally  does  so,  it  may,  I  think,  be  fiirly 
styled  abortive  in  contradistinction  with  others  which  make  no  pretence 
to  prevent  the  ordinary  evolution  of  the  malady."  Certainly,  such  a 
treatment  might  be  called  abortive  if  it  did  prevent  secondary  manifesta- 
tions and  stamp  out  the  disease,  but  no  one  thus  far  has  given  us  any 
evidence  that  such  a  treatment  has  produced  such  a  result.  Mr.  Hutch- 
inson says  that  we  must  not  strain  the  word  "abortion"  to  mean  utter 
annihilation,  and  he  concedes  that  after  his  early  and  active  medicinal 
dosage  (using  gray  powder)  he  sees,  somewhat  exceptionally,  scaling 
patches  on  the  palms  of  the  hands,  sores  in  the  mouth,  and  sometimes  a 
general  rash,  and  again,  in  some  cases,  tertiary  lesions.  As  a  matter  of 
fact,  therefore,  he  has  seen  the  secondary  stage  delayed  and  the  third 
stage  not  prevented.  Seeing  that  such  early  and  late  manifestations 
have  really  appeared  after  the  trial  of  a  well-ordered  and  vigorous  early 
preventive  mercurial  treatment,  the  thought  obtrudes  itself  upon  us  that 
in  cases  in  which  such  an  early  treatment  has  not  been  followed  by 
general  manifestations  a  simple  non-syphilitic  sore,  in  its  incipiency,  has 
been  diagnosticated  as  a  hard  chancre.  It  is  very  often  impossible  for 
many  days  to  say  that  a  given  sore  is  syphilitic,  though  it  may  present  a 
specific  appearance.  Consequently,  the  liability  to  error  on  the  part  of 
those  who  in  the  very  earliest  days  of  a  sore  begin  mercurial  treatment  is 
very  frequent  and  very  great.  But  an  attentive  reading  of  Mr.  Hutch- 
inson's paper  has  convinced  me  that  his  abortive  method  is  a  treatment 
of  sentiment  rather  than  of  reality.  He  tells  us  that  the  early  free  use  of 
mercury  causes  the  indurated  nodule  to  melt  away  with  astonishing  rapidity 
— a  fact  which  can  very  frequently  be  verified  by  any  one.  But  it  must 
be  remembered  that  this  induration  is  not  a  very  early  sign  or  symptom 
of  syphilis,  considering  the  requirements  of  this  early  abortive  treat- 
ment. It  may  be  stated,  I  think,  without  fear  of  contradiction,  that 
when  we  encounter  a  well-marked  indurated  nodule,  that  lesion  is  at  least 
two  weeks,  and  more  probably  three  or  even  four  weeks,  old.  Induration 
in  a  few  cases  occurs  quite  rapidly,  but  in  most  cases,  particularly  in  pri- 
vate practice  on  carejpul  and  cleanly  persons,  the  initial  sore  is  soft,  oi', 
rather,  not  appreciably  hard,  for  one  or  two  weeks  and  sometimes  for  a 
longer  period.  After  that  time  induration  may  develop  more  or  less  rap- 
idly. Therefore,  I  am  led  to  think  that  in  many  cases  Mr.  Hutchinson's 
abortive  treatment  merely  antedated  the  evolution  of  the  secondary 
period  by  a  short  time.  Then,  again,  Mr.  Hutchinson  speaks  of  the 
early  involution  of  the  syphilitic  fever  under  active  mercurial  treatment 
as  being  an  evidence  of  the  early  abortion  of  the  disease.     It  is  true  that 

i"On  the  Abortive  Treatment  of  Syphilis,"  British  Medical  Janrnal,  Feb.  25,1888; 
and  "  The  Modern  Treatment  of  Syphilis,"  The  Pmditioner.  June,  1891. 


814  SYPHILIS, 

mercury  will  lower  the  temperature  in  early  syphilis,  but  it  is  none  the 
less  true  that  this  rise  of  temperature  is  generally  concomitant  with  the 
appearance  of  general  manifestations,  though  in  some  cases  it  may  be  ob- 
served a  few  days  or  a  week,  or  at  the  most  ten  days,  before  that  critical 
period.  Here,  again,  we  have  in  Mr.  Hutchinson's  paper  intrinsic  evi- 
dence that  while  he  entertained  the  idea  that  he  could  abort  syphilis  in 
some  cases,  he  only  began  the  treatment  at  about  the  same  time  that 
others  usually  begin  it.  I  have  taken  the  pains  within  a  few  years  to 
question  carefully  a  number  of  gentlemen  who  begin  the  use  of  mercury 
early  or  who  rely  upon  its  early  use  as  a  means  of  aborting  syphilis,  with 
a  view  of  ascertaining  just  how  soon  in  the  life  of  the  sore  or  in  the 
evolution  of  syphilis  they  begin  a  mercurial  treatment,  and  I  found  them 
divided  into  two  groups :  in  the  first  are  those  who  as  soon  as  they  see  a 
sore  which  they  regard  as  suspicious  immediately  give  mercury ;  and  in 
the  second  those  who  are  more  careful  and  scientific,  and  Avho  by  their 
own  confessions  admit  that  they  allow  days  and  wrecks  to  elapse  in  many 
cases  pending  the  verification  of  the  diagnosis  of  syphilis.  So  that  I  am 
led  to  think  that  while  many  men  cajole  themselves  with  the  idea  that 
they  begin  the  treatment  of  syphilis  at  once,  really,  for  one  reason  or 
another  (chiefly  those  of  doubt  and  uncertainty),  they  usually  wait  well- 
nigh  up  to  the  date  of  secondary  manifestations,  if  not,  indeed,  up  to  it, 
before  they  begin  general  mercurial  treatment.  They  pass  current,  how- 
ever, as  advocates  of  early  mercurialization.  The  truth  is  this,  that  in 
the  hands  of  most  men  who  are  careful  and  conservative  the  disease  is 
well  on  to  its  stage  of  generalization  before  treatment  is  instituted. 

A  method  of  abortive  treatment  of  syphilis  has  been  worked  out  by 
Bronson  on  a  purely  theoretical  basis.  Bronson  ^  thinks  that  we  may 
cause  the  rapid  disappearance  of  the  initial  lesion  and  the  probable  abor- 
tion or  prevention  of  the  secondary  stage  by  hypodermic  injections  around 
and  under  the  nodule  on  the  penis,  into  the  substance  of  the  inguinal 
lymphatic  ganglia,  and  into  the  territory  of  integument  "whose  lymphatic 
vessels  tend  in  their  course  to  the  ganglia  which  are  the  seat  of  the  dis- 
ease." This  theory  was  perhaps  tenable  in  the  days  when  we  thought 
that  the  chancre  was  the  circumscribed  focus  of  deposit  of  the  virus,  that 
the  lymphatic  vessels  were  its  means  of  transportation,  and  that  the 
nearest  ganglia  were  the  storehouses  of  the  ripening  infection.  Prac- 
tically, the  injection  of  mercurial  solutions  under  the  chancre  and  under 
the  skin  of  the  penis  will  turn  out  in  any  one's  hands  a  failure,  and  a 
source  of  discomfort,  suffering,  complaint,  and  lamentation  on  the  part  of 
the  patient.  Though  this  procedure  was  advocated  by  Weisflog,  Lipp. 
and  Lewin  some  years  ago,  I  have  no  knowledge  of  its  adoption  and  use 
by  any  one.  Therefore  I  think  that  Dr.  Bronson's  charmingly  written 
essay,  which  ends  Avith  this  passage,  "  Better  it  is  to  act  on  any  chance, 
however  slender,  than  be  bound  helplessly  to  a  dogma  that  is  open  to 
question,  and  that  would  leave  the  victim  of  an  insidious  infection  without 
succor  and  without  hope  during  what  may  be  the  most  momentous  period 
of  his  disease,"  will  go  to  posterity  as  a  sample  of  good  English  composi- 
tion and  of  humane  inspiration,  rather  than  as  a  watchword  against  a  sup- 
posed lethargy  in  the  therapeutics  of  syphilis.     In  my  judgment,  the  early 

^  "  On  Preventive  Treatment  of  Primary  Svphilis,"  New  York  Medical  Journal,  March 
24,  1888. 


ABORTIVE  TREATMENT,  AND   TREATMENT  OF  CHANCRES.      815 

preventive  treatment  is  barren  of  beneficial  results,  and  leads  to  all  sorts 
of  errors  regarding  all  kinds  of  sores  found  on  the  human  genitals.  I 
have  never  seen,  nor  have  I  heard  of,  a  well-detailed  authentic  case  of 
syphilis  thus  cured,  and  I  doubt  whether  I  ever  shall.  Consequently,  I 
am  not  a  believer  in  the  practical  application  of  Fournier's  dictum  that  it 
is  easier  to  prevent  than  to  cure.  I  agree  with  Kaposi  regarding  the  early 
preventive  treatment  of  syphilis,  that  it  is  rational  and  humane,  but  not 
practical. 

In  support  of  what  I  have  said  I  think  it  well  to  present  the  views  of 
a  number  of  eminent  authorities.  Thus,  Kaposi  ^  declares  that  early 
treatment  does  not  prevent  the  appearance  of  the  general  symptoms,  but 
only  delays  them,  that  the  symptoms  appear  irregularly,  and  that  mild 
eruptions  do  not  occur  exclusively,  but  that  there  may  be  very  early 
severe  symptoms.  Not  alone  is  the  development  of  severe  symptoms, 
especially  those  of  the  central  nervous  system,  accelerated,  but  in  rare 
cases,  in  which  severe  early  symptoms  remain  absent,  injury  results  to 
the  patient  in  that  the  syphilis  runs  a  much  slower  course  then  when  no 
early  treatment  has  been  adopted.  Doutrelepont^  very  correctly  states 
the  case  when  he  says,  "  Sometimes  very  disagreeable  gummous  forms 
appeared,  although  the  milder  secondary  symptoms  had  remained  absent." 
Neumann^  also  states  the  facts  very  clearly  when  he  says  that  while  cuta- 
neous eruptions  and  enlargement  of  the  ganglia  predominate  when  there 
has  been  no  early  preventive  treatment,  after  the  latter  we  find  that  the 
mucous  membrane  of  the  mouth  and  pharynx,  especially  the  lips  and 
tongue,  are  particularly  apt  to  present  patches  (and  ulcers)  in  spite  of  the 
most  careful  local  treatment.  He  found  that  the  rash  is  delayed  about 
sixty-two  days,  and  I  have  seen  it  appear  as  early  as  that,  and  as  late  as 
ninety  and  one  hundred  and  twenty  days.  He  rightly  concludes  that  the 
success  of  the  early  preventive  treatment  is  ephemeral,  and  that  notwith- 
standing its  adoption  syphilis  will  inevitably  run  its  course.  Further  than 
this  the  words  of  Kobner  *  are  of  great  significance.  This  observer  up  to 
the  sixties  of  this  century  followed  the  routine  then  in  vogue — namely, 
early  preventive  treatment — and  he  declares,  with  large  experience,  that 
he  has  seen  only  two  cases  in  which  the  outbreak  of  general  symptoms 
was  apparently  entirely  prevented.  In  all  other  cases  he  saw  syphilis  run 
its  course  in  spite  of  a  most  active  inunction-treatment  during  the  primary 
period.  He  further  says  that,  unfortunately,  he  has  frequently  observed 
that  those  individuals  who  had  received  inunctions  immediately  after  the 
diagnosis  of  the  primary  lesion  exhibited  disproportionately  early  severe 
and  fatal  symptoms  on  the  part  of  the  central  nervous  system.  Equally 
as  significant  are  the  words  of  Barensprung,'^  who  says:  "I  have  seen  the 
most  severe  and  rapid  destruction  almost  always  in  those  cases  in  which 
inunctions  were  used  against  the  primary  or  first  secondary  lesions;"  by 
which  latter  he  means  the  inguinal  adenopathy.  Diday  also  is  opposed 
to  an  early  preventive  treatment,  and  Leloir  concludes  that  it  is  produc- 

'  "Ueber  Therapie  der  Syphilis,"  Separat  abdruck  aus  der   Verhandlungen  der  Con- 
gresses fiir  Innere  Medizin,  Wiesbaden,  1886. 

2  Ibkl. 

3  Ibid. 

*  Ibid.,  and  "Aphorismen  zur  Behandlung  der  Syphilis,"  5eHm.  Min.  WochenschrifL 
Dec.  29,  1890. 

°  Die  Hereditdre  Syphilis,  Berlin,  18G4,  p.  17. 


816  SYPHILIS. 

tive  of  no  good.  Finally,  I  may  quote  the  recent  utterances  of  the  younger 
Zeissl/  who  voices  the  opinion  of  his  deceased  father  as  follows:  "As  a 
compensation  for  the  few  days'  delay  in  the  outbreak  of  the  general  symp- 
toms, these  run  an  irregular  course  and  severe  forms  occur  early.  A 
further  disadvantage  of  mercurial  preventive  treatment  is  the  fact  that  the 
syphilis  becomes  more  obstinate,  in  so  far  as  the  symptoms  of  the  condy- 
lomatous  period  yield  much  more  slowly,  than  if  mercury  has  not  been 
used  until  the  appearance  of  this  stage.  We  have  therefore  achieved 
nothing  by  preventive  treatment,  except  to  weaken  our  chief  weapon 
against  syphilis."  Further  evidence  certainly  is  not  necessary.  I  can 
confirm  from  prolonged  observation  and  experience  all  that  these  authori- 
ties have  said  and  claimed  as  to  the  inutility,  general  unadvisableness,  and 
even  danger  of  an  early  preventive  treatment. 

Treatment  of  Chancres. 

When  seen  at  a  very  early  date  upon  the  male  genitals  the  chancre 
usually  appears  like  a  minute  round  or  oval  excoriation  or  as  a  papule 
with  a  scaly  or  an  oozing  surface.  So  much  does  this,  the  earliest  of  all 
evidences  of  syphilis,  resemble  simple  benign  lesions  that  mistakes  are 
very  liable  to  occur,  and  a  chancre  may  be  diagnosticated  as  an  excoria- 
tion, an  abrasion,  or  as  a  simple  inflammatory  papule,  or  vice  ve7'sd. 
Under  these  circumstances  the  physician  cannot  be  too  careful  and  guarded 
in  the  diagnosis  of  any  seemingly  insignificant  lesion  upon  the  penis.  It 
is  well  to  warn  a  patient  not  to  indulge  in  sexual  intercourse  for  at  least 
two  weeks,  by  which  time  the  nature  of  the  lesion  will  be  beyond  ques- 
tion, since  if  it  is  benign  it  will  commonly  heal  under  simple  treatment 
and  cleanliness,  and  if  it  is  an  incipient  hard  chancre  its  evolution  will 
continue  and  its  appearance  will  indicate  its  character.  It  is  of  the  utmost 
importance  that  no  stimulating  or  escharotic  applications  should  be  made 
to  these  small  lesions,  for  very  good  and  sufficient  reasons.  In  the  first 
place,  if  the  lesion  is  simple  in  nature,  burning  it  with  acid  or  other  caus- 
tic will  not  destroy  it,  but  simply  transform  it  into  an  inflammatory  nodule, 
which  may  present  a  striking  resemblance  to  a  young  hard  chancre,  and 
thus  doubt  and  uncertainty  of  mind  are  induced  or  an  error  in  diagnosis 
is  the  result.  If  the  lesion  is  an  incipient  chancre,  it  is  a  localized  specific 
neoplasm,  which  cauterization,  however  severe,  cannot  possibly  destroy, 
but  it  can  cause  a  complicating  oedema  Avhich  may  be  troublesome  to  cure. 
Therefore  it  may  be  stated  as  a  golden  rule  that  we  must  not  lay  violent 
hands  on  these  seemingly  and  perhaps  insignificant  lesions.  Any  breach 
of  surface,  therefore,  should  be  kept  scrupulously  clean  by  washing,  and 
its  surface  may  be  covered  with  lint  or  absorbent  cotton  moistened  Avith 
water.  In  many  cases  a  water  dressing  is  sufficient,  but  mild  solutions  of 
sublimate  (1  :  1000,  2000,  or  3000)  may  be  applied,  or  very  dilute  watery 
solutions  of  carbolic  acid.  These  applications  may  be  made  every  two, 
three,  or  four  hours.  Peroxide  of  hydrogen  1  part  and  water  6  parts 
make  a  solution  which  will  produce  an  antiseptic  eff'ect.  As  the  hard 
chancre  grows  larger  it  may  be  treated  with  black  wash,  with  yellow  Avash, 
or  the  red  wash,  which  is  made  as  follows : 

^  "  Der  Geffenwiirtige  Stand  der  Sypliilis-therapie,"  KUnische  Zeit  und  Streiffragen, 
Vienna,  1887,  p.  173. 


ABORTIVE  TREATMENT,  AND   TREATMENT  OF  CHANCRES.     817 

^i.   Zinci  sulpliatis,  gr.  viij  ; 

Spiritus  lavandulae  comp.,  3ij  ; 

Aquae,  q.  s.  ad  siv. — M. 

It  must  be  understood  that  the  therapeutical  effect  of  these  lotions  is 
simply  protective  and  slightly  stimulating.  They  prevent  irritation  and 
ulceration  by  keeping  the  parts  clean  and  aseptic.  The  chancre  offers  a 
nidus  for  pus-producing  microbes,  and  when  it  is  not  large  antiseptic 
"washes  are  all  that  is  required  in  the  way  of  treatment. 

Petersen^  has  used  a  solution  of  yellow  and  blue  pyoktanin  of  Merck 
(1  :  1000,  or  even  1  :  100)  upon  hard  and  soft  chancres,  and  he  claims 
that  he  has  had  sood  results.  The  chief  advantages  are  that  it  is  inodor- 
ous,  and  in  antiseptic  power  not  inferior  to  iodoform.  The  stain  of  blue 
pyoktanin  may  be  removed  from  the  hands  by  washing  them  well  with  a 
strong  soap-lather  and,  after  drying,  pouring  alcohol  over  the  spots.  The 
late  Dr.  Palmer  of  Louisville  informed  me  that  he  had  employed  with 
much  satisfaction,  in  the  treatment  of  hard  and  soft  chancres,  a  watery 
solution  of  fuchsine  (1  drachm  to  the  ounce),  which  he  paints  Avell  over 
the  morbid  surface,  which  he  then  covers  Avith  absorbent  cotton. 

Chancres  covered  with  a  false  membrane,  thick  or  thin,  those  which 
show  a  tendency  to  become  necrotic  upon  their  surfaces  or  in  which  a 
decided  tendency  to  ulceration  is  seen,  may  not  be  sufficiently  influenced 
by  the  foregoing  applications.  In  these  cases  it  is  important  that  a 
decidedly  caustic  effect  should  be  produced.  In  cauterizing  hard,  as  well 
as  soft,  chancres,  carelessness  and  recklessness  must  be  carefully  avoided. 
The  lesion  to  be  treated  should  first  be  carefully  washed  with  soap  and 
water,  and  then  irrigated  with  a  5  per  cent,  carbolic  solution.  Then  it 
should  be  dried  and  a  solution  of  cocaine  applied  to  it,  and  then  it  should 
be  dried  again.  We  no  longer  use  the  carbo-sulphuric  paste  (sulphuric 
acid  and  charcoal)  nor  the  Vienna  paste  (chloride  of  zinc  and  flour),  for 
they  are  difficult  of  application  and  too  caustic  in  their  effects.  Cauteri- 
zation by  heat  is  repugnant  to  patients,  and  not  necessary.  As  a  routine 
application  nothing  is  better  than  fluid  carbolic  acid  or  pure  nitric  acid. 
These  agents  should  be  sparingly,  carefully,  and  not  frequently  applied  to 
the  surface  of  the  sore,  and  not  beyond  it.  A  small  quantity  of  cotton 
rolled  on  the  end  of  a  wooden  toothpick  offers  the  most  effective  and  satis- 
factory means  of  application.  It  may  be  well  to  mention  that  Gunz^  of 
Dresden  advises  the  use  of  concentrated  muriatic  acid,  after  which  he 
covers  the  surface  with  a  little  bicarbonate  of  sodium,  and  then  applies 
cold  compresses.  In  case  the  surfiice  cauterized  is  quite  large,  it  is  Avell 
to  send  the  patient  at  once  to  his  room,  where  he  should  lie  down.  It  is 
well  to  bear  the  fact  in  mind  that  this  destructive  treatment  is  only  indi- 
cated in  cases  in  which  the  surface  of  the  sores  is  unhealthy  and  shows  no 
tendency  to  heal.  After  cauterization  it  is  necessary  to  apply  antiseptic 
remedies  in  the  powder  form.  It  is  always  imperative  that  these  lesions 
should  be  carefully  Avashed  twice  a  day,  and  the  patient  should  be  Avarned 
to  destroy,  preferably  by  fire,  all  linen  used  in  the  cleansing,  and  to  be 

'  "Die  Desinficirende  Wirkung  der  Anilinfarben  von  Merck,  Pyoctanin," /S^.  Peters- 
burg med.  Wochen^chrift,   'So.  27,    1890. 

'^  Die   BehxindluiKj   der   Si/philitischen    Geschiciire   luich  den  Neuren  Methoden,  Leipsic, 

52 


818  SYPHILIS. 

careful  not  to  touch  Tvith  soiled  fingers   any  article  which   others  may 
handle. 

Among  antiseptic  powders  iodoform  still  holds  its  position  without  a 
peer  or  rival.  New  remedies  come  and  go,  but  this  one  stays  by  us. 
It  may  be  said  without  fear  of  contradiction  that  for  the  dressing  of 
ulcers  and  wounds  about  the  genitals,  male  and  female,  there  is  no 
remedy  so  efficient  or  which  has  such  a  wide  range  of  usefulness.  Its 
odor  is  of  course  objectionable,  but  with  care  much  of  this  inconvenience 
may  be  obviated.  In  the  first  place,  the  powder  must  be  very  carefully 
and  sparingly  put  on  the  surface,  and  not  allowed  to  drop  on  sound 
parts  or  upon  the  clothes.  Then,  if  the  lesion  is  under  the  prepuce, 
the  odor  may  be  kept  at  a  minimum  by  packing  cotton  in  the  preputial 
orifice.  If  the  lesion  is  on  an  uncovered  part,  it  should  be  enveloped 
in  absorbent  cotton  and  then  covered  with  gutta-percha  tissue.  A  little 
care  and  ingenuity  Avill  do  much  to  dissipate  a  patient's  disinclination 
or  repugnance  to  the  use  of  this  drug.  Though  many  drugs  have  been 
recommended  as  having  the  power  of  deodorizing  or  disguising  the  odor 
of  iodoform,  none,  in  my  judgment,  have  proved  successful.  By  far  the 
best  deodorant  is  cumarin,  which  in  small  quantities  may  be  added  to 
iodoform.  It  must  always  be  remembered  that  this  powder  is  only 
applicable  to  unhealthy  and  necrotic  surfaces,  and  that  when  a  smooth 
healing  surface  has  been  produced  its  use  must  be  discontinued  and  one 
of  the  simple  stimulating  or  antiseptic  lotions  or  powders  should  be 
substituted. 

lodol  has  now  been  on  trial  a  number  of  years,  and  has  proved 
itself  to  be  a  feeble  agent,  comparable  in  its  effects  to  subnitrate  and 
subiodide  of  bismuth.  Where  little  is  required  it  may  be  used  and  may 
prove  satisfactory,  but  in  severe  cases  this  powder  forms  a  crust  over 
the  surface,  and  beneath  this  the  destructive  process  goes  steadily  on. 
When  there  is  danger  ahead,  never  trust  to  iodol. 

Loretin  is  the  name  of  a  new  yellow  crystalline  powder  recommended 
by  Schinzinger  ^  as  a  substitute  for  iodoform.  It  lacks  the  disagreeable 
odor  and  the  toxic  properties  of  iodoform.  In  operative  surgery  it  is 
said  to  have  proved  very  beneficial. 

The  latest  agent  presented  as  a  substitute  for  iodoform  is  called 
di-iodoform,  and  is  recommended  by  Maquenne  and  Taine.^  This 
preparation  is  an  iodide  of  carbon,  being  particularly  rich  in  iodine. 
It  is  said  to  be  very  efficacious  in  the  treatment  of  soft  and  hard  chan- 
cres and  of  unhealthy  ulcers  and  wounds.  Kept  in  the  dark,  it  remains 
odorless ;  exposed  to  the  light,  it  turns  brown  and  emits  a  characteristic 
but  slight  odor.  Hallopeau  is  said  to  have  found  its  effects  in  chan- 
croids identical  with  that  of  iodoform. 

Aristol  is  scarcely  more  efficient  in  really  active  lesions  than  is  iodol. 
There  are  those  who  see  good  effects  in  every  new  preparation,  but  they 
are  usually  not  careful  and  critical  judges.  The  fact  that  aristol  will 
act  seemingly  favorably  upon  a  chancre  whose  course  is  attended  with 
slight  ulceration  and  destruction  is  no  evidence  that  in  a  graver 
exigency  it  will  prove  efficient.  In  my  experience  (and  I  have  tried  it 
extensively)  aristol  has  shown  no  decided  therapeutic  power,  certainly 

1  Centrcdbhtt  fur  Chimrgie,  189.3,  No.  45,  p.  984. 

2  Lancet,  Nov.  20,  189.3,'  p.  1355. 


ABORTIVE  TREATMENT,  AND   TREATMENT  OF  CHANCRES.     819 

none  more  marked  than  that  shown  by  iodol,  subiodide  of  bismuth,  sub- 
benzoate  of  bismuth,  and  other  such  powders.  Though  it  is  odorless, 
it  leaves  an  objectionable  sticky  feeling  on  the  fingers  and  on  the  parts 
to  which  it  is  applied.  If  you  have  a  bad  case,  be  sure  to  use  iodoform  ; 
and  if  you  have  a  mild  case  that  any  indiiferent  powder  will  help,  pre- 
scribe iodol,  aristol,  or  some  other  new  remedy.  If  you  do  nothing 
else,  you  will  show  that  you  are  progressive  and  that  you  keep  abreast 
of  the  times,  and  among  some  that  will  have  its  effect. 

Many  chancres  in  a  necrotic  state  will  be  much  benefited  by  the 
application  of  calomel  covered  with  cotton.  Salicylate  of  mercury  has 
been  recommended  for  this  purpose,  but  it  should  never  be  applied  in 
its  pure  state,  for  it  exerts  an  unpleasant  irritant  and  destructive  action 
upon  the  mucous  membrane.  It  may  be  combined  with  talcum  powder 
or  starch  in  the  proportion  of  1  drachm  of  the  mercurial  to  4  or  6 
drachms  of  the  inert  powder.  Salicylic  acid  is  uncertain  in  its  effects, 
and  if  applied  in  its  purity  causes  irritation. 

The  cup  of  happiness  of  the  seeker  after  therapeutic  novelties  must 
certainly  now  be  nearly  full,  for  every  month  brings  us  a  new  antiseptic 
remedy,  usually  from  Germany,  which  is  to  supplant  iodoform.  In  order 
that  I  may  not  appear  behind  the  times,  I  will  enumerate  these  new 
remedies  and  their  sponsors,  so  that  any  one  can  put  them  to  a  practical 
test : 

Bazilivitch^  claims  that  he  has  had  excellent  results  in  ulcerated 
chancres  by  freely  powdering  their  surfaces  twice  a  day  with  antifebrin 
(Merck).  He  further  claims  as  advantages  that  it  is  cheap,  free  from 
odor,  and  will  not  give  rise  to  dangerous  phenomena  from  absorption. 

Salol  has  also  been  extolled  by  Salsotto  ^  and  others  in  the  treatment 
of  hard  chancres,  but  the  drawback  to  its  use  is  the  fact  of  the  difficulty 
of  obtaining  it  in  sufficiently  fine  poAvder  that  it  will  not  act  as  an  irri- 
tant. A  combination  of  salol  1  part  and  some  inert  powder  2  parts  may 
be  of  service  in  some  mild  cases  of  ulcerating  chancres. 

Sozo-iodol  has  been  extolled  by  Lassar,^  and  it  may  do  good  service 
in  some  mild  cases. 

The  subgallate  of  bismuth,  also  called  dermatol,  has  been  proposed  by 
Heinz  and  Liebrecht*  as  a  substitute  for  iodoform.  They  claim  that  it 
has  decided  healing  properties  and  that  it  is  inodorous  and  non-poisonous. 

Sansoni  ^  of  Turin,  among  other  remarkable  qualities,  claims  that 
euphorin  (Merck)  is  better  than  any  other  remedy  as  an  application  to 
obstinate  ulcers.  I  suspect  that  within  a  short  time  we  shall  have  some 
highly  laudatory  accounts  of  the  effect  of  this  agent  in  the  cure  of  chancres. 

Europhen,  introduced  and  recommended  by  Goldmann,®  is  said  to 
have  a  brilliant  future  before  it  as  an  antiseptic. 

And,  lastly,  sulfaminol  (Merck)  comes  before  us  as  an  inodorous, 
painless,   antisuppurative    remedy,   which    Robertson"^  regards    as    supe- 

^  Medizinskoie  Obozrenie,  Nos.  13  and  14,  1890. 

*"  Salol  ed  il  sn.  iiso  terapeutico  in  alcuni  morbi  venerei,"  Giornale  Ilal.  del  maL 
Ven.  e  della  Pelle,  1887,  pp.  345  et  seq. 

'  "Ueber  das  Sozoiodol,"  Thempeut.  Monatshefle,  Nov.,  1887. 
*  Beiiiner  kUnbic.Jm  Wochenschrift,  No.  24,  1891. 
^  Therapeuiische  Monalnhcfle,  Sept ,  1 890. 
®  Pharinamiii.  Zeitung,  Jiilv  lo,  1S91. 
^  British  Med.  Journal,  Aiig.  29,  1891. 


820  SYPHILIS. 

rior    to    iodoform.     It  has  not    as    yet  been    used  in  the   treatment  of 
chancre. 

It  must  not  be  forgotten  that  the  main  benefit  of  all  antiseptic  rem- 
edies for  chancre  consists  in  their  power  of  preventing  ulceration,  and  by 
this  means  they  hasten  the  cure.  It  is  important,  however,  that  a  specific 
action  should  be  brought  to  bear  on  all  chancres  which  show  a  tendency 
to  become  indurated.  Having  by  the  proper  means  produced  a  healthy 
surface,  the  chancre  should  then  be  treated  with  mercurial  ointment.  The 
surface  having  been  washed  and  rendered  as  nearly  as  possible  aseptic,  a 
layer  of  absorbent  cotton  or  lint  well  smeared  with  this  ointment  should 
be  placed  upon  it,  and  then  kept  in  constant  apposition.  It  is  important 
that  the  dressing  should  be  renewed  two  or  three  times  a  day. 

Chancres  of  women  require  the  same  general  treatment  as  is  used  for 
those  of  men.  In  many  cases  they  run  their  course  and  disappear  with- 
out treatment  and  perhaps  without  recognition.  In  some  cases,  however, 
they  are  obstinate  and  persistent,  and  require  time  and  care  for  their 
removal.  It  is  always  imperative  that  the  vagina  and  vulva  should  be 
kept  particularly  clean  in  women  having  syphilitic  chancres.  They  should 
use  frequent  irrigations  of  hot  water  to  which  borax,  alum,  sulphate  of 
zinc,  or  carbolic  acid  is  added.  Then  the  parts  should  be  kept  as  dry  as 
possible,  for  which  purpose  tampons  of  absorbent  cotton  are  very  effective. 
In  some  cases  extensive  and  troublesome  indurating  oedema  becomes  a 
complication  of  the  vulvar  chancre,  and  its  presence  means  a  long  siege 
of  annoyance  and  perhaps  sufi'ering.  When  possible,  chancres  in  the 
female  should  be  dressed  with  mercurial  ointment  in  the  manner  above 
described.  If  the  induration  is  extensive  or  if  it  shows  a  tendency  to 
spread,  it  is  well  to  cover  the  chancre  and  a  liberal  area  of  the  parts 
around  it  with  the  ointment.  In  some  cases  a  strong  calomel  or  white- 
precipitate  ointment  may  be  used  in  place  of  the  mercurial  ointment. 


CHAPTER    LXXXV. 

THE  GENERAL  METHODICAL  TREATMENT  OF  SYPHILIS. 

It  is  very  important  to  know  when  to  begin  systemic  treatment  in 
syphilis,  and  the  questions  naturally  arise :  Shall  we  begin  general  sys- 
temic treatment  as  soon  as  a  positive  diagnosis  is  made,  or  shall  we  wait 
until  the  evolution  of  the  secondary  period  proves  to  us  that  the  climax 
has  at  last  been  reached  and  that  the  whole  organism  has  been  involved  ? 
We  have  already  seen  that  no  clear  evidence  has  been  adduced  proving 
that  an  early  mercurial  course  can  abort  or  favorably  modify  the  syph- 
ilitic infection ;  and  it  has  been  shown  that,  in  spite  of  such  treatment, 
early  and  late  lesions  have  appeared.  This  fact  has  been  observed  by 
many  physicians.  As  I  have  already  said,  it  is  very  probable  that  few 
authorities  follow  the  letter  of  the  law  which  tliey  lay  down — namely, 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      821 

to  begin  treatment  at  once  as  soon  as  they  are  reasonably  certain  that 
they  have  syphilis  to  treat.  Though  the  advocates  of  this  method  of 
procedure  are  quite  numerous,  those  who  counsel  delay  until  all  possible 
doubt  of  diagnosis  is  removed  are  even  more  numerous.  These  advo- 
cates of  early  treatment  base  their  view  largely  on  sentimental  grounds, 
and  do  not  present  strong,  telling  facts  in  their  support.  They  picture 
a  patient  in  the  meshes  of  a  severe  chronic  infectious  disease,  and  claim 
that  the  dictates  of  humanity  call  for  its  early  eradication.  On  the 
other  hand,  those  who  advocate  a  policy  of  delay  are  equally  as  much 
impressed  with  the  gravity  of  the  patient's  position,  and  are  equally 
ready  and  zealous  to  help  him ;  and  they  think  that  they  can  do  so 
with  more  certainty  by  waiting  until  they  have  a  distinct  morbid  entity 
to  treat  than  they  can  if  they  begin  the  use  of  mercury  when  the  disease 
is  yet  in  an  unsettled  and  mythical  condition.  At  best,  early  treatment 
only  delays  the  appearance  of  secondary  manifestations  for  a  longer  or 
shorter  time,  and  as  a  rule  does  not  lessen  the  severity  or  extent  of  their 
distribution,  and  in  many  cases  seems  to  render  them  more  severe.  And 
when  we  have  said  this  we  have  said  about  all  that  we  can  in  favor  of  the 
treatment  of  syphilis,  early  or  late,  in  its  primary  stage.  On  the  other 
hand,  it  is  the  consensus  of  opinion  of  very  many  eminent  men,  as  Ave 
have  already  seen,  that  this  early  treatment  is  really  productive  of  harm, 
in  the  fact  that  it  induces  a  disorderly  course  of  the  disease. 

Moreover,  early  treatment  takes  from  the  physician  at  the  outset — 
which  is  the  most  important  period  in  the  life  of  the  syphilitic — those 
criteria  which  are  to  guide  him  in  the  management  of  the  patient,  and 
very  often  leaves  him  in  a  very  uncertain  and  uncomfortable  state  or 
condition  of  indecision  and  doubt  as  to  Avhether  his  patient  is  really 
syphilitic.  Then,  again,  Avhen  a  patient  has  been  pronounced  to  be  syph- 
ilitic, he  himself  generally  wants  to  see  some  undoubted  signs  and  symp- 
toms of  the  disease.  I  have  many  times  seen  patients  who  had  received 
early  mercurial  treatment,  and  had  witnessed  no  other  evidence  of  syph- 
ilis than  a  chancre,  cease  treatment  or  refuse  treatment  after  the  lapse  of 
a  month  or  two  of  early  mercurialization,  and  later  on  develop  severe,  and 
even  deadly,  lesions.  Many  patients,  seeing  nothing  on  their  bodies  in 
the  early  months  of  the  infection  (as  a  result  of  early  treatment),  convince 
themselves  that  they  never  had  syphilis,  and  others  remain  in  doubt,  and 
in  very  many  cases  they  will  not  follow  subsequent  treatment  in  the  per- 
sistent and  methodical  way  Avhich  is  so  essential  for  the  cure  of  the  dis- 
ease. These  cases  have  a  surfeit  of  treatment  very  early  in  the  disease, 
and  an  absence  of  it  later,  so  that  while  they  are  not  the  gainers  by  the 
early  medication,  they  are  often,  to  their  sorrow,  the  losers  by  the  absence 
of  treatment  at  subsequent  periods.  Further,  we  must,  as  Von  During  ^. 
remarks,  consider  fully  the  mental  injury  inflicted  upon  a  patient  by  a 
premature,  and  perhaps  unfounded,  diagnosis  of  syphilis,  which  causes 
him  during  his  Avhole  life  to  be  in  constant  dread  of  relapses,  and,  I  may 
add,  to  be  in  a  state  of  mind  which  attributes  to  his  early  (perhaps  puta- 
tive) syphilis  every  lesion  or  affection,  however  simple,  Avhich  may  there- 
after befall  him.  To  my  mind,  it  is  most  salutary  for  the  syphilitic  to  be 
convinced  beyond  any  doubt  that  he  is  syphilitic,  for  in  most  cases  the 

^  "Friihbehandlung  der  Svphilis  oder  Xicht,"  Monutshefte  J'iir  Prak.  Dermat.,  vol.  ix., 
1889,  p.  490. 


822  SYPHILIS. 

revelation  brings  him  to  a  realization  of  his  true  condition,  and  impresses 
upon  him  the  necessity  of  care  and  watchfulness  as  to  his  mode  of  life 
and  docility  to  his  physician  in  order  that  in  due  time  he  may  be  cured. 
Let  us  now  turn  to  the  pathological  condition  which  syphilis  presents. 
It  is  chronic  and  infectious  in  character,  and  manifests  itself  by  the  devel- 
opment of  a  low  grade  of  connective  tissue,  which  tends  to  indefinite 
reproduction  in  greater  or  less  degree  through  periods  of  activity  and  re- 
mission in  any  and  all  of  the  tissues  and  organs  of  the  body.  In  all 
probability  the  malign  influence  of  syphilis  upon  the  human  organism  is 
directly  due  to  the  infiltration  of  this  tissue,  to  the  irritative  and  inflam- 
matory conditions  incident  to  the  hypergemia  which  accompanies  this 
proliferation,  and  last,  but  far  from  least,  to  the  secondary  destructive 
and  atrophic  changes  which  take  place  in  the  tissues  in  the  various  meta- 
morphoses of  these  specific  new  growths.  Clinical  and  pathological 
observations  have  shoAvn  that  mercury  possesses  a  specific  power  over  this 
low  grade  of  infectious  tissue,  and  it  is  very  probable  that  it  causes  its 
necrobiosis  or  its  burning  up,  or  that  it  produces  its  removal  by  the  in- 
duction in  it  of  fatty  degeneration,  which  renders  it  ready  for  absorption. 
In  my  judgment,  syphilis  is  not  mature  until  the  date  of  secondary  man- 
ifestation, when  the  newly-formed  young  round-cells  are  proliferated  in 
vast  quantities,  and  are  thrown  into  the  general  circulation,  and  by  it 
carried  throughout  the  body.  In  the  same  way  in  the  acute  infectious 
diseases  small-pox  is  not  ripe  until  the  evolution  of  the  pustular  rash,  nor 
scarlatina  until  the  appearance  of  its  intense  generalized  erythema. 
When,  therefore,  the  morbid  processes  have  so  far  advanced  that  a  gener- 
alization of  their  products  has  occurred,  syphilis  may  be  said  to  be  ripe, 
and  then,  and  not  till  then,  have  we  anything  really  tangible  to  treat. 
Mercury  given  before  this  critical  cell-explosion  has  very  little  to  work 
upon,  and  therefore  is  productive  of  a  limited  amount  of  good.  Indeed, 
to  my  mind,  when  given  thus  early,  while  it  may  have  some  influence 
upon  local  processes — namely,  on  parts  the  seat  of  the  chancre  and  the 
adjoining  territory — it  is  productive  of  harm  by  influencing  the  tissues 
too  early,  which  influence  does  not  give  them  an  immunity  to  the  subse- 
quent sj^philitic  process  of  invasion.  In  other  words,  mercury  given 
before  the  generalization  of  syphilitic  products  does  not  favorably  influ- 
ence the  resistance  of  the  tissues  to  the  impending  invasion,  and  certainly 
does  not  render  them  immune  to  it.  On  the  contrary,  the  early  exhibi- 
tion of  mercury  induces  a  condition  of  tolerance  in  the  tissues  which  ren- 
ders its  action  less  powerful  and  certain  at  a  later  date  when  they  are 
infiltrated  with  syphilitic  products.  In  short,  we  take  the  cutting  edge 
off"  of  our  most  potent  remedy  by  administering  it  to  a  system  as  yet  not 
charged  with  the  virus  which  it  is  our  hope  to  destroy.  We  are  really 
treatingr  before  -we  have  got  anvthino;  to  treat. 

We  very  frequently  see  a  parallel  condition  later  on  m  syphilis  in 
patients  who  have  for  long  periods  taken  small  and  continuous  doses  of 
mercury,  and  in  whom  (as  so  often  occurs)  syphilitic  new  growths  appear 
in  the  skin  and  elsewhere.  In  these  cases  a  low  grade  of  mercurialization 
is  induced  which  has  no  power  at  all  over  syphilis,  since  its  lesions  appear 
notwithstanding  the  fact  that  the  patient  is  taking  mercury  regularly. 
Now,  this  mercurialization  tends  to  lower  vitality  and  impair  nutrition, 
and  the  general  condition  which  it  induces  ties  our  hands,  so  that  we  can 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      823 

do  very  little  good  with  mercury  until  the  system  has  been  renovated ; 
then  by  the  use  of  proper  doses  of  the  drug  the  syphilitic  lesions  may  be 
made  to  yield. 

There  is  another  important  consideration.  In  the  primary  period  of 
syphilis  it  is  well  to  prepare  for  the  secondary  stage  by  fortifying  the 
patient's  system,  by  putting  him  in  a  good  physical  condition,  and  in 
preparing  the  stomach,  if  necessary,  for  the  ordeal  which  it  will  have  to 
pass  through.  In  this  primary  period  in  very  many  cases  tonics  and 
remedies  designed  to  improve  digestion  should  be  given.  Then  in  due 
time  mercury  will  be  well  borne,  and  it  will  promptly  act  upon  the  syph- 
ilitic virus  and  its  effects. 

I  have  carefully  studied  this  question  for  more  than  twenty-five  years, 
and  I  am  now  more  than  ever  convinced  that  it  is  by  far  the  best  plan  in 
most  cases  to  wait  until  the  onset  of  the  secondary  stage  before  we  begin 
a  mercurial  course.  In  thus  waiting  it  must  be  remembered  that  we  are 
not  to  fold  our  arms  and  do  nothing ;  we  must  regularly  examine  our 
patient ;  we  must  look  after  his  general  well-being,  mental  and  physical, 
encourage  him  with  hopeful  prospects,  and  prepare  him  for  his  coming 
ordeal,  the  crucial  one  perhaps  of  his  life.  Then,  just  as  soon  as  general 
symptoms  and  manifestations  begin  to  appear,  and  we  know  that  we  are 
right  and  appreciate  fully  what  we  have  got  to  treat, — then  we  must 
begin  our  mercurial  treatment  with  vigor  tempered  by  watchful  care  of 
our  patient  and  an  enlightened  and  conservative  knowledge  of  thera- 
peutics. 

While,  therefore,  it  is  best  to  begin  the  treatment  of  syphilis  at  the 
very  earliest  moment  of  the  secondary  period,  there  are  conditions  or 
exigencies  which  arise  in  the  primary  period  which  call  for,  and  some- 
times demand,  the  very  earliest  administration  of  mercury.  These  may 
be  summed  up  as  follows  : 

1.  When  the  initial  lesion  from  its  site,  size,  depth,  or  extent  causes 
much  pain  and  discomfort  or  interferes  with  the  function  of  parts,  or 
from  activity  of  ulceration  threatens  to  destroy  them — prepuce,  penis, 
urethra  (chiefly  in  cases  of  phimosis  and  paraphimosis),  clitoris,  fingers, 
eyes,  nose,  lips,  tongue,  tonsils,  breast,  and  anus.  Also  in  cases  in 
which  dense  induration  around  the  urethral  orifice  or  in  the  urethral 
canal  produces  a  stenosis  of  that  canal,  and  again  in  cases  of  very  large 
(elephantine)  extra-genital  chancres  upon  the  legs,  arms,  buttocks,  and 
cheeks  or  face. 

2.  In  some  cases  in  which  there  is  a  tendency  to  the  development  of 
exuberant  indurating  oedema  around  the  chancre,  which  may  seriously 
discomfort  or  cripple  the  patient  or  impair  the  functions  of  the  part,  as  we 
sometimes  see  in  chancres  of  the  lips,  near  the  frgenum,  and  upon  the 
external  female  genitalia,  and  complicating  chancres  of  the  anus,  and  also 
in  cases  of  chancres  just  within  the  vaginal  introitus. 

3.  In  certain  of  those  cases  in  Avhich,  from  its  situation,  the  chancre 
may  lead  to  infection  of  others,  such  as  the  fingers  of  surgeons,  obstetri- 
cians, dressers,  orderlies,  and  raidwives,  the  nipples  of  wet  nurses  and 
others  who  suckle  children  other  than  their  own,  in  cases  of  chancre  of 
the  lips  and  tongues  of  infimts,  and  in  cases  in  Avhich  tlie  lesion  occurs  on 
the  lips  or  elsewhere  of  young,  careless,  and  thoughtless  persons  who  are 
liable  to  spread  the  infection. 


824  SYPHILIS. 

4.  When  the  enlargement  of  the  lymphatic  ganglia  or  the  lymphatic 
cords  (particularly  of  the  penis)  is  excessive  and  causes  inconvenience, 
impairment  of  function  or  locomotion  or  movement  of  the  arms,  or  pro- 
duces much  discomfort  and  disfigurement  in  the  neck  and  submaxillary 
region,  at  the  elbow,  in  the  axillae,  and  groins. 

5.  In  some  cases  in  which  chancres  are  complicated  with  a  pyogenic 
infection  attended  with  pain,  fever,  and  perhaps  typhoidal  symptoms, 
chiefly  on  the  fingers,  but  also,  though  rarely,  on  the  nipple  and  mammae, 
and  sometimes  on  the  penis  and  vulva  (in  careless,  uncleanly  subjects). 
Also  in  some  cases  in  which  gangrene  and  phagedena  are  complications. 

6.  In  cases  in  which  conjugal  or  sexual  relations  render  the  disappear- 
ance of  the  chancre  necessary  or  imperative. 

7.  When  the  extreme  anxiety  and  fear  and  the  unreasonable  impa- 
tience of  the  bearer  render  it  imperatively  necessary. 

8.  In  those  somewhat  exceptional  cases  in  which  severe  cephalalgia, 
neuralgia,  pleuritic  and  intrathoracic  discomfort  and  pain,  pains  in  the 
bones,  joints,  and  fasciae,  are  precocious. 

9.  In  cases  of  women  infected  in  the  early  months  of  pregnancy,  in 
order,  if  possible,  to  prevent  subsequent  abortion ;  and  in  cases  of  chan- 
cre of  the  vulva  and  introitus  vaginae  in  order  to  remove  a  possible 
obstacle  to  childbirth,  and,  if  very  late  in  gestation,  to  prevent  the  infec- 
tion of  the  child  in  transitu. 

Kaposi  ^  says  that  whenever  he  has  been  led  astray  by  logic  or  exter- 
nal conditions  to  adopt  a  general  treatment  by  mercury  before  the  onset 
of  the  second  stage,  he  has  been  sorry  for  it  afterward ;  and  my  experi- 
ence in  the  main  accords  with  his.  In  these  early  medicated  cases  there 
are  always,  of  necessity,  data  and  criteria  lacking,  and  as  a  result  the 
physician  does  not  feel  as  certain  of  his  ground  as  he  does  when  he  and 
his  patient  have  seen  the  earliest  general  manifestations  of  syphilis,  and 
when  he  has  by  their  observation  and  study  gained  a  pretty  clear  general 
idea  of  what  course  the  syphilitic  infection  is  going  to  take. 

To  sum  up,  then,  we  may  state  that  in  most  cases  no  advantage  or 
possible  benefit  to  the  patient  is  lost  by  withholding  mercury  until  the 
onset  of  the  second  stage,  nor  is  the  patient  thereby  put  in  any  jeopardy, 
present  or  future,  nor  are  his  chances  for  ultimate  permanent  cure  in  any 
way  impaired,  modified,  or  crippled.  On  the  other  hand,  his  syphilis  will 
be  more  orderly,  and  conspicuously  more  amenable  to  treatment,  his 
physician  will  not  grope  in  the  dark,  and  will,  if  he  promptly  attacks  the 
disease  in  the  conservative  but  vigorous  manner  soon  to  be  detailed,  be 
spared  the  hesitancy,  doubt,  and  uncertainty  of  mind  which  are  the  inev- 
itable lot  of  those  who  attack  the  disease  prematurely. 

The  date,  therefore  (as  a  general  rule),  at  which  the  treatment  of 
syphilis  should  begin  is  that  at  which  the  disease  culminates  in  the 
general  infection  of  the  economy — namely,  just  as  soon  as  the  general 
rash  appears,  together  with  the  other  manifold  symptoms  of  the  secondary 
period. 

Mercury. — The  experience  of  more  than  three  hundred  years  has 
shown,  in  no  uncertain  manner,  that  mercury  has  the  most  marked  and 
salutary  effect  in  the  treatment  and  cure  of  syphilis,  and  that  if  prop- 
erly handled  it  may  almost  be  termed  an  antidote  or  specific  for  that 

'  Loc.  cil. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      825 

dread  and  potent  disease.  Though  sarsaparilla,  guaiac,  saponaria,  stil- 
lincia,  smilax,  chinge,  sassafras,  dock-root,  cascara  amarga,  berberis 
aquifolium,  tayuya,  and  other  vegetable  agents,  as  well  as  preparations  of 
gold,  chroruate  of  potassa,  etc.,  have  from  time  to  time  been  put  forward 
and  vaunted  as  the  true  specific,  they  have  none  of  them  attained  a  firm 
standing  in  the  therapeutics  of  syphilis,  and  have  each  been  abandoned 
as  powerless  and  Avorthless.  To-day  there  are  few  authorities  Avho  decry 
or  inveigh  against  mercury,  whereas  fifteen  or  twenty  years  ago  the 
doughty,  noisy,  illogical,  and  bigoted  disciples  of  old  Ulrich  von  Hiitten 
were  ever  ready  with  their  imprecations  against  the  drug,  and  with  their 
false  assertions  as  to  its  dangerous  and  even  lethal  character. 

Mr.  Hutchinson,^  referring  to  British  medicine,  says:  "Excepting 
in  Edinburgh,  I  believe  that  there  are  at  present  in  the  profession 
scarcely  any  antimercurialists  left,  and  I  may  remark,  in  passing,  that 
during  the  last  fcAv  years  some  of  the  most  severe  cases  of  syphilis  which 
I  have  seen  have  come  from  Edinburgh,  and  had  been  treated  in  the  early 
stages  by  systematic  abstinence  from  mercury."  I  know  of  but  one  anti- 
mercurialist  in  America. 

Used  carelessly  and  in  the  unstinted  manner  of  old  times,  mercury 
certainly  may  be  productive  of  harm  ;  but  in  no  department  of  medicine 
have  more  advances  been  made  and  more  enlightened  conservatism  been 
engrafted  than  in  the  treatment  of  syphilis  by  mercury.  In  place  of  the 
powerful  doses  and  inevitable  salivation  and  other  bad  results  arising 
from  the  use  of  mercury  as  given  years  ago,  we  to-day  use  milder  doses, 
which  produce  amelioration  and  cure  of  the  disease  without,  as  a  rule, 
untoward  complications.  While  it  may  be  said  that  the  modern  atten- 
uation of  the  dosage  of  mercury  has  been  an  incalculable  advance  in 
syphilis  therapy,  it  must  also  be  confessed  that  in  the  hands  of  some 
physicians  this  attenuation  has  gone  on  almost  to  the  point  of  emascu- 
lation. In  other  words,  in  the  reaction  from  the  rash  and  vigorous 
mercurial  dosings  of  other  days  some  observers  have  jumped  too  far, 
and  to-day  give  mercury  with  so  sparing  a  hand,  and  with  so  much 
mystifying  arithmetical  calculation,  founded  on  theory  rather  than  on 
prolonged  observation  of  the  disease  and  its  treatment,  that  they  pro- 
duce a  treatment  which  is  really  a  perversion  of  one  of  the  greatest 
therapeutic  blessings  Avhich  we  possess.  While,  therefore,  mercury  is 
by  all  odds  the  great  and  reliable  remedy  against  syphilis,  its  dose 
must  not  be  too  much  attenuated.  On  the  other  hand,  it  must  not  be 
administered  with  too  lavish  a  hand,  but  carefully,  guardedly,  with 
full  and  repeated  observation  of  the  patient's  general  condition,  and 
with  a  watchful  care  as  to  how  the  lesions  are  affected  by  its  use. 
In  short,  the  treatment  of  syphilis  means  on  the  part  of  tlie  physician 
a  full  knowledge  of  the  disease,  a  consideration  of  the  patient's  strength 
or  weakness,  a  close  familiarity  with  the  lesions  and  with  the  workings 
of  the  syphilitic  virus  in  his  system,  and  an  accurate  knowledge,  based 
upon  frequent  observation  and  interrogation,  of  the  manner  in  which 
the  remedial  agent  affects  his  system  and  the  general  morbid  condition. 
In  other  words,  the  physician  has  not  the  abstract  problem — syphilis — 
to  treat,  but  he  has  a  human  being  infected  with  a  chronic  multiform 
disease  as  the  subject  of  his  study,  and  for  whose  relief  and  cure  he 

^  "  The  Modern  Treatment  of  Syphilis,"  The  Praclilioner,  June,  1891,  p.  403. 


826  SYPHILIS. 

must  familiarize  himself  Avith  his  constitution  and  watch  and  guide  the 
eifect  of  his  therapeutic  agent. 

As  an  adjuvant  to  mercury  in  the  main,  and  rather  exceptionally  as 
the  mainstay  of  syphilitic  medication,  we  also  have  iodide  of  potassium 
and  of  sodium.  These  agents  play  a  very  important  part  in  syphilitic 
therapeutics,  and  fairly  deserve  second  place  to  mercury. 

Then,  also,  w^e  have  as  adjuvants  all  kinds  and  modes  of  hygienic 
and  careful  regimen,  and  we  invoke  to  our  aid  all  the  most  efficient 
tonics  and  haematics.  Let  us  now  consider  some  of  the  principal  methods 
of  treating  syphilis  in  vogue  at  the  present  day. 

Expectant  Method. — The  expectant  treatment  is  the  outcome  of 
the  theoretical  cogitations  of  Diday,  and  is  advocated  mainly  by  him- 
self and  the  younger  Zeissl,  who  inherited  this  therapeutic  heirloom 
from  his  father,  who  was  also  given  to  Diday's  way  of  thinking.  It  is 
an  easy-going,  happy-go-lucky  system  of  therapeutics,  which  is  fraught 
with  uncertainty,  danger,  and  disaster  to  the  unhappy  person  who  is 
subjected  to  it.  As  a  piece  of  sophistry  these  therapeutic  lucubrations  of 
Diday  charm  us  by  their  bright  diction  and  their  brilliant  but  untenable 
assumptions.  The  only  points  Avorthy  of  mention  in  this  treatment  are 
— first,  that  it  carries  with  it  injunctions  to  begin  treatment,  as  a  rule,  at 
the  commencement  of  the  secondary  period ;  and,  second,  that  all  cases 
have  their  own  peculiar  form  of  this  disease,  and  that  they  must  be  watched 
as  to  the  character,  extent,  and  portentousness  of  their  manifestations  from 
early  until  late.  The  latter  injunction  is  to  my  mind  the  only  part  of 
Diday's  writing  upon  this  subject  worthy  of  remembrance.  Diday  claims, 
for  the  reason  that  a  small  percentage  of  cases  seem  to  end  in  the  second- 
ary stage,  that  syphilis  is  a  self-limited  disease,  with  a  constant  tendency 
to  expend  itself,  or,  as  we  may  say,  run  itself  out.  He  divides  syphilis 
mainly  into  two  varieties — the  mild  and  the  severe — for  each  of  which  he 
gives  mercury  only  temporarily  according  to  various  figurative  data.  He 
calls  his  system  also  the  opportunistic  treatment,  and  bases  it  upon  the 
assumption  that  Nature  makes  an  eff"ort  to  rid  herself  of  syphilis.  He 
very  rightly  emphasizes  the  importance  of  careful  hygiene  and  regimen 
during  the  course  of  syphilis.  He  denies  in  toto  any  preventive  action 
of  mercury,  particularly  in  the  secondary  period,  and  claims  that  in  many 
mild  cases  tonics  and  hygiene  will  cure  the  disease.  He  singularly  fails 
to  emphasize  the  fact  we  so  often  notice  that  a  very  mild  early  syphilis 
very  often  leads  to  disaster  and  death.  Succinctly  stated,  Diday's  oppor- 
tunistic treatment  consists  in  giving  mercury  or  iodide  of  potassium  when 
syphilitic  symptoms  show  themselves,  and  Avhen  these  have  disappeared  to 
wait  again  for  another  outburst.  He  is  emphatic  in  his  disbelief  that 
mercury  has  any  preventive  or  curative  action  in  the  intervals  of  repose 
or  latency.  Though  I  think  that  Diday's  doctrine  of  therapeutics  is  false, 
sophistical,  and  dangerous,  it  is  none  the  less  a  part  of  the  history  of 
syphilis ;  therefore  I  give  it  here  for  what  it  is  worth,  as  it  may  appeal 
favorably  to  some  minds.  Not  only  do  his  therapeutic  assertions  hinge 
very  often  on  false  clinical  foundations,  but  his  deductions  are  very  often 
based  upon  pure  hypotheses  and  assumptions.  I  will  quote  liberally  from 
his  most  recent  utterances. 

Diday  ^  accepts  the  microbian  origin  of  syphilis,  chiefly  on  analogical 

^  La  Pratique  des  Maladies  vencriennes,  Paris,  1890,  pp.  380  et  seq. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      827 

grounds,  for  he  concedes  that  the  microbe  has  not  at  all  been  clearly 
demonstrated.  A  microbe  being  of  vegetable  origin,  he  ingeniously 
argues  that  when,  as  a  pathological  factor,  it  is  deposited  in  the  human 
tissues,  it  runs  its  course  according  to  the  law  of  vegetable  life,  in  which 
are  observed  alternating  periods  of  activity  and  of  repose.  He  thus 
continues  :  "  Now,  the  first  attribute  common  to  bodies  of  this  order  (for 
It  is  the  condition  of  their  development)  consists  in  the  two  phases  which 
alternately  succeed  each  other :  the  one  of  repose — latent  life  ;  the  other 
of  activity — manifest  life.  Now,  this  is  the  character  of  syphilis,  which 
from  its  commencement  to  its  end  is  marked  by  a  series  of  sleepings  and 
wakings ;  that  is  to  say,  intermissions,  then  resumptions  of  manifest  life ; 
and  resumptions  to  which  medical  language  has  justly  given  the  name  of 
manifestations.  These  manifestations  in  every  plant  mark  the  period  in 
which  it  borrows  from  the  surrounding  media  the  elements  necessary  to  its 
growth.  It  is  therefore  during  this  state,  and  it  is  only  during  this  state, 
that  there  are  established  admissible  exchanges  between  the  media  and 
the  plant.  Consequently,  the  media  can  act  favorably  or  unfavorably 
upon  the  plant.  The  evolution  of  syphilis  is  strikingly  intermittent. 
Does  not  this  character,  which  is  its  distinctive  sign,  indicate  a  state 
equally  intermittent  in  the  vitality  of  the  vegetable  organism  presumed 
to  be  its  cause  ?  This  demonstrated,  the  law  applies  itself  most  naturally 
to  our  pathogenic  microphytes.  Our  organism  is  the  habitat  of  these 
parasites,  their  feeding-ground,  their  field  of  battle  and  of  strife  against 
the  defensive  forces  of  our  living  tissues."  He  then  goes  on  to  say  that 
if  these  organisms  overwhelm  us,  we  must  try  to  exterminate  them.  "  If 
we  wish  that  our  tissues  (terrain)  shall  cause  their  death,  we  must  prepare 
them  to  that  end  the  moment  they  show  signs  of  life.  Since  we  cannot 
by  means  of  the  soil  (living  tissues)  attack  the  microbe,  we  must  wait 
until  it  begins  to  increase  and  multiply.  It  is  a  benefit  of  nature  that  at 
the  time  when  the  microbe  becomes  pathogenic  it  is  particularly  accessible 
to  our  means  of  attack.  The  principle  of  this  therapeutic  system  con- 
sists in  waiting  in  the  employment  of  specifics  until  the  evidence  of  mani- 
festations, and  after  a  study  of  their  clinical  physiognomy  we  can  first 
seize  the  moment  when  the  pathogenic  agent  awakes  and  is  at  the  mini- 
mum of  its  resistance  ;  and,  second,  settle  in  our  minds  the  nature,  the 
doses,  and  the  duration  of  the  medication  necessary  to  oppose  it." 
Lancereaux  laconically  sums  up  Diday's  system  as  follows  :  "  When  there 
is  a  lesion,  intervention;  in  the  intervals,  expectation." 

It  may  be  remarked  that  it  seems  almost  foolhardy  for  a  man  to  base 
a  system  of  therapeutics  upon  a  simple  hypothesis,  and  yet  this  is  what 
Diday  has  done,  supporting  it  with  far-fetched  analogy  and  a  pure  and 
simple  assumption  of  the  behavior  of  the  various  syphilitic  processes. 
What  evidence  have  we  that  the  cells  of  syphilis  behave  in  the  tissues  of 
man  as  do  the  seeds  of  the  vegetables  in  the  fields?  The  one  process  is 
pathological,  the  other  normal,  the  latter  depending  very  much  for  its 
development  upon  cyclical  changes  of  time  and  season,  the  former  upon 
the  various  unknown  conditions  of  the  disease  and  numerous  complex 
conditions  of  the  human  system. 

If  any  one  wishes  to  get  a  good  idea  of  the  expectant  or  opportunistic 
system  of  treating  syphilis,  let  him  study  the  disease  in  dispensaries, 
clinics,  and  hospitals.     Patients  who  are  treated  in  those  institutions  as  a 


828  SYPHILIS. 

rule  do  not  apply  until  more  or  less  urgent  manifestations  and  symptoms 
begin  to  trouble  them.  In  general,  they  merely  get  patched  up,  for  they 
only  remain  as  long  as  their  immediate  trouble  is  present  and  urgent. 
Then  off  they  go,  to  return  later  on  with  new  and  perhaps  worse  mani- 
festations, no  medicine  having  been  taken  in  the  mean  time.  Then, 
again,  let  any  man  who  sees  in  his  practice  many  cases  of  syphilis  watch 
those  who  follow  treatment  regularly  and  carefully,  and  compare  their 
condition  with  that  of  patients  who  are  careless  and  only  apply  for  relief 
in  times  of  urgency,  and  he  will  find  that  the  laissez-aller  cases  are  the  ones 
which  as  a  rule  do  badly.  However,  let  me  allow  the  younger  Zeissl  ^  to 
speak  for  himself,  and  he  but  voices  the  tenets  of  his  deceased  father.  In 
his  most  recent  paper  he  says  :  "  When  syphilis  is  treated  expectantly — 
that  is,  when  an  antisyphilitic  remedy  is  not  given  to  the  patient  after 
the  first  secondary  symptoms — the  eruption  requires,  on  an  average,  a 
period  of  two  to  eight  months  for  its  disappearance,  while  the  initial 
sclerosis  requires  at  least  four  months,  oftener  five  or  more,  for  its  involu- 
tion. Defluvium  capillorum  and  enlargement  of  the  ganglia  often  re- 
mained noticeable  for  a  year  ;  with  the  return  of  the  growth  of  the  hair 
the  symptoms  successively  disappeared,  Zeissl  (senior)  very  rarely  ob- 
served any  relapses,  especially  of  a  severe  kind,  when  purely  expectant 
treatment  Avas  continued  until  complete  disappearance  of  the  syphilitic 
symptoms.  We  can  confirm  the  observation  from  our  own  experience." 
He  further  states  that  if  patients  in  private  practice  demanded  rapid  relief 
from  disfiguring  cutaneous  affections,  mercury  Avas  given  to  them.  It 
seems  to  me  that  to  pursue  a  system  like  the  one  thus  called  opportunistic, 
which  can  but  expose  the  patient  to  trouble,  danger,  and  disaster,  is 
almost  criminal.  It  has  always  seemed  to  me  that  this  treatment,  based 
on  fantasies  and  assumptions,  is  founded  upon  a  hopeless  view  of  the  pos- 
sibility of  curing  syphilis,  and  upon  a  fear  that  the  active  use  of  mercury 
will  be  productive  of  harm.  I  can  well  understand  why  the  elder  Zeissl 
(as  is  reported)  recklessly  said  that  if  a  man  once  had  syphilis,  his  ghost 
would  be  syphilitic.  His  idea  of  the  treatment  of  syphilis  would  cer- 
tainly warrant  that  belief.  The  expectant  or  opportunistic  system  of 
treatment  is  utterly  unscientific  and  perniciously  dangerous,  and  it  is  well 
for  humanity  that  it  is  growing  into  disfavor,  disrepute,  and  disuse. 

Continuous  or  '■'■Tonic"  Treatment. — The  continuous  or  so-called  tonic 
treatment  of  syphilis  is  in  reality  only  a  modification  of  Fournier's  system 
of  treatment,  amplified  by  considerable  theoretical  elaboration.  It  has 
had  as  its  champion  in  England,  Mr.  Jonathan  Hutchinson,^  who  may 
be  said  to  be  the  pioneer  in  the  doctrine  of  long-continued  mercurializa- 
tion  in  syphilis.  In  this  country  my  friend  Dr.  Keyes"*  has  long  been  a 
believer  in  its  efiicacy,  and  he  is  the  sponsor  for  a  system  of  medication 
which  he  terms  "the  tonic  treatment  of  syphilis."  The  therapeutical 
agent  employed  in  this  scheme  of  treatment  is  the  protoiodide  of  mercury 
(Hutchinson  uses  gray  powder),  which  is  to  be  given  without  cessation 
for  two  or  more  years.      Here  is  the  system  in  the  author's  words :  "  Sup- 

^  "  Die  Gegenwtirtige  Stand  der  Syphilis-therapie,"  Klin.  Zeit  und  Streitfagen,  1887, 
p.  160. 

^  "  When  and  How  to  Use  Mercury  in  Syphilis,"  address  before  the Hunterian  So- 
ciety of  London,  .January  8,  1874. 

^  The  'Tonic  Treatment  of  Syphilis,  New  York,  1877. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      829 

posing  that  the  centigramme  granule  (protoiodide  of  mercury  gr.  ^)  has 
been  selected  as  the  medicine  to  be  used,  the  instructions  to  the  patient 
are  as  follows  :  Take  one  granule  immediately  after  each  meal  (i.  e.  three 
times  a  day)  during  three  days.  On  the  fourth  day  add  one  granule  to 
the  midday  dose,  taking  one  in  the  morning,  two  at  noon,  one  at  night. 
Continue  this  during  three  days.  Again,  on  the  fourth  day  add  one 
granule — two  in  the  morning  and  at  noon,  and  one  at  night.  Continue 
this  for  three  days,  and  again  on  the  fourth  add  a  granule.  Continue  in 
this  manner,  being  very  careful  as  to  food,  drink,  exposure,  etc.,  until 
there  is  very  positive  evidence  of  irritation  in  the  intestine,  such  as 
colicky  pains  with  positive  diarrhoea,  or  until  the  gums  begin  to  show 
signs  of  being  slightly  touched. 

"  The  daily  amount  now  taken  is  known  to  be  the  patient's  dose  of  the 
given  preparation  of  mercury,  beyond  which  he  cannot  go  without  aid 
from  opiates,  and  of  which,  if  long  maintained,  the  eifect  upon  the  general 
health  will  be  certainly  damaging. 

"  The  amount,  whatever  it  may  be,  I  call  the  full  dose  in  contradis- 
tinction to  his  'tonic  dose.' 

"It  is  impossible  to  find  what  the  full  dose  of  a  patient  is  except  by 
experiment.  The  '  full  dose  '  being  ascertained,  it  may  be  continued  by 
the  aid  of  opiates  and  unirritating  food  until  the  eruptions  or  the  syph- 
ilitic symptoms,  whatever  they  may  be,  are  overcome.  As  soon,  then,  as 
the  active  symptoms  have  yielded  the  patient's  dose  is  reduced  one-half, 
and  this  half  dose,  which  will  act  as  a  tonic  (I  call  it  the  '  tonic  dose '),  is 
to  be  continued  unceasingly  day  after  day,  month  after  month,  waiting 
for  new  symptoms.  Should  such  symptoms  appear  (there  may  be  none 
whatever  except  throat  and  mouth  lesions),  the  half  dose  held  in  reserve 
(I  call  it  the  '  reserve  dose ')  may  be  at  once  added  to  the  '  tonic  dose,' 
and  the  '  full  dose '  continued  until  the  symptoms  yield,  after  which  the 
'tonic  dose'  is  to  be  again  resumed." 

I  have  never  been  an  advocate  of  this  scheme  of  treating  syphilis.  It 
has  always  appeared  to  me  that  the  system  is  very  thoroughly  pervaded 
with  theory  and  built  upon  confusing  arithmetical  problems.  It  assumes 
to  gauge  the  therapeutic  power  of  mercury  by  the  state  of  the  gums  and 
of  the  intestines  of  patients  taking  the  drug  for  syphilis.  I  do  not  con- 
sider these  buccal  or  intestinal  criteria  of  such  importance  or  of  such 
reliability  that  they  should  be  the  guiding-points  in  medicinal  treatment. 
In  most  cases  salivation  can  be  prevented  by  scrupulous  care  of  the  mouth, 
and  the  patient  put  in  such  a  condition  that  he  can  stand  large  doses  of 
mercury,  whereas  while  he  had  his  buccal  infirmity  he  suff'ered  from  sore 
mouth  from  very  minute  doses.  So  that,  as  a  broad  general  rule,  it  may 
be  said  that  the  state  of  the  mouth  is  not  an  index  as  to  the  amount  of 
mercury  the  patient  can  take  or  as  to  its  therapeutic  eifect  on  the  disease. 
Moreover,  the  condition  of  the  intestines  is  not  in  any  sense  a  reliable 
guide  in  the  treatment  of  syphilis.  The  mercurial  taken  by  the  stomach 
may  cause  mild  or  severe  gastro-enteritis  and  have  no  effect  upon  the 
syphilis,  and  the  believer  in  this  doctrine  might  then  think  that  he  was 
at  the  end  of  his  tether — that  he  had  gauged  the  patient's  dose  and  found 
it  irritating  and  inefficacious.  Now,  let  that  man  leave  the  patient's 
stomach  alone,  and  administer  to  him  hypodermic  injections  of  mercurials 
or  inunctions  of  mercurial  ointment,  and  he  will  generally  find  that  with 


830  SYPHILIS. 

careful  management  the  symptoms  and  lesions  will  be  made  to  yield  with- 
out untoward  effects,  though  he  may  be  a  little  wavering  in  his  mind  as 
to  the  arithmetical  quantity  of  mercury  he  has  given  that  patient.  In 
this  case  certainly  the  intestines  are  not  good  guides. 

Then,  again,  a  man  who  pins  his  faith  on  one  remedy  and  one  form  of 
pill  in  the  treatment  of  syphilis  is  like  a  man  Avho  attempts  to  run  with 
a  chain  and  ball  attached  to  his  leg.  The  treatment  of  syphilis  is  far  from 
being  a  matter  of  routine  or  a  mere  problem  of,  dose-arithmetic.  To  be 
thorough  and  successful,  as  I  have  said  before,  it  must  be  based  on  broad 
principles,  upon  an  accurate  and  full  knowledge  of  the  disease,  and  upon 
frequent  and  thorough  study  and  observation  of  the  patient.  In  the  course 
of  syphilis  many  conditions,  exigencies,  and  complications  are  apt  to 
arise,  and  the  physician  to  be  successful  in  its  cure  must  be  ready  with  all 
known  modifications  and  expedients  of  treatment.  I  would  ask  what 
latitude  a  surgeon  has  in  the  treatment  of  syphilis  with  only  protoiodide- 
of-mercury  granules,  pellets,  or  pills  at  his  command  ?  In  what  condition 
is  he  to  cope  with  unusual  features,  exigencies,  or  complications  ? 

Furthermore,  the  fatal  shortcoming  of  this  treatment  resides  in  the- 
mercurial  preparation  itself.  Though  much  vaunted  years  ago  in  the 
therapeutics  of  syphilis,  the  protoiodide  of  mercury  has,  after  years  of 
trial  by  many  syphilographers,  been  found  to  have  only  a  certain  scope 
and  very  many  limitations.  It  is  a  very  excellent  preparation  within 
certain  limits,  but  beyond  them  it  is  feeble  or  even  inert.  I  have  used 
this  remedy  for  more  than  twenty  years,  and  to-day,  after  careful  study 
and  observation,  I  am  led  to  place  little  value  upon  its  efficacy  in  the 
treatment  of  syphilis  after  the  lapse  of  the  first  few  months.  In  early 
secondary  syphilis  it  may  be  used  with  decided  benefit,  but  later  on  in  the 
vast  majority  of  cases  it  will  be  found  wanting,  and  can  be  replaced  with 
benefit  by  other  mercurial  compounds  taken  by  the  mouth  or  by  other 
methods  of  administering  mercury. 

Finally,  the  unremitting  use  of  the  drug  has  its  disadvantages,  its  draw- 
backs, and  its  dangers.  We  find  some  patients  who,  having  a  mild  form 
of  syphilis,  keep  on  taking  the  protoiodide  for  long  periods  for  the  reason 
that  it  is  easily  taken.  Some  people  can  take  mercury  for  years,  and 
seemingly  be  unaffected  injuriously.  The  drug  seems  to  stimulate  their 
portal  system,  and  takes  the  place  of  saline  laxatives.  I  very  much  doubt 
whether  the  mercury  in  many  of  these  cases  is  at  all  absorbed  into  the  cir- 
culation. The  continuous  use  of  mercury  by  stomach  ingestion  induces  a. 
condition  of  tolerance,  and  after  a  time  it  ceases  to  be  a  therapeutic  agent, 
or  has  no  effect — certainly  none  that  is  beneficial.  For  many  years  I  have 
seen  patients  who  have  come  of  their  own  accord,  or  have  been  sent  by 
physicians,  who  have  been  treated  continuously  and  without  any  intermis- 
sion whatever  for  two  or  more  years  with  mercury,  and  who  still  have.' 
some  syphilitic  lesion  which  refuses  to  disappear — perhaps  dermal,  osseous,, 
or  articular,  or  even  cerebro-spinal,  ocular,  or  visceral.  These  patients, 
and  very  often  their  physicians,  cannot  understand  why  it  is  that  a  treat- 
ment so  constant  and  seemingly  energetic,  and  in  most  cases  so  conscien- 
tiously administered,  should  be  productive  of  such  unsatisfactory  results. 

The  answer  is  clear  and  simple.  They  have  used  mercury  in  a  Aveak 
and  impotent  manner  in  the  early  days  of  syphilis,  and  have  continued  its 
use  long  after  it  had  ceased  to  have  any  therapeutic  effect— long  after  it 


THE  GENERAL   METHODICAL   TREATMENT  OF  SYPHILIS.      831 

had  lost  its  influence,  when  given  by  stomach  ingestion,  over  the  syphilitic 
diathesis.  Strange  to  say,  some  of  these  patients  had  escaped  without 
serious  injury,  but  in  others  the  chances  of  cure  had  been  materially 
jeopardized  or  rendered  more  remote.  In  very  many  cases  this  incessant 
mercurial  treatment  is  productive  of  very  bad  results.  I  have  seen  most 
distressing  instances  of  neurasthenia  and  a  general  undermining  of  the 
constitution,  which  predisposed  the  patient  to  such  grave  disorders  as 
pneumonia,  phthisis,  erysipelas,  etc.,  which  were  undoubtedly  due  to  the 
debilitating  influences  of  a  long-continued  mercurial  treatment,  which 
greatly  defibrinizes  the  blood  and  weakens  the  tissues.  Dilatation  of  the 
stomach  (Jullien)  and  a  low  grade,  or  even  a  severe  and  ulcerative  form, 
of  enteritis,  have  (Overbeck,  Heilbronn,  and  Mehring)  been  known  to  be 
caused  by  these  continuous  mercurial  courses.  Thus  given,  mercury  does 
not  cure  the  syphilis,  which  may  slumber  or  may  break  forth,  but  it  in- 
duces a  low  grade  of  health,  which  is  fraught  with  trouble,  danger,  and 
disaster  to  the  patient.  I  scarcely  know  of  a  more  difficult  task  than  that 
of  curing  an  old  syphilitic  who  presents  more  or  less  distressing  or  dan- 
gerous lesions  for  which  he  has  undergone  an  attenuated,  low  grade,  and 
prolonged  mercurial  medication,  which  kept  him  on  the  ragged  edge  and 
failed  to  dislodge  his  enemy.  I  have  seen,  during  many  years  of  careful 
observation,  so  much  trouble,  suff"ering,  misery,  and  even  disaster,  result 
from  this  method  of  treatment  that  I  feel  it  my  duty  to  raise  my  voice 
against  it  as  being  unscientific,  irrational,  and  mischievous,  and  a  perver- 
sion of  one  of  the  greatest  therapeutic  blessings  which  we  possess.  It  is 
gratifying  to  note  that  among  advanced  syphilographers  there  are  very 
few  indeed  who  advocate  chronic  continuous  mercurialization.  This  fact 
has  been  well  shown  in  all  of  the  discussions  at  the  recent  great  congresses 
of  Medicine  and  Surgery. 

The  Interrupted  Treatment  of  SypJiilis. — The  method  of  successive 
treatments  or  the  interrupted  treatment  of  syphilis  was  proposed  by 
Fournier  ^  in  1872,  and  was  the  outcome  of  a  reaction  against  the  short 
and  vigorous  six  months'  mercury  and  three  months'  iodide  of  potassium 
treatment  which  had  been  introduced  by  Ricord,  which  with  certain 
minor  modifications  was  followed  by  most  French  surgeons  of  those 
times,  though  some  of  them  were  contented  with  a  three  months'  course. 
Fournier  says :  "I  am  fully  satisfied  of  the  truth  expressed  by  Chomel, 
that  the  duration  of  the  treatment  is  more  important  than  large  doses. 
It  is  a  hundred  times  better  to  treat  a  patient  for  a  long  time  with  suf- 
ficient doses  of  mercury  than  within  a  short  time  to  give  him  large 
doses.  This  point,  however,  is  scarcely  open  to  dispute,  for  it  is  certain 
that  in  order  to  derive  all  the  good  which  mercury  can  give,  and  to 
avail  ourselves  of  its  curative  influence  for  the  future.,  it  is  necessary  to 
administer  it  for  a  longer  time  than  is  generally  laid  down."  Fournier 
recognizes  that  when  given  over  long  periods  mercury  loses  its  efficacy, 
and  says :  "  It  is  the  same  with  mercury  as  with  other  remedies :  its 
continuous  use  induces  a  condition  of  tolerance  which  lessens  and  finally 
destroys  its  therapeutical  effect.  Now,  what  interpretation  more  simple 
or  rational  can  be  given  to  the  fact,  which  every  observer  has  seen 
many   times,  than  that  a  certain  dose  of  mercury,  having  exerted  an 

'  Lemons  diniques  sur  la  Syphilis,  etudiee  plus  particuliermenl  chcz  la  Femme,  Paris,  1881, 
pp.  782  et  seq. 


832  SYPHILIS. 

influence  on  the  disease  for  a  certain  time,  beyond  that  has  lost  its 
influence  because  the  organism  has  become  habituated  to  itf'  He 
therefore  advised,  in  1872,  that  over  a  period  of  two  years  mercury 
should  be  given  for  a  time,  and  that  then  it  should  be  stopped  for  a 
certain  time,  during  which  the  patient  becomes  unaccustomed  to  the 
remedy.  By  so  doing,  he  says,  "I  should  preserve  the  peculiar  inten- 
sity of  action  of  the  mercury  during  the  whole  period  of  treatment." 

He  then  continues  :  ''  The  second  intention  of  this  method  is  to 
confer  upon  patients  the  advantages  of  a  long-continued  treatment,  and 
this  method  is  better  adapted  than  any  other  to  this  essential  indication. 
In  fact,  it  enables  patients  to  be  treated  for  a  long  time  without  Aveary- 
ing  them,  and  to  take  for  as  long  a  period  as  may  be  necessary  a  remedy 
which,  if  continuously  administered,  would  not  be  long  either  in  being 
not  tolerated  or  in  losing  its  curative  action." 

Fournier's  method  of  treatment,  concisely  stated,  is  as  follows :   He 
beo-ins  by  administering  from  three-quarters  to  one  and  a  half  grains  of 
the  protoiodide  daily  in  divided  doses.     In  three  or  four  weeks  the  erup- 
tion will  in  all  probability  have  disappeared.     The  treatment,  however,  is 
prolonged  for  tAvo  months.     (That  is,  the  patient  is  put  under  treatment 
in  the  primary  stage  and  mercury  is  given  for  eight  weeks.)     Fournier 
then  says:    "After  that,  what  shall  I  do?     After  that,  whatever  may 
happen  (bear  this  well  in  mind),  I  Avould  suspend  treatment,  being  very 
certain  from    experience    that    my   patient   will   have    already   become 
accustomed  to  the  mercury,  of  Avhich  continued  doses  would  only  have 
a  relatively   small   effect.     I   would  leave   him   without    treatment  for 
several  weeks ;  to  be  more  definite,  at  least  a  month.     That  time  having 
elapsed  (understand  this  well  also),  I  would  recommence  the  treatment, 
whatever  might  have  happened;   whether  the  patient  has  or  has  not 
had  new  lesions,  he  would  be  none  the  less  syphilitic  nor  less  liable  to 
the  manifestations  which  it  is  my  desire"  to  prevent."     The  reneAved 
treatment  should  last  six  weeks  or  tAvo  months,  and  then  a  respite  of 
three  months  is  granted.     Then  mercury  is  given  again  for  six,  seA^en, 
or  eight  weeks.      Then  a  suspension  of  several  months,  until  at  the  end 
of  tAvo  years  a  patient  has  taken  mercury  for  ten  months,  and  has  at 
intervals  been  Avithout  it  for  fourteen  months.     This  treatment,  intro- 
duced in   1872,  has  been  adopted  by  many,  and  has  been  attacked 
violently    by    a    feAv,  notably    by    Diday,   against    Avhose    therapeutics 
Fournier  directed  much  incisive  logic  and  many  facts.     It  evidently 
has   not   fulfilled   the    expectation   of  its   originator,  for   we    find   that 
within  a  fcAV  years  Fournier^  writes:   "  Syphilis  is  an  infectious  chronic 
constitutional  disease,  diathetic  like  gout  and  scrofula,  and  should  have 
a  lifelong  treatment."      So  in  1889  he  says  that  in  the  third  year  there 
should  be  four  courses  of  six  weeks  each  with  respites  of  equal  length, 
and   that  iodide   of  potassium   should  be   taken.     In   the   fourth   year 
four  similar  courses  of  six  Aveeks"  duration,  and  in  the  fifth  year  three 
courses.     We  also  find  that  Martineau  advocated  a  five  years'  course, 
while  Besnier  says  that  it  should  be  indefinite,  and  Leloir  has  recently 
put  forAvard   a   system   of  treatment  of  four   or   five    years'   duration. 
Indeed,  there  seems  to  be  in  France  a  prevailing  belief  among  many 

1  "Direction  generale  du  Traitement  de  la  Syphilis,"  Gazette  des  Hopilaux,  Nos.  103 
and  107,  1889. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      833 

that  syphilis  is  an  incurable  disease,  such  a  statement  being  the  keynote 
to  a  series  of  clinical  lectures  by  Denis-Dumont,  published  in  1880.^ 

For  many  years  I  was  an  advocate  of  the  plan  proposed  by  Fournier 
for  the  treatment  of  syphilis,  and  I  had  the  pleasure  of  first  presenting 
his  views  in  the  English  tongue.^  But  as  years  went  on  I  found  that 
although  the  general  plan  is  an  excellent  one,  the  treatment  as  a  whole 
is  very  defective.  The  objections  to  it  are  mainly  those  which  I  have 
detailed  in  the  section  on  the  continuous  treatment  by  mercury,  which 
is  really  only  Fournier's  treatment  kept  up  without  cessation,  and  is 
even  more  defective  and  inefficacious  than  the  latter. 

As  a  general  working  plan,  however,  Fournier's  system  has  much 
to  commend  it,  though  I  am  free  to  say  that  I  can  only  condemn  its 
essential  feature — the  protoiodide  of  mercury  as  the  therapeutic  piece 
de  resistance  and  the  general  arrangement  of  treatment  in  the  primary 
and  early  secondary  stages.  For  very  many  years  I  have  studied  this 
question  carefully  and  conscientiously,  having  at  my  command  a  vast 
clinical  field ;  and  in  the  light  of  knowledge  already  gained,  and  of 
what  I  learned  from  my  successes  and  my  failures,  I  have  arrived  at 
conclusions  which  embody,  I  venture  to  think,  a  most  eff"ective  and 
practical  system  of  treating  syphilis — one  which  in  the  great  majority 
of  cases  will  eradicate  or  suppress  the  disease  and  restore  its  victim  to 
health.  In  this  treatment  there  is  nothing  particularly  new  and  start- 
ling, and  in  its  essential  points  I  have  the  support  of  many  of  the 
ablest  Continental  authorities.  My  observation  from  year  to  year  has 
thoroughly  convinced  me  that  the  current  emasculated,  theoretical  sys- 
tems of  treating  syphilis  are  dire  failures,  and  bring  very  many  patients 
to  discomfort,  suffering,  disaster,  invalidism,  and  death.  While  some 
may  get  through  by  reason  of  some  lucky  chance,  I  feel  very  certain 
that  a  man  in  the  long  run  will  have  a  far  better  chance  to  be  cured  of 
his  syphilis  by  the  old-time  vigorous  six-months'  mercury  and  three- 
months'  iodide  treatment  than  he  will  by  the  long-spun-out,  attenuated 
courses  which  have  as  a  watchword  the  phrase  pregnant  with  ignorance 
and  complaisant  indifference,  that  time  and  mercury  will  cure  or  Avear 
out  syphilis. 

The  General  Methodical  Treatment  of  Syphilis. — We  have  already  seen 
that,  for  very  cogent  reasons,  it  is  best  to  wait  until  the  onset  of  the  sec- 
ondary period  before  beginning  a  general  antisyphilitic  treatment.  If  the 
patient  is  under  observation  during  the  course  of  the  chancre,  much  can 
be  done  for  him  in  advance  by  the  surgeon.  At  this  time  he  can  be  pre- 
pared, if  necessary,  for  the  coming  ordeal  by  a  preparatory  tonic  course, 
or,  if  there  are  indications  of  gastro-intestinal  impairment  or  debility, 
measures  to  remedy  them  may  be  instituted.  Then,  again,  in  this  period, 
if  there  are  very  much  swollen  lymphatics  or  ganglia  (and  they  wnll  be 
found  in  association  with  the  chancre),  a  Avell-directed  external  regional 
treatment  may  be  followed.  To  this  end  mercurial  plasters,  such  as 
emplastrum  de  Vigo,  or  Unna's  and  Quinquaud's  plasters,  or  simple  mer- 
curial ointment,  may  be  used.  This  regional  treatment  will  have  no  per- 
ceptible effect  upon  the  general  deepening  of  the  infection.     At  this  time 

'  De  la  Syphilis:  unite  d'orir/ine ;  incurabilile ;  trailement,  Paris,  1880. 
^  "On  the  Treatment  of  Syphilis,"  by  Alfred   Fournier,  M.  D.,  translated  by  E.  W. 
Taylor,  M.  D.,  New  York  Med.  Journal,  Aug.  and  Sejt.,  1872. 
53 


834  SYPHILIS. 

also  the  condition  of  the  mouth,  gums,  teeth,  and  pharynx  should  be 
inquired  into,  and  these  parts  should  be  put  as  nearly  as  possible  into  a 
■condition  of  health. 

Before  putting  a  patient  upon  general  antisyphilitic  treatment  it  is  well 
for  the  physician  to  place  before  him  certain  facts  as  to  his  condition  and 
liis  duties,  and  to  forecast  for  him,  as  far  as  possible  or  prudent,  his  future 
pathological  balance-sheet,  so  that  he  may  know  clearly  what  he  has  to  do, 
what  he  has  to  fear,  and  what  he  may  expect.  With  the  onset  of  second- 
ary syphilis  a  most  important  and  eventful  epoch  in  the  life  of  the  patient 
begins,  and  much  can  be  done  for  him  by  a  little  kindliness  and  common 
sense.  The  physician  must  impress  upon  the  patient  the  fact  of  the  gravity 
of  his  disease  and  prepare  him  for  the  ordeal  which  is  in  store  for  him. 
He  must  be  made  to  understand,  in  a  gentle,  kindly  manner,  that  the 
ensuing  two  years  at  least  are  the  most  critically  momentous  ones  in  his 
whole  life,  and  that  his  future  health  and  happiness,  and  those  of  his 
family,  depend  upon  his  care  of  himself  during  this  trying  epoch.  It  is 
cruel  and  unnecessary  to  paint  a  dismal  and  lugubrious  picture  to  these 
patients,  or  by  word  or  manner  to  depress  or  discourage  them.  We  are  in 
the  position,  thanks  to  our  advanced  therapeutics,  to  speak  encouragingly 
and  even  brightly  of  their  future,  and  to  hold  out  to  them  the  assurance 
that  the  ordeal  of  treatment  will  not  be  irksome  or  painful,  and  that  a 
future  cure  is  in  store  for  them.  We  can  tell  our  patients  truthfully  that 
two  or  two  and  a  half  years  of  careful,  methodical,  watchful  treatment  are, 
if  they  will  conform  to  its  regulations,  sufficient  to  cure  them  of  their 
disease.  As  a  result  of  the  treatment  they  will  see  the  syphilitic  lesions 
cease  and  fail  to  return,  they  will  enter  into  a  period  of  health  in  which 
there  are  no  signs  whatever  of  syphilis  about  them,  and  they  will  thus 
remain  and  will  possess  the  power  of  procreating,  healthy  children.  The 
requirements  for  this  gratifying  state  and  for  this  future  immunity  are  a 
fairly  good  state  of  health  previous  to  infection,  the  docility  and  loyalty 
of  the  patient  to  his  physician,  and  a  treatment  begun  sufficiently  early 
and  carried  out  in  a  watchful,  thorough  manner.  This  is  the  tripod  upon 
which  his  future  happiness  rests.  In  the  treatment  of  syphilis  the  duties 
of  the  physician  and  patient  are  reciprocal.  While,  therefore,  in  the 
majority  of  cases,  particularly  those  of  the  intelligent  and  well-to-do 
classes,  we  are  warranted  in  giving  a  hopeful  and  satisfactory  prognosis, 
there  are  cases  in  which,  under  the  best  of  circumstances,  the  progress 
toward  cure  is  slow,  often  disappointing  and  halting,  and  attended  with 
much  suffering,  discomfort,  debility,  and  illness.  But  even  in  these  cases, 
trying  and  often  discouraging  alike  to  the  patient  and  the  physician,  there 
is  usually  no  necessity  for  doubt  or  despair,  since  with  the  rich  therapeutic 
armamentarium  at  our  command  we  are  enabled  to  adapt  ourselves  to 
urgent  necessities,  exigencies,  and  emergencies,  and  even  to  cope  with 
formidable  crises.  In  his  early  interviews  with  a  sj^philitic  patient  it  is 
the  duty  of  the  physician  to  make  a  careful  study  of  the  man,  to  acquaint 
himself  with  his  temperament,  his  standard  of  health  and  vitality,  his 
greater  or  less  power  of  resistance  to  disease  and  bodily  strain — in  fact, 
his  mental  and  physical  stamina,  modes  of  life,  tendencies,  habits,  sur- 
roundings, and  his  duties,  obligations,  cares,  and  responsibilities — since 
from  such  a  study  much  valuable  knowledge  is  gained. 

It  must  always  be  remembered  that  weakly,  cachectic  persons  of  poor 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      835 

fibre;  flabby  subjects;  those  who  may  be  classed  generally  as  under- 
weight individuals ;  persons  of  very  light  and  sandy  complexion ;  those 
suffering  from  rheumatic,  gouty,  tuberculous,  neurotic,  malarious,  or  other 
adynamic  conditions  or  influences ;  those  having  visceral  disease  of  any 
kind  or  any  inherited  or  acquired  morbid  tendency  ;  and  particularly  per- 
sons addicted  to  alcoholic  indulgences, — are  liable  to  suffer  more  or  less 
severely  from  syphilis,  and  that  in  such  cases  the  prognosis  is  less  favor- 
able and  a  longer  time  for  cure  may  be  required. 

Besides  its  lesions  proper,  syphilis  tends  in  many  cases  to  produce 
in  the  economy  anaemia,  cachexia,  and  even  a  condition  of  marasmus. 
Though  there  are  some  patients  in  whom  it  does  not  produce  debility,  and 
Avho,  despite  their  disease,  seem  as  well  as  they  ever  were,  we  must  always 
be  on  the  lookout  for  its  depressing  effects  upon  the  system.  Therefore  the 
first  rule  to  be  laid  down  in  the  treatment  of  syphilis  is  that  the  hygiene, 
regimen,  and  surroundings  of  the  patient  shall  be  made  as  nearly  as  pos- 
sible perfect.  The  diet  must  be  simple,  ample,  and  nourishing,  and  the 
patient's  habits  as  to  eating,  drinking,  and  sleeping  should  be  regular  and 
systematic.  All  health-giving  sources  of  recreation  and  exercise  should 
be  made  use  of,  and  every  attention  should  be  given  to  maintaining  the 
health  and  vitality  of  the  patient  at  as  high  a  plane  as  possible.  There- 
fore patients  must  be  warned  against  overtaxing  themselves  physically  or 
mentally,  or  in  any  way  putting  themselves  on  a  strain.  The  physician 
should  always  be  watchful,  particularly  in  the  treatment  of  patients  of  the 
higher  classes,  about  the  mental  wear  and  tear  that  so  many  are  liable  to. 
In  such  cases  syphilis  is  very  prone  to  produce  cerebral  and  mental 
disturbances. 

While  in  general  abstinence  from  alcoholic  drinks  is  to  be  recom- 
mended for  syphilitic  patients,  it  is  always  well  to  exercise  wholesome 
common  sense  in  dealing  with  this  question.  Many  authors  go  to  an 
extreme  in  considering  that  syphilitics  should  become  prohibitionists. 
The  ordeal  of  the  syphilitic  is  not,  as  a  rule,  a  very  happy  one,  and  the 
less  Ave  surround  him  with  irritating  restrictions  the  more  docile  will  he 
be  in  the  long  run  in  following  treatment.  Therefore  I  think  that  a  man 
who  by  habit  partakes  moderately  of  claret  or  burgundy  or  other  mild 
stimulant  at  his  chief  meal,  and  who  enjoys  it  and  is  seemingly  none  the 
worse  for  it,  should  not  generally  be  deprived  of  it.  Then,  again,  there 
are  patients  Avho  partake  in  moderation  of  ale  and  beer,  and  who  are  to 
their  thinking  benefited  thereby.  Provided  these  stimulants  do  not  dis- 
order the  stomach,  they  can  hardly  be  called  deleterious ;  therefore  their 
use  should  not  be  abruptly  interdicted.  On  the  other  hand,  indulgence 
in  strong  alcoholic  drinks  and  champagnes  must  be  peremptorily  stopped. 
Nothing  is  more  galling  to  patients,  according  to  my  experience,  than  a 
treadmill  treatment  which  surrounds  them  with  all  sorts  of  restrictions 
and  imposes  upon  them  blue-law  abstinence.  The  plan  which  works  best 
in  the  long  run  in  handling  syphilitics  is  that  which,  compatible  with  their 
Avell-being,  gives  them  most  latitude  and  revolutionizes  their  habits  and 
modes  of  life  as  little  as  possible.  To  sura  up,  alcohol  should  only  be 
used  by  syphilitic  patients  in  great  moderation  and  under  conditions  which 
tend  to  improve  their  strength  and  digestion. 

It  is  almost  unnecessary  to  say  that  excessive  sexual  indulgences  are 
depressing  and  exhausting  and  that  they  are  to  be  wholly  avoided.    Vei'j 


836  SYPHILIS. 

many  cases  of  cerebral  and  nervous  syphilis  have  their  origin  in  sexual 
excess,  and  many  men  have  become  infirm  or  have  perished  from  such 
over-indulgence  while  in  the  power  of  syphilis.  As  to  tobacco,  we  can 
hardly  speak  with  the  same  latitude  and  tolerance  as  we  can  of  alcoholics 
in  syphilis.  Smoking  and  chewing,  even  in  mild  indulgence,  are  so  prone 
to  induce  irritation  and  inflammation  of  the  mouth  and  throat,  parts  which 
it  is  so  vitally  necessary  to  keep  in  a  high  state  of  health,  that  we  are 
forced,  as  a  rule,  absolutely  to  prohibit  them.  It  requires,  very  often, 
considerable  moral  courage  to  deny  the  touching  appeal  of  a  patient  to  be 
allowed  one  or  two  cigars  a  day,  but  we  must  in  general  stand  firm.  Still, 
there  are  cases,  happily  for  them,  in  which,  despite  syphilis  and  its  treat- 
ment, irritation  of  the  mouth  and  throat  does  not  exist,  and  such  patients 
may  perhaps,  under  observation,  indulge  in  their  favorite  habit.  Wherever 
the  use  of  tobacco  produces  even  mild  hypersemia  of  the  mouth  and  throat 
it  should  be  firmly  forbidden. 

All  functional  derangements  or  affections  of  internal  organs,  stomach,  in- 
testines, liver,  spleen,  kidneys,  etc.,  should  be  carefully  attended  to.  Patients 
prone  to  pulmonary  affections,  and  those  having  a  tendency  to  rheumatism 
and  gout,  should  be  w^arned  in  advance  to  observe  very  great  care  in  the 
avoidance  of  the  causes  which  are  liable  to  light  up  or  develop  these  dor- 
mant tendencies.  In  like  manner,  neuropathic  subjects,  and  those  suff'er- 
ing  from  any  hereditary  or  acquired  cerebral  or  nervous  trouble,  should 
be  carefully  but  impressively  made  to  understand  that  the  nervous  system 
is  their  weak  part,  and  that  while  they  are  in  the  grip  of  syphilis  they 
must  be  more  than  ordinarily  careful  not  to  overtax  it  or  to  abuse  it. 

It  is  very  important  that  the  changes  of  the  season  and  weather  should 
be  accompanied  with  appropriate  clothing,  and  that  the  utmost  precaution 
should  be  taken  against  catching  cold. 

While  the  physician  should  thus  impress  his  patient  with  the  gravity 
of  his  condition,  he  should  also  constantly  hold  out  to  him  that  most  con- 
soling hope,  that  he  will,  in  all  probability,  in  the  end  be  free  from  his 
disease.  While  some  patients  are  calm  and  sensible,  and  others  light- 
hearted  and  indiff"erent  to  their  physical  condition,  others,  again — happily 
not  many — show  a  tendency  to  worry,  fret,  and  solicitude,  or  even  to  a 
depression  of  spirits  and  melancholy  which  is  termed  syphilophobia — a 
most  distressing  state  of  mind  both  for  the  patient  and  his  physician. 
Such  cases  should  be  treated  with  constant  encouragement  and  kindness 
mingled  with  firmness  ;  their  doubts  should  be  dispelled,  their  fears  should 
be  allayed,  and  bright  hopes  should  be  held  out  to  them.  By  such  a 
course  many  a  rough  spot  will  be  made  smooth,  and  many  a  man  will  be 
auspiciously  brought  through  his  syphilis  who  otherwise  would  have  faltered 
or  have  fallen  by  the  wayside. 

With  the  onset  of  the  generalized  manifestations  of  syphilis  at  the 
beginning  of  the  secondary  period  the  regular  methodical  treatment  should 
be  commenced.  At  this  time  and  at  short  intervals  thereafter  the  patient 
must  be  carefully  examined  as  to  the  condition  of  his  skin  and  its  append- 
ages, of  his  mouth  and  throat,  and  lymphatic  system  generally.  Taking 
for  an  example  a  case  of  roseola  with  its  usual  concomitants  of  slight 
fever,  malaise,  and  perhaps  nocturnal  headaches  or  rheumatoid  pains,  Ave 
should  immediately  put  the  patient,  as  a  general  rule,  upon  treatment  by 
the  mouth.     Later  on  the  inunction  method  may  be  employed,  but  as  a 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     837 

rule  pills  are  quite  effective,  particularly  in  the  very  early  secondary  stage. 
While  intelligent  patients  will  usually  submit  gracefully  to  inunction  treat- 
ment later  on,  its  adoption  at  the  very  outset  is  apt  to  be  irksome,  and  to 
give  them  the  idea  that  they  have  a  very  trying  and  unpleasant  ordeal 
before  them.  Though  many  preparations  of  mercury  are  employed,  my 
preference  is  for  the  protoiodide  and  the  tannate  when  the  drug  is  given 
in  pill-form.  Calomel  and  blue  pill  are  usually  not  satisfactory  agents. 
Calomel  is  very  apt  to  salivate  promptly,  and  its  action  is  far  from 
certain  ;  and  as  to  blue  pill,  it  may  be  said  that  when  given  in  small 
doses  it  does  nothing  for  syphilis,  though  it  may  act  upon  the  liver, 
and  when  it  is  given  in  sufficient  quantity  one  never  knows  how  soon 
severe  salivation  may  be  induced.  Bichloride  of  mercury  is  given  by 
some  physicians  in  pill-form,  and  is  the  active  ingredient  in  the  Dupuy- 
tren  pills  so  much  used  in  France,  but  it  is  very  apt  to  produce  pain  in 
the  chest  and  bowels  and  gastro-intestinal  irritation.  Then,  again,  its 
action  cannot  be  relied  upon,  for  in  small  doses  by  the  stomach  it  does 
little  if  any  good,  and  in  large  doses  it  is  very  irritating.  Its  action 
when  used  hypodermically  is,  however,  very  efficient  and  satisfactory,  and 
its  local  action  in  lotions  and  ointments  is  very  prompt  and  beneficial. 
Within  recent  years  the  carbolate,  salicylate,  thymolate,  alanilate,  and 
other  preparations  of  mercury  have  been  vaunted  as  possessing  marked 
potentiality,  but  when  put  to  the  test  they  give  evidence  of  possessing  no 
advantage  over  the  drugs  I  have  named.  In  the  section  of  this  chapter 
upon  hypodermic  injections  all  the  new  compounds  are  treated  of. 

Since  every  case  of  syphilis  is  a  law  unto  itself  as  to  the  amount  of 
mercury  which  will  be  required  for  its  cure,  we  can  only  state  the  doses 
approximately.  For  an  adult,  male  or  female,  a  quarter  or  a  third  of  a 
grain  of  the  protoiodide  of  mercury  may  be  given  at  a  dose,  of  which 
three  a  day  will  be  sufficient.  Very  large  and  robust  persons  may  re- 
quire one  half  of  a  grain  at  a  dose.  These  are  always  good  doses  to 
begin  with,  and  by  them  the  tolerance  of  the  drug  may  be  gauged  and 
its  remedial  action  estimated.  I  have  elsewhere  in  this  chapter  called 
attention  to  the  very  minute  doses  of  the  drug  given  by  some  physi- 
cians, but  it  is  appropriate  to  repeat  here  that  the  one-fifths  and  one- 
sixths  of  a  grain  of  the  mercurial  preparation  recommended  by  some  are 
utterly  useless  for  the  cure  of  syphilis. 

In  the  early  secondary  stage  there  are  certain  conditions  favorable  to 
an  active  treatment — namely,  a  system  virgin  to  mercurial  action  and  a 
greater  susceptibility  of  the  lesions  to  the  action  of  mercury.  This, 
then,  is  the  most  favorable  time  for  efficient  treatment,  and  it  is  the 
most  critical  one  in  the  life  of  the  syphilitic,  for  if  the  disease  is 
actively  attacked  then,  its  backbone  may  be  broken.  It  is  very  prob- 
able that  much  of  the  late  rebelliousness  and  malignity  of  syphilis  is 
due  to  the  fact  that  the  newly-formed  infecting  granulation-cells  and 
the  concomitant  subacute  inflammation  induce  in  organs  and  tissues, 
particularly  delicate  ones,  structural  and  nutritive  changes  which  pre- 
dispose them  to  subsequent  low  grades  of  inflammation  and  cell- 
increase  ;  besides,  to  a  repetition  of  the  essential  syphilitic  process. 
Therefore  every  effort  should  be  made  to  destroy  these  young  infectious 
cells,  and  to  remove  them  as  (piickly  as  possible  from  the  parenchyma 
of  organs  and  tissues,  before  thcv  shall  have  had  time  to  induce  these 


838  SYPHILIS. 

subtle  and  dangerous  structural  changes.  In  proportion  as  a  systematic 
and  vigorous  mercurial  course  is  entered  upon  late,  so  it  is  more  and 
more  heavily  weighted  in  its  action.  There  is  no  doubt  whatever  in  my 
mind  that  a  mercurial  treatment  covering  the  first  six  months  of  the 
disease  is  far  more  salutary  and  effective  than  a  course  extending  over  a 
year  and  more,  instituted  later  on. 

It  is  important,  therefore,  that  the  initial  course  should  be  active 
and  prolonged,  and  in  attaining  this  end  the  case  must  be  carefully 
handled  and  watched.  As  a  rule,  the  physician  can  form  a  correct 
estimate  as  to  the  probable  effect  of  mercury  upon  his  patient  within  a 
week  or  ten  days.  Having  put  the  stomach  and  intestinal  canal  in 
normal  condition,  and  the  mouth  and  throat  having  received  proper 
attention  (see  section  on  Stomach  Ingestion),  the  dose  of  the  mercurial 
may  be  increased  within  a  few  days  to  one  grain  or  one  grain  and  a 
half,  and  even  to  a  larger  quantity.  It  is  rarely  necessary  to  give  more 
than  three  grains  of  the  protoiodide  in  a  day,  and  most  cases  will  do 
well  with  about  two  grains,  or  even  less.  The  tannate  of  niercury  is 
a  very  active  drug,  which  from  a  large  experience  I  have  come  to  place 
much  confidence  in.  It  is  not  as  mild  as  it  has  been  claimed  to  be,  and 
cannot  (as  has  been  implied)  be  used  with  impunity.  In  some  cases  it 
causes  gastro-intestinal  irritation,  and  in  my  early  days  of  its  trial  I 
saw  several  cases  of  prompt  and  severe  salivation.  Its  initial  dose  is 
best  fixed  at  one  half  a  grain,  instead  of  a  grain,  as  recommended  by 
some.  Brousse  and  Gay  ^  have  recently  introduced  the  gallate  of  mer- 
cury into  the  therapeutics  of  syphilis.  They  consider  this  salt  more 
stable  and  of  more  definite  composition  than  the  tannate  of  mercury. 
The  gallate  is  said  to  be  a  very  active  agent,  causing  secondary  lesions 
to  rapidly  disappear.  It  does  not  disagree  with  the  stomach  and  boAvels 
or  cause  stomatitis.  It  is  rapidly  absorbed.  The  gallate  of  mercury  is 
of  a  greenish-black  color  and  contains  nearly  38  per  cent,  of  the  metal- 
lic base.  It  is  given  in  pill  form  combined  with  quinine.  The  dose  is 
10  to  20  centigrammes  daily. 

In  combination  with  the  mercurial  preparation  Ave  may  employ  a 
ferruginous  or  bitter  tonic,  and  as  an  adjuvant  we  may  add  a  sedative 
agent  to  calm  the  intestinal  canal.  I  think  a  note  of  warning  should 
be  raised  against  the  combination  of  preparations  of  opium  in  antisyph- 
ilitic  remedies.  There  is  really  no  need  for  them,  and  much  harm  may 
be  done  by  their  continued  use  in  producing  an  habituation  to  the  drug, 
with  all  its  deleterious  effects  upon  the  nervous  system,  the  digestive 
organs,  and  the  tissues  generally.  We  can  never  determine  the  exact 
condition  of  a  patient  under  mercurial  treatment  who  is  also  under  the 
influence  of  opium.  As  a  general  rule,  in  stomach  ingestion  mercury, 
if  carefully  given,  causes  little  trouble.  It  niay  produce  diarrhoea  and 
colicky  pains  for  a  day  or  two,  which  a  little  essence  of  ginger  or  pep- 
permint will  relieve,  or  it  may  be  necessary  to  omit  one  or  two  or  more 
doses.  In  general,  if  patients  are  careful  about  their  food  and  do  not 
take  too  much  fluid  into  their  stomachs,  the  mercurial  will  after  the  first 
disturbance  cause  no  irritation. 

The  following  formulse  may  be  used : 

'  "Sur  le  Gallate  de  Merciire,  nouvelle  preparation  antisyphililique,"  Journal  des 
Malad.  Qutan.  el  Syphilit.,  Aug.,  1893,  pp.  471  et  seq. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     839l 

^i.   Hydrargjri  protoiodidi,  gr.  viij  to  x; 

Ferri  et  quinin.  citrat.,  siss  ; 

Ext.  hyoscyami,  gr.  vj. — M. 
Ft.  pil.  XXX. 

I^.   Hydrargyri  tannici,  gr.  xv  to  xxx  ; 

Quinin.  sulph.,  3j  ; 

Ext.  hyoscyami,  gr.  vj. — M. 
Ft.  pil.  xxx. 

The  protoiodide  may  also  be  used  in  the  form  of  tablets,  and  the 
tannate  is  put  up  in  gelatin-coated  pills.  As  I  have  said  elsewhere,  the 
protoiodide  of  mercury  is  a  rather  feeble  preparation,  and  its  use  is 
most  effective  in  the  early  months  of  syphilis,  though  in  later  periods 
it  may  be  employed  if  we  desire  a  mild  mercurial  action.  When  we 
administer  it  in  the  initial  course  of  treatment  we  must  watch  its  effects 
very  carefully,  otherwise  we  may  waste  most  valuable  time.  I  am 
firmly  convinced,  from  ample  experience  and  conversations  with  physi- 
cians, that  since  the  adoption  of  the  long  mercurial  courses  with  minute 
doses  an  easy-going,  happy-go-lucky  feeling  has  taken  hold  of  many 
of  them  in  the  treatment  of  syphilis.  They  are  told,  in  some  of  the 
books  and  at  some  colleges,  that  with  doses  of  fifths  and  sixths  of  a 
grain  of  the  mercurial  salt  syphilis  may  be  cured  in  two  or  three  years, 
and  this,  practically,  is  the  extent  of  their  therapeutic  armamentarium. 
This  teaching,  I  know,  has  engendered  a  feeling  of  false  confidence  and 
security  and  a  tendency  to  superficial  and  dangerous  routine.  The 
physician  complacently  satisfies  himself  that  his  arithmetical  dose  is  all 
right,  and  he  contents  himself  with  the  thought  that  time  and  mercury 
will  wear  out  syphilis,  and  that  all  will  be  well  in  the  end.  Under 
these  conditions  the  patient  is  largely  lost  sight  of,  and  the  abstract 
problem — syphilis — is  uppermost  in  the  physician's  mind.  The  cure, 
of  syphilis  can  be  accomplished  only  by  constant  care  and  watchfulness 
on  the  part  of  the  physician,  who  should  feel  his  way,  should  push  his 
remed}^  cautiously,  and  keep  it  so  well  in  hand  that  he  will  get  all  of 
its  good  effects  and  avoid  all  drawbacks  and  harm  which  may  arise  if 
they  are  not  looked  out  for. 

The  criteria  which  indicate  that  our  treatment  is  correct  and  efiicient 
should  be  carefully  studied.  If  the  patient  looks  and  feels  well,  sleeps 
soundly,  eats  heartily,  holds  his  accustomed  weight,  and  is  mentally  and 
physically  in  a  satisfactory  condition,  there  is  strong  evidence  that  he  is 
being  benefited.  But  we  must  further  assure  ourselves  that  the  lesions 
are  being  acted  upon.  The  indurated  nodule  must  have  wholly  disap- 
peared, the  lymphatic  engorgement  must  show  evident  signs  of  involution, 
and  the  rash  must  have  faded.  The  throat  and  mouth  must  be  inspected 
very  often,  and  any  red  patches  or  ulcerative  lesions  must  be  actively 
treated.  It  is  always  a  good  rule  as  the  rash  is  declining  to  discontinue 
the  pills  and  to  give  the  patient  one  or  two  courses  of  mercurial  inunctions 
(see  section  on  Inunctions),  by  which  the  whole  surface  of  the  body  will 
be  acted  upon  by  mercury.  In  this  way  any  infectious  cells  which  may 
be  left  over  from  a  local  or  general  rash  may  be  acted  upon  and  destroyed. 
Even  while  the  patient  is  taking  pills  mercurial  ointment  may  be  used 


840  SYPHILIS. 

locally  upon  the  lymphatic  ganglia,  due  care  being  taken  that  an  over- 
dose be  not  given.  In  like  manner  papular  and  pustular  lesions  in  hairy 
parts  should  be  treated  locally.  The  physician  should  always  remember 
that  all  syphilitic  lesions,  even  the  most  minute,  are  to  be  feared  as  pos- 
sible sources  of  continuous  or  intermittent  reinfection  of  the  system. 
The  morbid  cells  contained  in  these  lesions  are  capable  of  great,  even 
infinite,  multiplication,  and  the  so-called  syphilitic  relapses  are  due  to  the 
recurrence  of  these  cell-proliferations,  which  develop  from  morbid  foci  left 
over  at  an  earlier  date.  Painful  spots  and  swellings  upon  bones  or  near 
or  at  joints,  thickening  of  the  fasciae  and  subcutaneous  connective  tissues, 
should  receive  regional  treatment.  In  like  manner,  in  cases  of  headaches, 
neuralgias,  rheumatoid  pains  of  muscles,  eye  and  ear  affections,  affections 
of  the  hairs  and  nails,  the  mercurial  action  should  be  brought  as  near  as 
possible  to  the  morbid  area.  It  is  also  advisable  to  watch  for  and  act 
promptly  upon  red  scaling  patches  and  papules  seated  upon  the  palms 
and  the  soles,  since  they  are  very  persistent.  Any  swellings  and  hyper- 
plasise  about  the  mouth  or  face,  vulva,  anus,  and  scrotum  should  receive 
careful  local  treatment.  As  time  passes,  in  some  cases  it  will  be  seen 
that  even  with  full  doses  internal  mercurial  medication  is  feeble  and  more 
or  less  ineffective.  If  the  case  is  carefully  watched,  this  will  be  promptly 
discovered,  and  the  patient  may  be  put  upon  inunctions,  fumigations,  or 
hypodermic  injections.  It  is  a  good  rule  never  to  be  content  with  the 
action  of  mercurial  pills  unless  we  see  a  decidedly  rapid  subsidence  of  the 
lymphatic  ganglia.  It  must  not  be  forgotten  that  the  action  of  the  pro- 
toiodide,  the  tannate,  and  other  mercurial  preparations  grows  less  pro- 
nounced as  time  goes  on  and  the  infecting  cells  become  more  stable  and 
hardy.  This  fact  being  evident,  it  is  necessary  to  substitute  another 
method  of  administering  mercury. 

Our  aim  should  be  to  keep  up  a  continuous  mercurial  action  during 
from  four  to  six  months  after  the  onset  of  the  secondary  stage.  In  gen- 
eral, this  can  be  done  without  experiencing  any  serious  drawbacks  if  the 
case  be  properly  watched.  There  may  be  periods  of  a  few  days  in  which 
it  is  necessary  to  suspend  medicine  and  either  leave  the  stomach  at  rest  or 
give  tonics.  But,  as  a  rule,  this  early  period  offers  us  our  golden  oppor- 
tunity, and  we  should  ahvays  avail  ourselves  of  the  then  existing  favorable 
condition  of  the  stomach  and  the  system  to  assimilate  mercury.  In 
somewhat  rare  cases  mercury  taken  by  the  stomach  acts  as  a  general  de- 
pressant and  the  patient's  nutrition  is  impaired.  I  have  many  times  seen 
these  grave  drawbacks  and  seeming  contraindications  promptly  dispelled 
by  the  employment  of  hypodermic  injections  of  the  bichloride  of  mer- 
cury. In  such  cases  it  is  well  to  begin  with  a  moderate  dose,  and  then 
"work  upward  as  fast  as  we  can. 

During  this  initial  active  and  energetic  course  w^e  must  take  especial 
care  of  the  patient's  nutrition  and  be  watchful  of  his  well-being.  If 
possible,  change  of  air  and  scene  at  the  seaside  or  the  mountains  should 
be  enjoyed,  and  as  much  recreation  indulged  in  as  possible.  The  lighter 
the  patient's  cares  and  the  less  burdensome  his  condition  of  life,  the 
more  auspicious  will  his  progress  be  toward  cure. 

While  a  patient  is  undergoing  this  mercurial  course  he  should  have 
one  or  two  warm  baths  each  week  on  going  to  bed,  in  order  to  produce 
diaphoresis.     AVhen  practicable  he  should  take  Turkish  baths,  without 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      841 

the  cold  plunge,  and  after  them  should  be  made  to  sweat  freely.  At  the 
seaside  cold  salt-water  baths  are  very  beneficial,  and  an  occasional  hot 
sea-water  bath,  followed  by  packing  and  a  sweat,  is  a  valuable  adjuvant 
to  mercurial  treatment. 

In  cases,  particularly  uncomplicated  ones,  well  treated  from  the  be- 
ginning there  are  usually  no  perceptible  secondary  or  tertiary  stages. 
The  secondary  stage  is  entered  upon,  the  disease  is  systematically  attacked, 
and,  excepting,  perhaps,  a  few  ephemeral  and  trifling  manifestations  upon 
the  skin  or  mucous  membrane  (and  they  are  largely  produced  by  extra- 
neous irritation,  friction,  coaptation  of  parts,  want  of  cleanliness,  smoking, 
etc.),  he  or  she  sees  no  further  development.  Still,  some  cases  are  re- 
bellious, and  tax  our  resources  and  patience,  and  some — happily  few — go 
badly  from  the  start. 

Early  in  the  secondary  period  in  some  cases  it  is  necessary  to  resort  to 
the  use  of  iodide  of  potassium,  sometimes  alone  and  again  in  combina- 
tion with  mercury.  As  a  rule,  these  cases  are  anomalous  ones,  in  which 
certain  lesions  show  a  tendency  to  early  and  precocious  development. 
The  early  onset  of  cerebral  symptoms,  some  forms  of  headache,  dementia, 
mania,  epilepsy,  hemiplegia,  paraplegia,  and  aphasia  call  for  the  vigorous 
use  of  the  iodide  in  combination  with  inunction-treatment,  which  should 
be  used  upon  the  neck  and  upper  part  of  the  body.  The  early  super- 
vention of  osseous  and  articular  lesions,  the  occurrence  of  epididymitis  or 
orchitis,  precocious  aflfections  of  the  ear  and  eye,  and  swelling  of  the 
spleen  and  liver  should  all  be  combated  with  a  combined  iodide  and 
mercurial  treatment.  In  like  manner,  the  precocious  development  of 
cutaneous  gummata  and  gummatous  infiltration  into  mucous  membranes 
(particularly  of  the  mouth  and  pharynx)  indicate  the  necessity  of  local 
mercurialization  when  practicable  and  the  internal  use  of  the  iodide  of 
potassium.  With  these  exceptions  the  use  of  the  iodide  is  absolutely  to 
be  condemned  in  early  and  secondary  syphilis,  for  reasons  given  else- 
where. In  some  cases  of  rheumatoid  pains  and  early  rheumatism  it  may 
be  necessary  to  use  the  iodide  quite  early. 

It  may  be  stated  as  a  broad  general  rule  that  when  cases  come  under 
treatment  after  the  disease  has  existed  for  several  months,  they  should  be 
placed  at  once  upon  the  inunction  method.  This  course  is  particularly 
to  be  followed  when  the  patient  presents  a  more  or  less  general  eruption. 
In  these  cases  we  very  often  cannot  bring  sufiicient  mercury  to  act  upon 
the  surface  of  the  skin  through  the  medium  of  the  blood-circulation,  and 
it  is  a  waste  of  time  and  effort  to  make  the  patient  swallow  pills.  In  all 
cases  in  which  treatment  is  begun  rather  late  the  physician  should  be 
particularly  careful  to  try,  as  far  as  possible,  to  exert  a  prompt  and  effi- 
cient influence  upon  the  disease,  and  to  keep  up  the  treatment  for  (as  a 
rule)  six  months  without  much  interruption.  In  this  way  he  may  be  able 
to  make  up  for  lost  time,  which,  I  cannot  too  often  repeat,  is  so  vitally 
valuable. 

While  in  general  the  initial  course  of  treatment,  occupying  six  months 
if  possible,  should  consist  mainly  of  medication  by  the  mouth  or  byinunc- 
,tion,  the  physician  should  be  watchful  of  all  complications  and  develop- 
ments, should  be  on  the  lookout  for  all  drawbacks  and  dangers,  and  should 
be  ever  prompt  and  ready  with  such  modifications  of  treatment,  such 
expedients,  and  such  reserve  resources  of  aid  as  the  case  may  demand. 


842  SYPHILIS. 

Having  administered  an  efficient  treatment,  with  few  and  short  inter- 
ruptions, for  about  six  months,  it  is  safe  to  say  that  in  most  cases,  partic- 
ularly uncomplicated  ones,  the  patient  will  be  well  on  his  way  to  recovery. 
I  have  very  many  times  seen  patients  who,  for  various  reasons,  had,  many 
years  before,  undergone  but  one  thorough  mercurial  course  of  six  months, 
and  who  thereafter  had  been  entirely  well,  had  never  shown  any  further 
evidence  of  syphilis,  and  who  had  procreated  perfectly  healthy  children. 
Cases  like  these  convinced  me  of  the  great  efficacy  of  early  thorough 
treatment,  and  I  am  glad  to  see  that  several  eminent  Continental  authori- 
ties have  reached  the  same  conclusion.  As  I  have  said  before  (and  the 
repetition  is  pardonable),  a  man's  chances  of  being  cured  of  syphilis  are, 
in  my  judgment,  a  hundredfold  better  and  surer  by  means  of  a  single 
thorough  early  treatment  of  six  months'  duration  than  they  are  by  the 
long-spun-out,  ready-made,  and  emasculated  method  of  small  and  contin- 
uous doses. 

If  the  condition  of  the  patient  is  satisfactory,  as  shown  by  the  absence 
of  all  lesions,  by  almost  entire  subsidence  of  the  lymphatic  ganglia,  by  a 
good  condition  of  his  nutrition  and  strength,  and  by  the  absence  of  symp- 
toms pointing  to  nervous  depression  and  debility,  at  the  end  of  six  months 
he  may  have  a  rest,  the  moral  effect  of  which  w'ill  be  very  salutary. 
Patients  very  often  weary  of  the  long-continued  dosing,  and  in  the  inter- 
val of  repose  they  cease  to  consider  themselves  sick,  and  have  an  oppor- 
tunity to  judge  of  their  condition  when  they  are  free  from  the  effect  of 
drugs.  Therefore,  a  month's  cessation  of  medication  should  be  granted, 
and,  if  possible,  the  patient  should  go  to  the  seaside  or  the  mountains  and 
have  an  entire  change  of  air  and  scene.  It  is  not  uncommon,  however,  to 
see  patients  who  do  not  desire  a  period  of  freedom  from  medication,  but 
persist  in  carrying  on  the  treatment. 

According  to  the  old-time  Ricord  plan  of  treatment,  the  six-months^ 
mercurialization  was  followed  by  a  three-months'  course  of  iodide  of  potas- 
sium. Under  proper  conditions  this  course  may  be  followed  in  those  cases 
in  which  the  patients  are  unusually  anxious  about  themselves,  and,  as  they 
usually  express  it,  "do  not  want  to  lose  valuable  time."  But  in  general 
my  preference  is  to  begin,  after  about  a  month's  interval,  a  systematic 
inunction  course.  In  cases  in  Avhich  this  is  impracticable  or  for  any  reason 
contraindicated,  I  have  come  to  look  w4th  much  favor  and  confidence  upon 
a  combination  of  a  full  dose  of  mercury  with  a  small  dose  of  the  iodide 
of  potassium.     The  following  prescription  will  illustrate  my  meaning : 

!^.  Hydrarg.  biniodidi,  gr.  ij  to  iv ; 

Potassii  iodidi,  3ss ; 

Tr.  cinchona  comp.,  giiiss  ; 

Aquae,  •     |ss. — M. 

Sig.   One  teaspoonful  three  times  a  day,  an  hour  after  eating,  in  a 
wineglassful  of  water. 

In  this  combination  the  mercurial  is  the  efficient  agent,  and  the  iodide 
simply  serves  the  purpose  of  rendering  it  soluble.  AVhen  there  is  debility 
the  fluid  extract  of  coca  may  be  added  to  this  combination.  As  shown 
elsewhere,  this  agent  is  a  very  valuable  adjuvant  in  the  treatment  of 
syphilis.      From  a  wide  experience  I  have  convinced  myself  that  this 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      843 

combination  of  mercury  and  iodide  of  potassium  is  remarkably  efficient 
and  beneficial  after  the  sixth  or  eighth  month  of  the  secondary  period, 
particularly  in  cases  which  have  been  previously  subjected  to  treatment. 
This  combination  is  usually  well  borne  by  the  stomach  even  when  the 
maximum  quantity  of  the  biniodide  is  ordered.  But  great  care  must  be 
observed  in  its  administration,  and  if  gastro-intestinal  irritation  is  pro- 
duced, the  dose  must  be  made  smaller ;  and  if  a  depressing  eifect  upon 
the  general  nutrition  or  upon  the  nervous  system  is  observed,  the  remedy 
must  for  a  time  be  suspended.  In  these  cases  rest  and  change  of  air  and 
scene  are  very  beneficial. 

The  second  course  of  treatment  may  be  kept  up,  with  or  without  slight 
interruptions,  for  three  or  four  months,  or  even  longer  if  the  patient  shows 
no  signs  of  deterioration  of  health  referable  to  the  treatment.  Duringr 
this  second  course  inunctions  also  may  be  used,  with  proper  spaces  of  rest, 
or  fumigations  may  be  employed,  according  to  the  indications  of  the  case. 
There  may  be  circumstances  present  which  render  a  course  of  hypodermic 
injections  of  sublimate  preferable.  In  this  way  the  first  year  passes, 
during  which  the  patient  will  have  been  under  dosage  treatment  nine  or 
ten  months. 

Toward  the  end  of  the  first  year,  if  not  before,  combinations  of  mer- 
cury with  iodide  of  potassium  in  quite  large  doses  are  very  often  most 
beneficial.  The  use  of  these  combinations  is  generally  known  as  the 
"mixed  treatment."     The  following  prescriptions  are  of  much  value: 

I^.   Hydrarg.  biniodidi,  gr.  j-ij  ; 

Potassii  iodidi,  5ss— sj  ; 

Syr.  aurantii  cort.,  ^iij  ; 

Aquae,  ij. — M. 

Sig.  One  teaspoonful  three  times  a  day,  an  hour  after  eating,  in  a 
wineglassful  of  water. 

I^.   Hydrarg.  bichloridi,  gr.  j-ij-iij  ; 

Potassii  iodidi,  ^ss-sj-siss ; 

Tr.  cinchonse  comp.,  §iiss  ; 

Aquae,  ^ss. — M. 

To  be  taken  in  the  same  manner  as  the  foregoing. 

The  combination  of  the  inunction-treatment  with  iodide  of  potassium 
taken  internally  is  often  very  beneficial  indeed,  and  should  be  remembered 
in  late  secondary  and  tertiary  lesions,  particularly  when  localized  to  cer- 
tain regions,  which  should  be  acted  upon  directly  by  the  mercurial  oint- 
ment. The  simultaneous  employment  of  hypodermic  injections  of  a 
mercurial  salt  with  the  ingestion  of  iodide  of  potassium  is  sometimes  pro- 
ductive of  prompt  and  marked  benefit.  As  a  general  rule,  the  foregoing 
combinations  are  vevy  useful  toward  the  end  of  the  first  year  of  syphilis, 
but  in  many  cases  having  an  unusual  course,  and  chiefly  those  in  which 
late  lesions  appear  precociously,  it  may  be  necessary  to  resort  to  them  at 
an  earlier  date.  It  is  always  necessary  to  Avatch  the  condition  of  the 
stomach  when  the  mixed  treatment  is  being  employed  or  when  large  doses 
of  the  iodide  are  administered.  As  soon  as  signs  of  gastric  irritation  show 
themselves  the  remedy  must  be  suspended,  and,  if  necessary,  symptomatic 


844  SYPHILIS. 

treatment  should  be  adopted.  The  iodide  alone  or  in  combination  may 
act  as  a  depressant  upon  nutrition  and  upon  the  nervous  system.  In  these 
cases  it  may  be  necessary  to  reduce  the  dose  or  to  intermit  the  treatment. 

Late  secondary  and  tertiary  lesions  of  the  skin  and  mucous  mem- 
brane, affections  of  the  bones,  periosteum,  and  joints,  late-appearing 
affections  of  the  eye,  ear,  and  cerebro-spinal  system,  of  the  viscera,  and 
of  the  testes  and  penis,  require  a  combination  or  mixed  treatment.  In 
many  cases  it  is  necessary  to  increase  the  dose  of  the  iodide  far  beyond 
those  already  mentioned. 

It  must  be  remembered  that  the  arbitrary  rule  laid  down  by  some 
authors,  that  early  in  syphilis  mercury  is  indicated,  and  that  later  on 
the  iodide  alone  should  be  given,  is  not,  in  general,  a  good  one:  Many 
a  case  of  tertiary  syphilis  has  remained  unaffected  by  the  use  of  the 
iodide  alone,  and  has  promptly  improved  and  soon  recovered  after  mer- 
cury also  was  given.  The  use  of  mercury,  therefore,  should  not  be 
limited  to  the  secondary  stage,  but  should  also  be  employed  in  tertiary 
syphilis,  either  by  inunction  or  hypodermic  injection,  combined  with 
the  iodide  given   internally. 

It  will  be  generally  found  that  patients  who  have  followed  a  sys- 
tematic and  thorough  course  of  treatment  during  the  first  year  very 
rarely  present  tertiary  lesions.  The  cases  which  present  these  graver 
disorders  are  usually  those  which  have  been  the  subject  of  complica- 
tions in  the  secondary  stage,  or  those  in  which  an  early  efficient  treat- 
ment has  not  been  followed  or  has  been  indifferently  followed.  Patients 
presenting  tertiary  lesions  should  be  actively  treated,  but  at  the  same 
time  close  attention  must  be  paid  to  their  general  condition,  for  in 
many  of  them  nutrition  is  impaired  and  a  condition  of  cachexia  exists. 

In  the  carrying  out  of  the  methodical  general  treatment  of  syphilis 
in  the  second  year  of  the  disease  the  periods  of  dosage  may,  on  an 
average,  be  stated  at  two  to  three  months,  with  intervals  of  rest  of  a 
month  or  six  weeks.  In  this  way  about  eight  months  are  occupied  by 
actual  medication.  In  most  cases  at  the  end  of  the  second  year  of 
thorough  treatment  patients  may  be  pronounced  cured,  provided  they 
have  not  for  many  months  shoAvn  evidence  of  the  disease,  that  their 
lymphatic  system  appears  healthy,  and  their  general  health  and  nutri- 
tion are  good.  Though  there  is  a  disposition  on  the  part  of  those  who 
rely  chiefly  on  mouth-medication  to  extend  the  treatment  of  syphilis 
indefinitely,  as  I  have  already  shown,  I  see  no  reason  whatever  for 
altering  the  opinion  that  I  have  many  times  stated,  that  if  an  ener- 
getic and  thorough  treatment  (such  as  I  have  sketched)  be  followed  for 
two  years  or  two  years  and  a  half,  the  patient  Avill  be  cured,  as  shown 
by  the  enjoyment  of  good  health,  by  freedom  from  all  syphilitic  mani- 
festations, and  by  his  or  her  ability  to  procreate  healthy  children.  In 
some  cases  this  auspicious  result  may  be  the  outcome  of  treatment  by 
pills,  but  in  most  it  will  only  be  attained  by  the  zealous  and  intelligent 
employment  of  inunctions,  supplemented  by  other  methods  and  by  the 
use  of  the  iodide.  In  the  sections  upon  Methods  of  Treatment  and 
upon  Special  Local  and  Regional  Treatment  further  information  may 
be  found. 

There  are  four  classical  methods  of  administering  antisyphilitic 
remedies :  first,  by  the  mouth,  or  stomach  ingestion ;  second,  by  inunc- 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      845 

tion  ;  third,  by  fumigation ;  and  fourth,  by  hypodermic  injections.  In 
addition  to  these  specific  methods,  there  are  many  adjuvant  and  acces- 
sory modes  of  treatment,  which  have  for  their  object  the  general  im- 
provement of  the  economy  and  the  production  of  a  condition  in  which 
the  antisyphilitic  remedies  will  be  better  borne  and  attended  with  a 
greater  and  more  salutary  potentiality.  In  the  latter  categories  we 
may  mention  baths  of  various  kinds,  massage,  the  hygienic  influences 
of  change  of  scene  and  climate,  and  various  tonic  and  stimulant  courses 
of  treatment. 

Treatment  of  Syphilis  hy  Means  of  the  Mouth,  or  Stomach-ingestion. — 
This  method  is  one  very  largely,  and  by  some  exclusively,  used,  and 
it  has  a  quite  broad  scope,  but  also  many  drawbacks  and  limitations. 
Antisyphilitic  remedies  administered  by  the  mouth  (and  these  are  com- 
posed mainly  of  mercury  and  iodide  of  potassium,  used  singly  or  in 
combination)  consist  of  pills,  granules,  tablets,  capsules,  powders,  and 
of  liquid  preparations  of  various  kinds. 

As  we  have  shown  in  preceding  pages  that  these  two  agents  possess 
decided  therapeutic  effects,  we  must  now  consider  their  drawbacks  and 
the  accidental  and  toxic  effects  to  which  they  may  give  rise. 

Mercury  administered  by  the  mouth  may  cause  gastro-intestinal 
disturbances  and  dyspeptic  symptoms  of  various  degrees,  ptyalism, 
stomatitis,  and  salivation,  and  a  general  depression  and  impairment  of 
nutrition.  It  is  well  to  remember  that  inunctions  and  fumigations  may 
also  give  rise  to  similar  depressing  and  annoying  conditions,  and  that 
the  hypodermic  use  of  mercurial  preparations  is  also  attended  with 
these  drawbacks  in  greater  or  less  degree,  according  to  the  particular 
agent  used  and  the  extent  to  which  it  is  employed. 

The  most  common  form  of  disturbance  due  to  the  ingestion  of 
mercury  is  a  mild  form  of  enteritis,  Avhich  is  attended  with  colicky 
pains,  borborygmus,  and  diarrhoea.  In  many  cases  this  condition  is 
very  ephemeral  and  passes  away  of  itself  in  a  few  days,  during  which 
the  system  is  becoming  accustomed  to  the  action  of  the  drug.  The 
pain  and  disturbance  are  felt  shortly  after  taking  the  dose,  and  last  for 
an  hour  or  more,  and  then  pass  off,  to  follow  in  like  manner  the  next 
dose.  In  other  cases  the  effect  is  more  severe  and  lasting,  and  the 
patient  suffers  and  becomes  weak.  To  remedy  and  prevent  this  unto- 
ward action  of  mercury,  the  utmost  care  must  be  exercised  in  the 
matter  of  diet,  which  should  be  bland  and  easily  digestible,  and  in 
the  avoidance  of  large  quantities  of  fluids  and  of  alcoholic  and  malt 
liquors.  In  very  many  books  the  advice  is  given  that  the  mercurial 
should  be  combined  with  a  small  but  efficient  dose  of  opium,  in  order 
to  prevent  gastro-intestinal  intolerance.  As  a  rule,  this  advice  is  very 
reprehensible  and  liable  to  be  followed  by  bad  consequences.  The  mer- 
curial treatment  must  of  necessity  be  long  continued,  and  it  is  highly 
improper  to  combine  it  with  opium,  since  addiction  to  that  drug  is  very 
liable  to  be  produced.  Moreover,  no  system  is  in  a  normal  state  in 
which  opium  is  given  for  a  considerable  length  of  time.  It  is  well, 
therefore,  if  the  necessity  is  urgent,  to  let  the  patient  have  a  little 
paregoric  or  other  mild  opium  preparation — ^_just  enough  to  ease  the 
pain — which  he  may  take,  under  great  restrictions,  as  the  occasion  may 
require.     Commonly  only  a  few  doses  will  be  necessary,  particularly  if 


846  SYPHILIS. 

extract  of  hyoscyamus  is  combined  with  the  mercurial.  In  many  cases 
chalk  mixture  or  a  small  quantity  of  tincture  of  ginger  will  be  sufficient 
to  help  a  patient  over  a  rough  spot.  It  must  always  be  remembered 
that  in  the  greater  number  of  cases  the  urgent  intestinal  symptoms  are 
of  short  duration,  and  that  very  soon  the  digestive  tract  will  tolerate 
mercury  without  discomfort  to  the  patient. 

In  some  cases  in  which  pills  are  taken,  but  chiefly  in  those  in  which 
inunctions,  fumigations,  and  hypodermic  injections  are  vigorously  given, 
colitis  of  different  degrees  is  produced.  This  condition  is  attended 
with  much  pain  and  discomfort,  and  with  a  diarrhoea  which  may  be 
so  severe  as  to  be  bloody.  Under  these  circumstances  the  specific 
treatment  must  be  temporarily  suspended  and  the  bowel  affection  treated 
symptomatically. 

Many  patients  who  have  taken  mercury,  even  in  comparatively 
small  quantities,  for  a  long  or  even  short  period,  begin  to  complain 
of  symptoms  referable  to  the  stomach.  They  say  that  they  have 
flatulence  and  sour  stomach,  and  that  their  digestion  is  slow  and 
attended  with  eructations  and  discomfort.  In  its  early  days  this  con- 
dition may  not  be  accompanied  by  bodily  weakness,  but  its  continu- 
ance is  complicated  by  general  debility,  pallor  of  countenance,  indis- 
position to  exertion,  and  even  a  depression  of  the  nervous  system  of 
such  marked  intensity  that  we  may  call  it  neurasthenia.  This  condition 
is  also  produced  by  combinations  of  mercury  and  iodide  of  potassium. 

The  mouth-lesions  produced  by  the  use  of  mercury  are  certainly 
less  common  than  those  just  spoken  of.  As  a  rule,  most  patients  bear 
mercury  well ;  others  are  at  first  moderately  affected  by  it ;  while  in  a 
very  few  cases  its  use  in  a  short  time  produces  toxic  effects  of  greater 
or  less  severity.  There  is  no  point  deserving  of  greater  emphasis  in 
the  treatment  of  syphilis  than  that  it  is  most  essential  to  conciliate  the 
mouth.  Therefore  the  physician  must  examine  this  cavity  in  every 
instance  before  putting  the  patient  upon  treatment.  If  there  are  any 
bad  teeth,  they  must  be  removed  if  possible,  and  if  there  are  any 
teeth  which,  being  misplaced,  rub  or  press  against  the  tongue,  the 
cheeks,  or  the  lips,  they  must  be  taken  out  or  the  uneven  portion  must 
be  filed  off.  No  portion  of  them  should  be  allowed  to  produce  injurious 
pressure  or  friction  upon  the  parts  which  surround  them.  Then  the 
condition  of  the  gums  must  be  observed,  and  any  tumefaction,  ulcera- 
tion, or  abnormal  condition  must  be  cured.  The  presence  of  irri- 
tating microbes  and  of  epithelial  debris,  which,  with  the  tartar,  forms  a 
morbid  layer  around  the  teeth  and  upon  the  gums,  is  capable  of  doing 
much  harm.  It  is  imperative  that  this  condition  shall  be  removed. 
Hypergemia  or  inflammation  of  the  mouth,  soft  palate,  and  pharynx 
often  presents  very  serious  obstacles  to  the  continuance  of  mercurial 
treatment ;  therefore  these  structures  must  receive  careful  attention,  and 
local  medication  should  be  used  for  the  removal  of  all  abnormalities 
affecting  them.  Sigmund,^  who  in  his  day  laid  so  much  stress  upon 
the  necessity  of  a  healthy  mouth  in  the  treatment  of  syphilis,  also 
emphasized  the  fact  that  abnormal  conditions  of  the  nasal  mucous 
membranes   often   acted   as   serious   drawbacks   to   antisyphilitic    treat- 

1  "Zur  ortlichen  Behandlung  syphilitisclie    Mund  Nasen  und  Eachenaffectionen," 
Wien.  med.  Wochenschrift,  Nos.  32  and  34,  June  and  July,  1870. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      847 

ment.  My  own  experience  has  taught  me  that  it  is  absolutely  essential 
that  the  nasopharynx  in  syphilitics  should  be  carefully  watched  and  kept 
in  a  normal  state,  in  order,  first,  that  no  drawbacks  to  a  mercurial-and- 
iodide-of-potassium  treatment  may  exist  there,  and,  second,  that  syphilitic 
processes,  so  prone  to  develop  there,  may  be  prevented.  To  sum  up,  there- 
fore, I  will  say  that  in  all  cases  the  condition  of  the  nose,  pharynx,  and 
mouth  of  syphilitics  must  be  sedulously  watched,  and  if  necessary  treated 
during  the  whole  period  of  general  treatment.  By  following  this  advice, 
many  a  time  will  the  physician  be  able  to  prosecute  his  treatment, whereas 
otherwise  he  would  have  had  to  stop  for  a  time  or  give  it  up. 

As  a  rule,  salivation  does  not  come  on  very  abruptly ;  as  Fournier 
says,  "it  does  not  burst  out  like  a  thunder-clap;  it  announces  itself." 
But  it  must  always  be  remembered  that  after  the  ingestion  chiefly 
of  calomel  and  blue  pill,  in  the  course  of  the  inunction-treatment 
applied  with  too  lavish  a  hand,  in  case  of  the  too  frequent  repetition 
of  very  strong  mercurial  fumigations,  and  during  an  active  course  of 
hypodermic  injections,  particularly  when  the  insoluble  salts  of  mercury 
are  employed,  very  sudden  and  severe,  even  alarming,  salivation  may 
occur.  In  these  cases  severe  gastro-intestinal  complications  may  be 
present.  With  the  avoidance  of  an  intemperate  and  careless  system 
of  medication,  and  with  the  watchful  attention  of  the  patient  by  his 
physician,  these  formidable  accidents  will  rarely  occur. 

The  most  common  symptom  of  mouth-lesion  produced  by  mercury 
is  a  sensation  of  soreness  of  the  gums,  felt  chiefly  upon  cleaning  the 
teeth,  and  also  in  mastication,  or  from  contact  with  vinegar  or  other 
acid  fluids.  Many  patients  Avill  first  experience  uneasiness  and  pain 
around  one  or  both  wisdom  teeth.  In  either  of  these  instances  of  gin- 
givitis we  find  the  gums  red,  swollen,  and  more  or  less  exulcerated, 
and  perhaps  at  their  teeth-margin  covered  with  a  film  of  necrotic 
tissue  or  membrane  which  consists  of  microbes  and  degenerated  epithe- 
lial cells.  In  some  cases  this  condition  is  confined  to  the  interdental 
prominences  of  the  mucous  membrane ;  in  others  the  entire  gums  are 
swollen,  softened,  and  tender.  Under  these  circumstances  the  teeth 
often  feel  very  uncomfortable,  and  even  painful ;  they  become  more  or 
less  loose,  and  the  patient  feels  that  they  are  longer  than  usual.  In 
very  bad  cases  they  drop  out.  As  concomitants  of  this  state  there 
is  a  metallic  taste  in  the  mouth  and  the  breath  is  more  or  less  foetid. 
Other  patients  will  first  complain  of  a  metallic  taste  in  the  mouth, 
and  it  will  be  noticed  then  that  the  breath  is  disagreeable.  Or  before 
the  supervention  of  these  symptoms  they  may  notice  that  the  quantity 
of  saliva  is  increased,  and  it  may  be  watery  or  more  or  less  viscid. 
Inspection  of  the  mouth  then  shows  a  general  condition  of  oedematous 
hypertiemia.  The  gums  and  the  mucous  membrane  of  the  cheeks  at  the 
root  of  the  tongue  and  of  the  pharynx  are  of  a  deep-red  or  a  whitish-red 
color.  The  submaxillary  glands  may  be  more  or  less  swollen  and  pain- 
ful, and  the  parotid  may  likewise  be  aff'ected.  Unless  the  process  ceases, 
either  spontaneously  or  as  a  result  of  treatment,  the  swelling  of  the 
parts  increases,  the  tongue  swells,  the  mouth  can  with  difliculty  be 
opened,  and  then  not  to  its  full  extent ;  the  teeth  make  deep  impressions 
in  the  mucous  membrane  of  the  cheeks,  and  ulcerations  may  occur. 
In  these  severe  cases  the  suff'ering  of  the  patient  is  very  distressing  and 


848  SYPHILIS. 

painful,  and  deglutition  is  more  or  less  impaired.  The  patient  cannot 
clieAv  or  partake  of  solid  food,  and  has  to  rely  upon  milk  and  nutritious 
liquids  for  sustenance.  To  add  to  his  trouble,  he  groAvs  weak,  nervous, 
restless,  and  apprehensive ;  he  sleeps  little,  and  has  no  comfort  anywhere. 
His  pallid,  anxious  facies,  his  immobile  and  perhaps  swollen  mouth  and 
lips,  together  with  the  constant  flow  of  viscid  saliva  and  the  foetid 
breath,  present  a  truly  pitiable  spectacle.  Luckily,  we  now-a-days  very 
seldom  see  these  formidable  cases  of  salivation. 

A  general  depression  and  impairment  of  the  nutrition  of  the  body 
sometimes  occurs  quite  early  after  the  ingestion  or  absorption  of 
mercury.  But  those  cases  in  which  it  may  be  said  that  there  is  an 
intolerance  to  mercury  are  happily  very  rare.  In  most  of  them  it 
wall  be  found  that  if  "the  mercurial  by  the  mouth  be  stopped,  and  its 
guarded  use  by  inunction  or  hypodermic  injection  be  substituted,  the 
intolerance  will  cease,  and  that  the  drug  will  work  satisfactorily. 

As  a  result  of  greatly  prolonged  mercurialization,  general  debility 
and  impaired  nutrition  of  the  body  are  very  frequently  produced.  In 
very  many  of  these  cases  the  syphilitic  diathesis  is  still  active,  new  lesions 
appear,  while  old  ones  refuse  to  disappear,  and  coincidently  the  patient 
begins  to  look  pallid  and  sickly,  to  be  weak  and  apathetic,  and  to  suffer 
more  or  less  from  nervous  depression.  This  condition  is  a  frequent  out- 
come of  the  continuous  mercurial  treatment,  and  is  sometimes  seen  in 
persons  who,  fearful  of  the  disease,  have  an  insensate  and  irresistible 
desire  continually  to  dose  themselves  with  mercury.  It  is  attended  with 
dilatation  of  the  "^stomach,  gastro-enteritis  of  a  mild  and  chronic  type,  per- 
haps colitis,  and  a  general  impairment  of  the  nervous  system  and  of  the 
nutritional  powers  of  the  body.  Under  an  enlightened  system  of  anti- 
syphilitic  therapeutics  in  its  broadest  sense  such  conditions  as  these  can 
be  readily  avoided. 

Such  "^is  the  value  of  iodide  of  potassium  in  the  treatment  of  syphilis 
that,  although  we  cannot  call  it  a  specific  or  an  antidote  in  a  general 
sense,  it  certainly  may  be  termed  an  essential  adjuvant  or  an  important 
helpmate  to  mercury'  in  the  treatment  of  that  disease.  We  may  even  go 
farther  than  this,  and  claim  specificity  in  some  cases  in  which,  owing  to 
the  nature  of  the  lesion,  mercury  takes  second  place  and  the  iodide  the 
first.  In  other  portions  of  this  chapter  the  therapeutical  value  of,  and 
indications  for  the  use  of,  this  drug  are  described.  We  shall  here  con- 
sider the  drawbacks  and  accidents  which  sometimes  complicate  its  _em- 
plovment.  Iodide  of  potassium  is  rapidly  absorbed  into  the  circulation, 
as  can  readily  be  shown  by  the  starch  test  applied  to  the  mouth  or  by 
touching  the  tongue  or  mucous  membrane  of  the  mouth  with  a  solution  of 
nitrate  of  silver.  The  starch  test  promptly  shows  the  blue  color  of  iodide 
of  starch  if  iodine  is  present,  while  the  pearly  nitrate-of-silver  stain  is 
quickly  turned  into  a  yellowish  hue,  owing  to  the  formation  of  iodide  of 
silver.  It  is  by  many  thought  and  claimed  that  iodide  of  potassium  assists 
in  the  elimination  of  mercury  from  the  economy.  Melseus  and  Guillot 
claimed  that  this  drug  was  capable  of  rendering  soluble  mercury  or  any 
of  its  compounds  retained  in  the  tissues  of  the  body,  and  of  causing  their 
elimination  with  the  urine.      On  the  other  hand,  Suchoif  ^  claims,  after 

»  "  Effect  of  Iodide  of  Potassium  in  Combination  with  Mercury  in  Temporary  and 
After-treatment  by  Mercury,"  Vrach,  1886,  vii.  p.  840  et  seq. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      849 

very  minute  and  careful  investigations,  conducted  under  the  supervision 
of  Professor  Tarnowsky,  that  the  iodine  salt  really  retards  the  elimination 
of  mercury.  Suchoff  claims  that  the  elimination  of  mercury  by  the  urine 
begins  later,  and  the  quantity  of  mercury  eliminated  is  comparatively 
smaller,  when  the  patient  is  taking  at  the  same  time  iodide  of  potassium. 

Iodide  of  potassium  administered  during  or  after  a  mercurial  course 
lessens  at  once  the  quantity  of  mercury  eliminated  daily.  The  practical 
•conclusion  to  be  drawn  from  these  observations  is  that  the  iodide  is  not 
useful  in  mercurial  poisoning,  but,  on  the  contrary,  may  be  harmful.  My 
own  experience  in  the  treatment  of  mercurial  stomatitis  has  convinced 
me  that  no  benefit  whatever  results  from  the  administration  of  iodide  of 
potassium. 

Clinically,  however,  it  is  very  frequently  found  that  the  long-continued 
use  of  mercury  having  failed  to  give  relief  or  having  produced  a  cachec- 
tic condition,  the  substitution  of  iodide  of  potassium  is  followed  by  invo- 
lution of  the  symptoms  and  improvement  of  the  health.  This  fact,  how- 
ever, does  not  warrant  the  conclusion  that  the  auspicious  result  was  due 
to  any  efi"ect  produced  by  the  iodide  upon  mercury  supposed  to  be  stored 
up  in  the  system. 

The  advocates  of  the  expectant  treatment  and  the  antimercurialists  (if 
any  now  exist)  are  impressed  with  the  value  and  virtues  of  iodide  of 
potassium  in  early  secondary  syphilis,  and  also  later  in  the  course  of  the 
■disease.  That  this  remedy  is  useful  for  some  of  the  lesions  of  the  early 
secondary  stage  has  been  pointed  out  in  other  portions  of  this  chapter,  but 
it  certainly  does  not  follow  that  it  is  appropriate  as  a  systematic  remedy 
to  take  the  place  of  mercury.  Indeed,  much  harm,  in  the  long  run,  is 
-done  by  the  indiscriminate  use  of  the  iodide,  particularly  in  the  exanthe- 
matic  stage  of  syphilis.  In  this  stage  of  syphilis  there  is  a  tendency  to 
hyperaBmia  as  well  as  hyperplasia,  and  very  often  the  iodide  renders 
worse,  and  even  obscures,  syphilitic  lesions  of  the  mucous  membrane  of 
the  mouth,  throat,  and  also  lesions  of  the  skin.  Again,  as  we  shall 
shortly  see,  the  iodide  itself  produces  multiform  lesions  of  the  skin  and 
mucous  membranes  which  are  often  very  difficult  to  distinguish  from  syph- 
ilitic lesions.  I  have  many  times  seen  syphilitic  infiltrations  have  their 
starting-points  in  infiammatory  foci  in  the  skin  and  mucous  membranes 
which  were  caused  by  the  iodide.  Further  than  this,  the  iodide  is  inert 
against  most  of  the  early  lesions  of  syphilis,  and  is  powerless  to  cure  the 
general  condition.  Therefore  this  remedy  should  be  looked  upon,  as  a 
rule,  as  harmful  in  early  syphilis,  and  should  not  be  employed,  but  it 
should  be  used  in  the  cases  and  with  the  limitations  which  I  have  specified 
elsewhere. 

Iodide  of  potassium  is  rapidly  absorbed  when  taken  by  the  mouth, 
which  is  the  most  common  mode  of  its  administration.  It  is  also  absorbed, 
well  diluted  in  water,  when  injected  into  the  rectum,  but  its  use  in  this 
manner  very  often  has  to  be  suspended  by  reason  of  local  intolerance. 
The  researches  of  Welander  have  shown  that  this  salt,  administered  by 
the  mouth  to  a  syphilitic  mother,  may  be  found  in  the  urine  of  the  newly- 
born  offspring.  Considering  the  vast  number  of  people,  old  and  young, 
who  for  longer  or  shorter  periods  take  iodide  of  potassium,  it  certainly 
must  be  confessed  that,  as  a  general  rule,  the  remedy  is  well  borne  by  the 
human  system.     There  are,  however,  many  persons  with  whom  the  drug 

54 


850  SYPHILIS. 

disagrees  more  or  less  actively.  These  persons  are  said  to  have  the  iodide- 
of-potassium  idiosyncrasy  ;  that  is,  that  in  one  way  or  another  the  drug 
produces  unpleasant  and  even  toxic  effects  in  them,  which  we  group  under 
the  general  term  iodism.  We  also  read  of  iodide-of-potassium  intolerance, 
but  the  truth  is  that  the  cases  are  very  exceptional  in  which  the  drug  is 
so  badly  borne  that  its  use  has  to  be  totally  suspended.  While  there  are 
many  persons  who  have  a  greater  or  less  idiosyncrasy  against  the  iodide, 
there  are  few  who  are  wholly  intolerant  of  its  use.  Several  years  ago  it 
was  claimed  by  H.  C.  Wood^  that  in  all  cases  of  doubtful  diagnosis  of 
cerebral  syphilis  the  so-called  therapeutic  test  should  be  employed,  and 
if  60  grains  of  iodide  of  potassium  a  day  fail  to  produce  iodism,  for  all 
practical  purposes  the  person  may  be  considered  to  be  a  syphilitic.  This 
far-fetched  assumption  was  very  properly  questioned  and  combated  by 
J.  William  White,^  who,  in  a  circular  letter  to  many  syphilographers  and 
physicians,  solicited  their  opinion  on  the  subject.  Twelve  replies  were 
sent,  in  all  of  which  it  was  claimed  that  personal  idiosyncrasy  to  the 
iodides  was  as  great  in  non-syphilitics  as  in  syphilitics ;  that  there  are  no 
satisfactory  grounds  for  the  assertion  that  syphilis  in  any  of  its  stages 
prevents  the  production  of  iodism  ;  and  that  it  is  most  unsafe  to  base  any 
diagnostic  conclusions  upon  the  presence  or  absence  of  toxic  symptoms 
(iodism)  after  the  administration  of  full  doses  of  the  iodides.  As  stated 
in  my  reply  to  Dr.  White,  so  I  may  state  here,  that  I  think  Dr.  Wood's 
therapeutic  test  a  fallacy. 

There  are  many  peculiar  facts  connected  with  the  iodide  idiosyncrasy. 
In  some  cases  a  very  small  dose  (a  fractional  part  of  a  grain)  will  produce 
very  severe'  and  even  alarming  effects,  and  we  may  be  unable  even  by 
means  of  many  and  varied  expedients  to  overcome  the  intolerance.  In 
other  cases  a  very  small  dose  will  produce  unpleasant  and  even  severe 
effects,  whereas  a  large  one  will  be  well  borne,  either  at  first  or  after  several 
trials.  In  some  cases  I  think  that  we,  to  use  an  apt  expression,  weaken 
too  quickly,  and  give  up  the  drug  after  a  little  rebuff,  whereas  with  proper 
moral  courage  (the  urgent  necessity  existing)  we  can  increase  the  dose 
and,  by  persisting,  establish  toleration.  I  have  seen  cases  in  which  an 
intolerance  of  the  iodide  of  potassium  lasted  twenty  years,  and  at  both 
ends  of  that  period  produced  a  characteristic  bullous  eruption.  On  the 
other  hand,  I  have  seen  many  cases  like  that  of  a  man  who  had  gum- 
matous infiltration  into  the  soft  palate,  and  was  intolerant  of  iodide  of 
potassium,  but  in  whom  I  pushed  the  iodide  until  iodism  ceased  and  the 
new  growth  was  absorbed.  Four  years  later  (after  a  life  of  great  indul- 
gence) he  had  syphilitic  pachymeningitis,  took  heroic  doses  of  the  iodide, 
showed  no  intolerance,  and  got  well.  In  many  cases  abstinence  from 
liquors,  alcoholic  and  fermented,  care  as  to  the  simplicity  and  easy  diges- 
tibility of  food,  requisite  medication  for  the  stomach,  and  a  general 
improvement  of  the  condition  of  the  alimentary  canal,  will  be  followed 
by  a  proper  acceptance  of  the  drug,  after  perhaps  some  preliminary  skir- 
mishing. I  have  seen  several  cases  in  which  the  iodides  were  well  borne 
previous  to  the  onset  of  pathological  changes  in  the  kidneys,  and  after 

^  "  Iodide  of  Potassium  in  Syphilis:  a  discussion  by  J.  William  White  and  H.  C. 
Wood,"  Therapevtic  Gazette,  Dec,  1888. 

^  "  Contribution  to  the  Discussion  of  the  Diagnostic  Value  of  the  Tolerance  of  the 
Iodides  in  Syphilis,"  Therapeutic  Gazette,  March  15,  1889. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      851 

the  establishment  of  the  latter  they  were  more  or  less  toxic  in  their 
action — sometimes  so  much  so  that  their  administration  was  of  necessity 
suspended.  There  is  very  much  evidence  scattered  through  medical  liter- 
ature which  goes  to  show  that  pathological  conditions  in  the  kidneys  are 
a  very  frequent  cause  of  the  iodide  idiosyncrasy.  I  can  call  to  mind 
cases  in  which,  while  the  patients  were  high  livers  and  deep  drinkers  (one 
exclusively  of  champagne),  the  iodides  had  more  or  less  toxic  action,  but 
when  they  discarded  these  irritants  and  stimulants  the  iodides  produced 
no  disturbance.  In  syphilitics,  as  in  non-syphilitic  subjects,  an  intoler- 
ance of  to-day  may  be  replaced  by  a  condition  of  assimilation  a  month, 
a  year,  or  more  later.  This  fact  should  be  remembered  in  practice,  for 
there  is  a  tolerably  widespread  opinion  that  the  iodic  idiosyncrasy  is  a 
lifelong  condition. 

In  many  cases  symptoms  of  iodism  appear  early  in  the  use  of  the 
drug ;  in  others  this  complication  is  more  or  less  delayed.  Its  superven- 
tion should  not,  however,  lead  to  too  early  an  abandonment  of  the  drug. 
It  is  claimed  by  some  that  the  presence  of  free  ammonia  (the  carbonate 
or  aromatic  spirit)  in  a  solution  of  iodide  of  potassium  Avill  prevent  iodism, 
and  by  others  that  an  alkaline  salt,  like  the  bicarbonate  or  acetate  of 
potassium  in  combination,  will  also  have  this  salutary  effect ;  but  it  is  not 
well  to  rely  too  implicitly  upon  these  statements. 

Slight  or  severe  nausea  and  griping  pains  in  the  bowels  may  follow 
the  ingestion  of  iodide  of  potassium.  They  can  hardly  be  called  toxic 
effects,  however,  for  they  are  usually  readily  prevented  by  the  addition 
of  a  little  tincture  of  ginger  or  capsicum  to  the  mixture,  or  of  a  small 
quantity  of  tannin. 

The  toxic  effects  of  iodide  of  potassium  and  of  the  other  iodides  may 
be  mild  or  severe ;  they  may  be  simple  in  character,  or,  again,  they  may 
present  a  marvellous  uniformity.  Only  a  general  outline  of  these  symp- 
toms and  lesions  can  be  given  here. 

The  most  common  early  symptom  of  iodism  is  a  metallic  taste  in  the 
mouth  and  throat,  with  sometimes  foetor  of  the  breath.  Coryza,  mild 
and  severe,  is  also  frequently  complained  of,  and  is  often  regarded  by 
patients  as  cold  in  the  head.  There  may  be  mild  conjunctivitis  and 
lachrymation  combined  with  the  coryza,  which  may  be  accompanied  with 
much  sneezing  and  irritation  of  the  nose  and  eyes,  and  very  often  severe 
pain  in  the  frontal  sinuses.  In  some  cases  what  is  called  iodide  grip  is 
observed.  In  these  rather  rare  instances  the  upper  air-passages,  the  eyes, 
and  lachrymal  ducts  are  very  much  swollen  and  red.  The  face  becomes 
swollen,  and  a  red  blush  resembling  erysipelas  may  be  present.  The 
pharynx  becomes  red  and  swollen,  and  the  oedema  may  extend  to  the 
epiglottis  and  glottis.  The  patient  suffers  much  from  burning  sensations 
and  from  pain,  from  dyspnoea,  hoarseness,  and  dysphagia.  Together 
with  this  formidable  condition  there  are  fever,  weakness,  pain  in  the  head, 
and  extreme  restlessness.  Fenwick  '  reports  a  case  of  this  form  of  iodism 
in  which  after  four  ten-grain  doses  of  the  iodide  of  potassium  there  was 
such  oedema  of  the  glottis  and  difficulty  of  breathing  that  the  patient's 
life  was  only  saved  by  tracheotomy. 

In  other  cases  salivation  occurs,  which,  however,  is  not  usually  as 

^  "  Severe  Case  of  Iodism  :  Tracheotomy,"  Lancet,  Nov.  13, 1875, 


852  SYPHILIS. 

severe  as  that  due  to  mercury.  In  ruost  cases  it  is  of  a  mild  and 
ephemeral  character. 

Neuralgic  pains  in  the  head  or  ja"svs  are  very  frequently  complained  of, 
and  some  patients  suffer  from  more  or  less  severe  toothache  while  taking 
this  drug.  In  other  cases  there  is  swelling  of  the  parotid,  submaxillary, 
and  sublingual  glands,  which  gives  rise  to  very  uncomfortable  symptoms  in 
the  neck. 

It  is  not  uncommon  to  see  oedematous  hyperplasia  of  the  soft  palate, 
of  the  tissues  around  the  root  of  the  tongue,  of  the  tongue  itself,  and  of 
the  pharynx  in  cases  of  acute  or  chronic  iodism.  I  have  under  observa- 
tion at  the  present  time  a  gentleman  suffering  from  secondary  syphilis, 
who,  as  a  result  of  the  improper  and  intemperate  use  of  iodide  of  potas- 
sium, has  swelling  of  the  pharynx  and  root  of  the  tongue,  with  much  tur- 
gescence  and  prominence  of  the  circumvallate  papillae,  who  was  told  by  a 
promi-nent  surgeon  that  he  had  cancer  of  the  tongue  and  that  his  only  hope 
was  in  a  free  extirpation  of  that  organ.  This  inflammatory  condition 
of  the  throat  and  mouth  from  the  use  of  iodide  of  potassium,  particularly 
"when  given  in  large  doses  and  for  long  periods,  is  not  at  all  uncommon, 
is  little  understood,  I  find,  by  the  profession  at  large,  and  is  a  source  of 
trouble  and  annoyance  both  to  patient  and  physician. 

The  toxic  eff"ects  of  the  iodides,  chiefly  of  potassium,  upon  the  skin 
are  very  numerous  and  multiform  in  character.^  They  may  all  be  classed 
under  the  general  head  of  dermatitis,  of  which  we  find  a  papular  and 
papulo-pustular  form  (urticarial),  tubercular,  tuberous,  nodular,  bullous, 
and  ulcerative.  Besides  the  essential  inflammatory  dermal  lesions  the 
iodides  may  produce  purpura,  probably  from  their  defibrinizing  effects 
upon  the  blood.  In  some  cases  iodide  of  potassium  produces  such  rapid 
and  feeble  action  of  the  heart  that  its  use  must  be  given  up. 

Though  last  to  be  mentioned,  particular  attention  should  be  called  to 
the  gastro-intestinal  effects  and  intolerance  of  the  iodides,  chiefly  of  the 
iodide  of  potassium.  In  most  cases  the  stomach  receives  the  drug  kindly ; 
in  others  it  produces  a  feeling  of  discomfort  and  impairs  digestion.  This 
condition  may  soon  pass  off,  either  spontaneously  or  as  the  result  of  proper 
medication  and  alimentation.  In  other  instances  it  is  a  very  serious 
drawback,  necessitating  the  suspension  or  even  the  abandonment  of  the 
drug.  It  is  always  well  (the  necessity  existing)  to  use  every  possible 
means  to  overcome  this  troublesome  complication.  After  the  long  use  of 
full  doses  of  the  drug  patients  very  often  complain  of  distressing  dyspeptic 
symptoms  and  of  weakness,  and  show  evidence  of  emaciation.  Their 
heart-action  may  be  weak  and  their  nervous  system  profoundly  affected. 
Indeed,  a  condition  of  cachexia,  or  even  of  neurasthenia,  may  thus  be 
induced.  In  such  cases  we  must  stop  the  use  of  the  drug  at  once,  put 
the  patients  upon  a  careful  regimen,  see  that  their  hygiene  is  made  satis- 
factory, build  them  up  with  tonics,  and  bring  to  their  aid  all  fortifying 
influences. 

It  is  said  that  long-continued  use  of  the  iodides  may  produce  structural 
lesions  of  the  kidneys. 

Persons  are  frequently  met  with  who  have  taken  iodide  of  potassium 
for  many  years,  and  who  are  still   obliged  to  continue  it  if  they  would 

'  See  my  Clinical  Atlas  of  Venereal  and  Skin  Diseases,  Philada.,  1889,  for  further  par- 
ticulars. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     853 

keep  their  symptoms  in  check.  They  generally  become  familiar  with  its 
use,  and  take  it  in  large  quantities,  without  the  physician's  advice,  as 
regularly  as  they  take  their  meals.  Other  patients  cannot,  or  believe 
they  cannot,  tolerate  it  even  in  the  smallest  doses.  These  are  difficult 
cases  to  deal  with  in  emergencies.  Sometimes  the  evil  is  imaginary, 
and  the  idea  may  be  dispelled  by  a  little  adroitness  upon  the  part  of  the 
physician. 

Iodide  of  Rubidium. — This  drug  has  recently  been  recommended  as  a 
substitute  for  the  potassium  salt,  and  it  is  claimed  that  it  is  easily  borne  by 
the  stomach,  that  it  rarely  produces  iodism,  that  it  does  not  affect  weak 
hearts,  and  that  it  is  just  as  effective  as  the  old  remedy.  Leistikow^ 
reports  eight  cases  of  syphilis  in  which  this  drug  worked  well  when  taken 
in  three  daily  doses  of  a  tablespoonful  of  a  5  per  cent,  solution. 

lodol. — As  an  internal  remedy  lodol  was  first  used  by  Pick  ^  in  a  few 
cases  of  tertiary  syphilis.  This  observer  claims  that  he  observed  suf- 
ficiently favorable  results  from  its  use  to  warrant  its  continuance  as  a 
therapeutic  agent.  He  observed  that  very  little  toxic  effect  was  produced 
by  the  drug,  and  that  it  had  a  moderately  energetic  therapeutic  effect. 
Cervatesco  ^  also  claims  benefit  in  gummatous  affections  of  the  pharynx, 
hard  palate,  larynx,  and  liver  in  doses  of  two  or  three  grains  three  times 
a  day. 

Szadek  *  has  used  iodol  in  seventeen  cases  of  tertiary  and  five  of  sec- 
ondary syphilis.  This  author  used  the  drug  in  doses  of  from  8  to  16 
gi-ains  three  times  a  day,  continuously  for  two  or  three  months.  He 
thinks  that  its  value  consists  in  its  harmlessness,  tastelessness,  and  ab- 
sence of  odor,  and  in  the  large  proportion  of  iodine  which  it  contains. 
He  found  no  disturbance  of  the  gastro-intestinal  canal  from  its  use,  and 
claims  that  the  therapeutic  results  were  most  satisfactory,  except  in  two 
cases  of  chronic  syphilitic  hemiplegia.  Szadek  thinks  that  its  action  is 
like  that  of  other  preparations  of  iodine,  but  that  it  is  less  energetic  than 
iodide  of  potassium.  He  believes  that  iodol  can  be  used  instead  of  iodide 
of  potassium  when  a  mild  and  prolonged  action  is  desired,  but  that  when 
a  rapid  and  energetic  action  is  necessary  it  is  well  to  employ  the  latter 
drug. 

I  have  given  iodol  a  careful  trial  in  public  practice  in  a  goodly  number 
of  cases  of  tertiary  syphilis,  in  which  the  iodide  usually  acts  promptly 
and  satisfactorily,  and  have  become  convinced  that  it  has  very  little,  if 
indeed  any,  noteworthy  therapeutic  effect.  In  this  experience  I  find  that 
I  am  in  accord  with  Schwimmer.^  Though  I  have  not  observed  toxic 
catarrhal  symptoms,  I  have  seen  disturbances  of  the  stomach  and  diar- 
rhoea produced  by  doses  of  5  and  10  grains. 

For  some  cases  of  late  secondary  and  early  tertiary  lesions  of  the  skin, 
particularly  when  attended  with  scaling,  Donovan's  solution — liquor 
arsenii  et  hydrargyri  iodidi — is  sometimes  beneficial.      The  dose  is  5  to 

'  Monatshef/e  fur  Prak.  Dermat,  vol.  xvii.,  Nov.  15,  1893. 

^  "  Ueber  die  Therapentische  Verwendung  des  lodols,"  Vierleljahr.  fur  Derm,  und 
Syphili.%  1886,  pp.  583  et  seq. 

*  "  Ueber  die  Therapentische  Verwendung  des  lodols  bei  inneren  Krankheiten," 
BerL  kiln.  Wochensehrift,  1889,  pp.  26  et  seq. 

*  ''  Die  Tlierapentische  Verwendbarkheit  des  lodols  in  der  Syphilidolgischen  Praxis,'' 
Wiener  med.  Presste,  Nos.  8,  9,  and  10,  1890. 

^  Die  Grundllnien  der  Heuliyen  Syphili.'i-lherapie,  Hamburg,  1888. 


854  SYPHILIS. 

10  drops,  given  in  a  bitter  tincture  and  well  diluted  with  water,  an  hour 
after  eating. 

Decoctions  and  infusions  of  such  vegetables  as  sarsaparilla,  yellow 
dock,  saponaria,  stillingia,  and  others  have  long  been  held  in  high  esteem 
by  the  laity  for  the  treatment  of  syphilis.  They  have  absolutely  no  anti- 
syphilitic  influence,  and  if  they  are  beneficial  at  all,  the  effect  is  due  to 
their  influence  as  tonics,  stomachics,  diuretics,  or  diaphoretics.  They  may 
be  beneficial  as  adjuvants  to  mercury  and  iodide  of  potassium. 

In  Germany  largely,  and  in  America  not  very  frequently,  Zittman's 
decoction  is  used  in  old,  obstinate  cases  of  syphilis  when  the  usual  reme- 
dies are  badly  if  at  all  borne,  and  when  the  physician  is  at  his  wits'  end 
to  know  what  to  do.  In  many  very  unpromising  cases  I  have  seen 
beneficial,  and  even  striking,  results ;  hence  this  remedy  should  be  kept 
in  mind.  The  formulae  for  the  strong  and  the  weak  decoctions  are  as 
follows : 

Zittmann^s  Decoction — Strong.  Zittmann's  Decoction —  Weak. 

R .  Sarsaparilla,  cut,         .|xiiss ;  Add  to  the  dregs  of  the  strong  decoction. 

Water,                          ^325,  troy.  Sarsaparilla,  bruised,       0L; 

Digest  for  twenty -four  hours,  and  add —  Water,                                §325,  troy. 

Alum,  Heat  by  a  steam-bath,  in  a  covered  vessel, 

Sugar,                    da.  ^vj,  for  three  hours,  adding  toward  the  close, 

enclosed  in  a  linen  rag.     Heat  by  a  steam-  Lemon-peel, 

buth,  in  a  covered  vessel,  for  three  hours,  Cinnamon, 

adding  toward  the  close.  Cardamom, 

Anis,  Licorice-root,              da.  ^uj. 

Fennel,                  da.  .^iv ;  Express,   strain,  and    decant ;     it    should 

Senna,                          [^iij ;  weigh  312  troy  ounces.^ 

Licorice-root,             giss.  Label  "  Weak  Decoction." 
Express,  strain,  and  after  several  hours  de- 
cant.    It  should  weigh   312  troy  ounces. 
Put  aside  as  a  strong  decoction. 

When  decoction  Zitmani  (with  one  t)  is  prescribed,  it  is  prepared  in  a 
similar  manner,  except  that  to  the  sugar  and  alum  are  added — 

R .  Calomel,  5J  ; 

Cinnabar,  gr.  xv. — M. 

Enclosed  in  a  linen  bag. 

Of  the  strong  decoction  it  is  necessary  to  drink  a  pint  in  the  morning, 
and  of  the  weak  a  quart  in  the  evening.  The  efi'ect  of  this  treatment  is 
enhanced  by  placing  the  patient  in  bed  and  inducing  well-marked 
diaphoresis.  These  large  doses  produce  also  a  cathartic  action,  some- 
times very  violent,  and  it  may  be  necessary  to  reduce  them.  I  have 
seen  much  improvement  in  the  patient's  general  condition  produced  by 
this  method.  Tt  frequently  improves  the  appetite,  and  by  its  cathartic 
and  tonic  eff"ect  renders  the  system  tolerant  of  active  antisyphilitic 
remedies  which  previously  had  acted  badly. 

Under  the  name  "  succus  alterans "  a  remedy  has  attained  much 
vogue  within  a  few  years  in  the  treatment  of  syphilis,  chiefly  among  the 
laity.  It  is  made  of  roots  and  herbs.  This  preparation  was  first  ex- 
ploited by  the  late  Dr.  J.  Marion  Sims,wdio  claimed  that  it  had  produced 
wonderful  results  in  the  treatment  of  syphilis  in  Southern  negroes.     The 


THE  GENERAL  METHODICAL  TREATMENT  OF  SYPHILIS.      855 

following  is  a  modification  of  the  prescription  of  Dr.  McDade,  in  whose 
practice  Dr.  Sims  first  saw  it  used : 

I^.    Ext.  smilacis  sarsaparillse  fl., 
Ext.  stillingia  sylvat.  fl., 
Ext.  kappge  minoris  fl., 
Ext.  phytolaccge  decand.,  da.  fgij  ; 

Tine,  xanthoxlyon  carolin.,  fgj. — M. 

Take  a  teaspoonful  in  water  three  times  a  day  before  meals,  and  grad- 
ually increase  to  tablespoonful  doses. 

I  have  seen  many  patients  who  have  taken  this  remedy  at  the  advice 
of  physicians  and  of  their  own  accord,  and  have  never  seen  it  produce 
the  slightest  antisyphilitic  effect.  In  some  cases  it  seemed  to  exert  a  mild 
tonic  action,  and  in  others  produced  a  pleasing  purgative  effect.  It  is  a 
remedy  in  high  esteem  among  some  syphilitic  cranks,  who,  though  cured, 
will  persist  in  swallowing  drugs.  I  have  known  it  to  be  prescribed  as  a 
placebo  in  the  intermissions  of  a  mercurial  course.  Doing  no  harm,  it 
can  do  little  good,  and  the  human  race  will  not  be  the  loser  when  this 
compound  shall  have  had  its  day. 

Cathelineau  and  Rebourgeon^  have  called  attention  to  a  preparation 
much  used  by  the  natives  of  Brazil,  which  is  called  murur^  or  vegetable 
mercury.  It  is  a  drastic  cathartic,  and  is  used  by  the  natives  for  rheu- 
matism and  syphilis.  The  juice  is  a  reddish  liquid  of  vinous  odor  and 
sweetish  taste.  Injected  into  a  rabbit,  death  soon  followed,  and  at  the 
autopsy  the  stomach,  intestines,  heart,  and  kidneys  were  found  to  be  very 
hypersemic.     No  clinical  facts  are  given. 

I  have  seen  and  tried  these  so-called  vegetable  specifics  for  syphilis 
from  South  America,  and  beyond  a  purgative  effect  have  found  them 
inert. 

As  an  adjuvant  in  the  treatment  of  syphilis  the  fluid  extract  of  coca 
is  a  very  valuable  agent.  It  is  in  no  sense  a  specific,  and  its  beneficial 
action  consists  in  its  marked  tonic  effect  upon  the  heart,  capillaries,  and 
nervous  system,  and  upon  nutrition  in  general.  In  anaemia  and  cachexia 
and  in  the  adynamic  condition  occasionally  induced  by  mercury  and 
iodide  of  potassium  it  sometimes  works  wonders.  In  some  cases  I  have 
seen  it  induce  a  condition  of  health  by  which  mercury,  which  at  first  was 
badly  borne,  became  tolerated  and  curative.  In  malignant  precocious 
syphilis  it  acts  well  by  improving  the  general  nutrition.  It  is  very 
often  beneficial  to  patients  addicted  to  alcoholics,  and  it  may  then 
take  the  place  of  those  stimulants.  My  favorite  prescriptions  are  as 
follows : 

I^.    Fl.  ext.  erythoxylon  cocse,  §ij  ; 

Tine,  cinchon.  comp.. 
Tine,  gentian,  comp.,  da.  §ij. — M. 

Dose,  two  teaspoonfuls  in  a  wineglassful  of  water  three  times  a  day,  an 
hour  after  meals. 

^  "  Sur  I'Ecorce  de  Murure,  ou  le  Mercure  vegetal,"  Annales  de  Derm,  et  SyphiL,  April, 
1893,  pp.  458  et  seq. 


856  SYPHILIS. 


^.    Fl.  ext.  erythroxylon  cocse,  §ij  ; 
Tine,  gentian,  comp., 

Tine,   cinchon.  comp.,  da.  Ij  ; 

Elix.  ealisayse,  |iv.- — M. 

Dose,  one  tablespoonful  in  a  wineglassful  of  water  three  times  a  day, 
one  hour  after  meals. 

The  the  Mariani  is  a  very  reliable  preparation  of  coca,  being  prac- 
tically a  fluid  extract.  In  some  cases  this  preparation  produces  sour 
stomach,  which  may  be  obviated  by  temporarily  reducing  the  dose. 
In  others,  again,  a  sensation  of  fulness  in  the  head,  burning  of  the 
eyes,  and  buzzing  in  the  ears — in  fact,  a  sensation  of  mild  intoxica- 
tion— may  be  produced.  Under  these  circumstrnces  the  dose  should 
be  reduced. 

The  use  of  bichromate  of  potassium  in  syphilis  is  only  to  be  mentioned 
and  condemned. 

The  Inunction  Method. — The  inunction-treatment,  which  consists  in 
rubbing  into  the  skin  metallic  mercury  or  some  mercurial  preparation, 
mixed  or  suspended  in  a  fatty  vehicle,  is  the  oldest  method  known, ^  and 
is  the  one  concerning  which  the  testimony  of  all  physicians  is  that  it  is 
the  most  active,  sure,  and  rapid  in  its  effects  of  any  mode  of  adminis- 
tering mercury.  The  objections  to  it  are  that  it  is  dirty,  unpleasant,  and 
disagreeable ;  that  it  soils  the  skin  and  the  patient's  linen  and  the  bed- 
clothes ;  that  it  necessitates  time  and  trouble  in  its  use,  and  subjects 
the  patient  to  the  risk  of  exposure.  For  these  reasons  it  is  repugnant  to 
many  patients,  particularly  to  women.  Some  claim  that  the  method  is 
unscientific  and  not  exact,  which  may  be  true,  but  it  is  efficacious. 
Many  authors  lay  particular  stress  upon  the  occurrence  of  stomatitis 
from  the  employment  of  this  method,  and  give  their  readers  the  im- 
pression that  this  danger  is  inevitable.  Such  statements  are  either 
based  upon  the  want  of  a  thorough  knowledge  of  this  method  of  treat- 
ment and  of  its  technique,  or  upon  results  which  have  followed  its  care- 
less and  intemperate  use. 

Inunction  treatment  of  syphilis  by  mercury  has,  particularly  within 
the  past  ten  years,  come  into  more  general  use  and  favor,  and  the  present 
indications  are  that  it  will  be  more  and  more  widely  adopted  than  here- 
tofore, not  only  as  an  adjuvant,  but  also  as  the  regular  system  of  cure. 
A  very  noteworthy  fact  to  be  gleaned  from  the  words  and  Avritings  of  the 
most  advanced  syphilographers  is,  that  they  are  gradually  losing  faith  in 
mercury  by  mouth-ingestion  as  the  regulation  method  of  treatment,  and 
are  using  mercui'ial  inunctions  much  more  frequently  and  for  much 
longer  periods  than  they  did  in  former  years.  The  fear  which  was  once 
so  general  as  to  the  use  of  mercurial  frictions  has  very  largely  passed 

^  Mercurial  inunction  was  used  at  the  very  earliest  period  of  the  authentic  history  of 
syphilis.  In  Douglas's  Bibliographica  Anatomica,  Lyons,  1734,  it  is  said  that  Eeren- 
garius  was  tlie  discoverer  of  its  merits,  as  shown  by  the  following:  "Jacobus  Beren- 
garius  Carpensis  ita  dictus  a  Carpi  civitate  in  Italia  ....  inunctions  ex  hydrargyro  in 
cura  luis  venerese  primus  fuit  inventor  illoque  solo  quaettu  mir^  oppulentus  redditus  est." 
Also  in  Joseph  Griinpeck's  Traclntiis  de  Pestileiiliali.  Scorra  sive  mala  de  Franzos,  1496, 
mercurial  ointment  for  the  cure  of  syphilis  is  mentioned,  as  well  as  a  gargle  to  be  used 
in  case  of  salivation. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      857 

away,  and  confidence  in  this  method  is  gradually  extending.  This  is 
largely  due  to  the  fact  that  our  knowledge  of  syphilis  is  more  precise  and 
extended  than  in  former  days,  and  that  we  are  better  able  to  determine 
the  conditions  produced  by  the  disease,  and  also  the  morbid  states 
actually  caused  by  the  improper  use  of  mercury.  The  indications  to-day 
are,  that  this  mode  of  treatment  will  ultimately  supplant  in  a  general  way 
the  other  modes,  though  mouth-ingestion  will  of  necessity  be  used  in  very 
many  cases  under  certain  conditions  as  a  method  of  expediency,  and 
fumigation  will  still  be  employed,  and  injections  given  according  to  the 
varying  condition  and  peculiar  necessities  of  the  cases. 

It  is  a  mistaken  idea  that  most  patients  will  not  undergo  the  inunction 
cure.  There  are  those  who,  by  reasons  of  indifference  and  of  the  draw- 
backs incident  to  the  method,  and  for  prudential  considerations,  may  be 
unwilling  or  unable  to  submit  to  it.  But,  on  the  other  hand,  I  have  found, 
and  others  have  found  and  will  find,  that  if  the  advantages  of  the  treat- 
ment are  clearly  and  conspicuously  presented  to  the  patient,  he — or  even 
she — will  usually  adopt  it.  It  is  also  a  mistake  to  think  that  intelligent, 
well-to-do  patients  will,  as  a  rule,  refuse  this  method  of  treatment.  They 
of  course  would  prefer  the  simple  and  expeditious  method  of  mouth-inges- 
tion, but  Avhen  they  are  told  of  the  great  and  paramount  advantages  of 
the  inunction  method,  of  the  immunity  from  present  discomfort  and  suf- 
fering which  it  offers,  and  the  future  cure  which  it  renders  so  probable, 
they  very  generally  consent  to  undergo  it.  Indeed,  in  my  experience  it 
is  much  easier  to  obtain  the  consent  of  patients  in  the  upper  walks  of  life 
to  submit  to  and  follow  up  the  inunction-cure  than  it  is  to  deal  with 
patients  in  a  lower  sphere  of  life.  Intelligent  people,  having  syphilis,  as 
a  rule  realize  the  jeopardy  that  they  are  in,  and  are  willing  to  submit  to 
much  discomfort  and  annoyance,  provided  they  have  a  reasonable  hope 
that  they  are  to  be  the  gainers  thereby.  On  the  other  hand,  it  is  almost 
a  hopeless  task  for  physicians  to  treat  patients  who  are  not  intelligent  and 
whose  sanitary  surroundings  are  not  good.  In  dispensary  practice  it  is 
often  hard  work  to  make  patients  use  their  inunctions,  and  in  hospitals 
the  mercurial  friction  should  be  administered  by  the  orderly  or  nurses,  for 
as  a  rule  the  patient  will  make  away  with  his  packet  of  mercurial  oint- 
ment, and  little  if  any  of  it  will  reach  his  skin. 

Though  many  authors  have  written  in  favor  of  the  inunction-treat- 
ment, it  must  be  conceded  that  the  writings  of  Sigmund  ^  have  done  most 
to  popularize  the  method,  to  rid  it  of  its  dangers,  and  to  place  its  employ- 
ment upon  a  safe  and  scientific  basis.  In  earlier  days  the  method  was 
followed  in  a  crude  and  even  reckless  manner,  and  as  much  harm  as  good 
resulted  from  its  use.  A  quotation  from  Brandis  ^  will  be  of  interest  in 
this  connection.  He  says :  "  Formerly,  indeed,  the  dread  of  inunction 
was  well  grounded :  let  us  consider  how  patients  were  treated  who  were 
obliged  to  undergo  this  course.  For  weeks  at  a  time  they  remained  shut 
up  in  hot  chambers  filled  with  mercurial  vapor.  The  ingress  of  fresh  air 
was  carefully  avoided,  and  merely  starvation  diet  was  allowed.  Never- 
theless, surprising  cures  often  took  place,  which  caused  so  much  the  more 
astonishment  as  the  most  desperately  obstinate  and  severe  cases  were 
selected.     But  what  results  were  not  produced !     Salivation,  mercurial 

^  Die  Einreibungscur  niit  grauer  Quecki^Uhers^albe  bei  Si/philisfoi'men,  Vienna,  1878. 
^  Principles  of  the  Treatment  of  Syphilis,   Dublin,  1882. 


858  SYPHILIS. 

fever,  wasting  of  the  tissues,  even  death  itself,  not  infrequently  followed." 
Sigmund's  dictum  was  as  follows :  "In  the  treatment  of  syphilis  we  not 
only  do  not  require  the  manifestation  of  mercurial  poisoning,  but  we  cure 
venereal  disorders  more  surely  in  proportion  as  we  guard  the  body  from 
such  manifestations." 

In  adopting  the  inunction  method  many  considerations  should  be  borne 
in  mind.  In  the  first  place,  it  is  absolutely  essential  that  the  hygienic 
surroundings  of  the  patient  should  be  in  a  satisfactory  condition.  He 
should  have  plenty  of  fresh  air  and  good,  generous  food,  and  should  be 
comfortably  situated  at  his  home.  He  should  be  as  free  as  possible  from 
mental  and  physical  strain,  and  should  have  ample  time  for  exercise,  rest, 
recreation,  and  sleep.  While  undergoing  this  course  of  treatment  he 
should  use  every  effort  to  keep  his  health  and  nutrition  at  as  high  a 
standard  as  possible,  and  to  keep  himself  from  hurry,  bustle,  anxiety, 
care,  worry,  and  mental  over-strain.  He  should  eat  such  food  as  will 
nourish  best,  and  avoid  all  that  taxes  his  digestive  powers.  He  should 
be  careful  to  avoid  all  beverages  which  tend  to  derange  the  stomach  or 
cause  diarrhoea.  Exposure  to  cold  and  dampness  must  be  carefully 
guarded  against,  and,  though  an  abundance  of  fresh  air  is  necessary, 
ample  protective  clothing  must  be  worn.  In  winter  flannel  should  be 
worn  next  to  the  skin,  and  the  bed-room  should  be  well  ventilated  and 
kept  at  a  temperature  of  about  65°  Fahr.  Moderate  exercise  is  to  be 
commended,  but  violent,  excessive,  or  exacting  physical  exertion  (the  so- 
called  athletic  sports)  is  to  be  condemned.  As  a  general  rule,  if  the  con- 
dition of  the  case  is  not  urgent  and  will  admit  of  it,  it  is  well  during 
periods  of  severe  cold  and  great  dampness  to  omit  the  inunctions  if  the 
patient  is  obliged  to  be  out  of  doors,  and  also  during  periods  of  intense 
heat  in  the  city.  There  is  a  prevailing  opinion  among  the  profession  and 
the  laity  that  persons  undergoing  an  inunction-cure  are  to  an  unusual 
degree  liable  to  take  cold.  It  is  well  always  to  see  that  these  patients  are 
not  unduly  exposed  and  that  they  are  properly  protected,  but  as  I  look 
back  I  can  recall  many  patients  of  the  out-door  dispensary  class  who, 
despite  warning,  exposed  themselves  to  cold  while  using  the  inunctions. 
On  this  subject  Raphael,^  who  had  a  large  out-door-poor  service  for  many 
years  at  Bellevue  Hospital,  says :  "As  regards  the  danger  to  patients  of 
taking  cold  during  its  employment,  all  I  can  say  is  that  I  have  repeatedly 
seen  patients  come  to  my  out-patient  clinic  with  a  considerable  amount  of 
the  mercury  rubbed  in  upon  their  person,  without  the  least  harm  result- 
ing therefrom  (though  they  were  cautioned  against  such  a  course),  evi- 
dently having  gone  about  in  that  condition  for  days  without  washing  off 
the  ointment,  many  of  these  patients  being  insufficiently  clothed  at  that," 
My  experience  in  the  same  syphilitic  service  many  years  ago  was  precisely 
like  that  of  Dr.  Raphael.  Brandis  very  pertinently  says  on  this  subject : 
"  Excessive  dread  of  catching  cold,  even  at  the  present  day  so  widely  dis- 
seminated, causes  frequently  great  harm.  Of  course  every  intelligent 
patient  will  protect  himself  from  cold  ;  but  we  frequently  meet  with  people 
who  make  themselves  ill  by  carrying  their  precautions  too  far." 

Spreading  of  Mercurial  Ointment  on  the  Skin. — Welander^  has  lately 

^  "  On  Some  Practical  Points  in  the  Treatment  of  Syphilis  with  Inunction  of  Mer- 
cury," N.  Y.  Med.  Journal,  March  6,  1886. 

2  "Ueber  der  Behandlung  der  Syphilis  mittelst  Ueberstreichens,  etc.,"  Arch,  filr  Dei-m. 
und  Syph.,  Ergilnzungsheft,  ISo.  I,'l893,  pp.  115  et  seq. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      859 

proposed  this  method  of  smearing  the  skin  with  mercurial  ointment  and 
allowing  it  to  stay  on  indefinitely.  In  a  series  of  experiments,  in  which 
the  urine  was  carefully  analyzed,  he  convinced  himself  that  the  therapeutic 
agent  is  received  into  the  system  even  more  promptly  and  in  a  greater 
quantity  than  when  inunctions  are  practised.  The  advantages  claimed  for 
this  method  are  that  the  patient  can  treat  himself  and  thus  does  not  need 
a  rubber.  It  is  a  simple  and  easy  method  and  it  requires  little  time  for 
its  application.  In  this  way  of  using  blue  ointment  there  is  said  to  be 
less  liability  to  dermal  irritation. 

In  accordance  with  the  view  entertained  by  many  that  mercurial  in- 
unctions act  only  by  virtue  of  the  vapors  of  mercury  which  they  emit, 
Vigier,  Merg^,  and  Carles^  propose  the  use  of  flannels  saturated  with 
mercury  in  a  condition  of  minute  subdivision.  They  are  placed  on  the 
patient's  chest  or  upon  the  pillow  at  night.  It  is  claimed  that  these 
flannels  give  oS"  mercury  so  freely  that  it  can  be  detected  in  the  patient's 
urine.  The  authors  think  that  from  eight  to  nine  milligrammes  are 
absorbed  in  eight  hours.  Further  observation  of  this  method  is 
necessary. 

The  most  reliable  and  efiicient  preparation  of  mercury  for  the  inunc- 
tion-cure is  the  officinal  mercurial  or  blue  ointment — unguentum  hydrar- 
gyri — of  a  strength  of  50  per  cent.,  as  a  rule.  In  some  cases  the  mild 
ointment  (25  or  30  per  cent.)  may  be  used.  It  is  most  important  that 
this  preparation  shall  be  well  made  and  perfectly  fresh.  It  is  not  suffi- 
cient simply  to  order  the  blue  ointment,  but  the  patient  should  be 
impressed  with  the  necessity  of  obtaining  a  perfectly  pure  preparation, 
and  should  be  particularly  instructed  to  purchase  it  of  only  reliable 
apothecaries  who  frequently  renew  their  stock.  Many  instances  of 
irritation  of  the  skin  are  due  solely  to  the  rancidity  of  the  ointment 
rubbed  in.  The  matter  of  the  dose  should  be  carefully  looked  after,  so 
that  absolute  precision  is  obtained.  Some  authors — and  among  them 
Cheminade^ — think  that  lanolin  is  to  be  preferred  to  lard  in  the  manu- 
facture of  mercurial  ointment — an  opinion  with  which  I  must  emphati- 
cally differ.  I  had  some  mercurial  ointment  thus  prepared,  and  it  was 
pronounced  by  patients  who  were  by  no  means  faultfinding  to  be  very 
unsatisfactory,  in  being  less  readily  rubbed  in  and  being  sticky,  gummy, 
and  much  less  eff"ective  and  absorbable  than  the  officinal  ointment. 

On  the  other  hand,  a  blue  ointment  which  is  very  readily  absorbed 
by  the  skin  has  been  made  for  me  by  Fraser  &  Co.  Its  formula  is  as 
follows : 

I^.  Mercury,  8      ounces; 

Lanolin,  2^^  ounces ; 

Lard,  5^  ounces ; 

Tincture  benzoin  comp.,  160      min. ; 

Alcohol,  80      min. 

Triturate  the  mercury  with  the  tincture  and  alcohol  until  coarsely  sub- 
divided ;  then  add  portions  of  the  lanolin  and  lard,  and  continue 
the  trituration   until  the  mercury  is  thoroughly  subdivided. 

^  Journal  of  Cutaneous  and  Genlto-urinary  Diseases,  vol.  x.  1892,  p.  364. 

^  "  De  I'Emploi  de  la  Lanoline  comme  vehicule  de  rOnguent  napolitain  dans  le  Traite- 
ment  de  la  Syphilis,"  Gazette  Hebdom.  des  Sciences  med.  de  Bordeaux,  1887,  vol.  viii.  pp. 
433  et  seq. 


860  SYPHILIS. 

This  ointment  is  also  put  up  in  soft  gelatin  capsules,  called  "  ovules," 
which  contain  either  thirty  or  sixty  grains.  These  ovules  can  be 
used  very  expeditiously,  and  are  very  useful  to  a  patient  while  travel- 
ling. 

The  oleates  of  mercury  have  not  realized  the  hopes  that  were  for- 
merly entertained  as  to  their  ultimately  taking  the  place  of  blue  oint- 
ment in  the  treatment  of  syphilis.  In  the  form  of  20  and  30  per  cent, 
preparations  the  oleate  of  mercury  is  very  irritating  to  the  skin,  even 
more  so  than  blue  ointment.  My  colleague,  Dr.  Bumstead,  used  with 
preference  equal  parts  of  20  per  cent,  oleate  of  mercury  and  simple 
cerate,  which  is  an  unirritating  preparation.  Of  late  years  I  have 
used  a  combination  of  the  oleate  of  similar  strength  and  proportion 
with  vaseline.  Schwimmer^  uses  15  grains  of  oleate  of  mercury  (20 
per  cent.),  mixed  with  30  grains  of  vaseline — a  quantity  which  he  orders 
for  one  rubbing.  The  oleate  of  mercury,  however  combined,  is  rather 
more  apt  to  irritate  the  skin  than  blue  ointment,  and  must  be  used  with 
much  caution  and  with  not  too  much  friction.  It  is  at  best  a  less  reli- 
able and  efficient  preparation  than  blue  ointment,  and  should  be  reserved 
for  over-fastidious  patients.  As  a  remedy  for  general  medication  in 
syphilis  it  has  little  to  commend  it,  and  as  an  agent  for  local  or  regional 
treatment  it  is  far  inferior  to  white  precipitate  ointment  or  ointments 
made  of  several  other  mercurial  preparations,  notably  the  protoiodide, 
the  deutoiodide,  the  tannate,  salicylate,  and  the  bichloride. 

In  general,  the  quantity  of  mercurial  ointment  advised  by  writers 
is  too  large.  It  is  essential  for  the  successful  treatment  of  syphilis  to 
avoid  the  two  extremes  of  very  large  and  very  small  doses.  No  arbi- 
trary rules  can  be  laid  down,  but  general  principles  may  be  stated,  and 
by  them  a  physician  must  judge  how  much  of  this  remedy  he  shall 
prescribe.  It  is  important  to  remember  that  in  general  city  practice 
(the  patients  being  usually  of  the  active,  busy  order)  a  rather  smaller 
quantity  should  be  used  than  we  should  employ  upon  one  who  has  the 
opportunity  of  recreation  away  from  home  and  its  cares.  Fournier^ 
says  that  Doyon  has  been  able  to  use  five  drachms  of  mercurial  oint- 
ment at  the  IJriage  Thermal  Springs  in  combination  with  the  waters, 
and  at  other  thermal  springs  larger  quantities  of  the  ointment  can,  be 
used  than  at  home.  I  have  been  able,  the  necessity  existing,  to  use 
at  our  seaside  resorts,  the  patients  taking  daily  hot  salt-water  baths, 
quantities  of  mercurial  ointment  which  at  home  would  be  harmful. 
So  that  we  must  remember  that  there  is  an  average,  fairly  large  dose 
for  a  patient  who  is  at  a  watering-place  or  a  rural  abode  of  recreation, 
and  another  and  smaller  dose  for  those  who  have  to  stay  at  home,  and 
who  cannot  throv>'  off  their  social  or  business  cares,  but  are  confined  to 
the  daily  treadmill  of  city  life. 

In  general,  for  adult  recreating  patients  following  hygienic  rules 
60  grains  of  mercurial  ointment  may  be  employed  for  each  friction. 
This,  as  a  rule,  will  be  well  borne  by  a  man  of  good  physique  and 
average  build,  but  it  would  be  too  large  for  a  thin,  spare  man  of 
weakly   constitution.     At  thermal  springs  as  much  as  120  grains  are 

1  Op.  cit,  1888,  p.  51. 

2  "  De  I'Emploi  des  Frictions  mercurielles  dans  le  Traitemeut  de  la  Syphilis,''  Union 
mediccde,  June  11,  1891. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      861 

sometimes  used  in  their  "lightning  cures,"  but  such  quantities  are 
scarcely  called  for,  and  should  only  be  used  with  the  greatest  care 
and  circumspection. 

For  general  practice  the  average  dose  of  blue  ointment  may  be 
stated  at  from  40  to  45  grains,  a  larger  dose  being  used  upon  robust 
and  well-developed  patients,  and  a  smaller  one  upon  those  of  thin  and 
flabby  structure.  The  early  rubbings  are  largely  tentative,  with  a 
view  of  gauging  the  patient  and  the  dose.  The  inunction-treatment 
should  never  be  begun  in  a  careless  manner.  The  case  being  a  suit- 
able one,  two  or  three  frictions  of  60  grains  each  may  be  tried  and  the 
effect  watched.  Some  patients  bear  these  inunctions  when  of  generous 
quantity  with  remarkable  tolerance  for  very  long  periods ;  others, 
again,  show  evidence  contraindicating  their  use  after  from  three  to 
six  rubbings.  Therefore,  the  physician  should  have  his  patient  well 
in  hand,  and  watch  him  very  carefully  every  day  or  two  until  he  has 
been  under  the  treatment  for  at  least  two  or  three  weeks.  As  the  fric- 
tions are  given  and  benefit  is  evident,  the  dose  may  be  increased  to  60 
or  80  grains  of  the  ointment ;  and  in  general,  for  regular  routine  treat- 
ment, this  quantity  will  be  found  ample,  but  in  emergencies  and  exigen- 
cies a  larger  quantity  will  be  required.  While  the  patient  is  under 
this  treatment  (the  general  and  special  condition  being  favorable)  the 
physician  must  watch  and  question  him,  to  learn  that  he  feels  stronger 
and  even  gains  weight,  which  is  very  common  when  this  treatment  is 
beneficial,  and  is  really  one  of  the  first  signs  of  improvement,  or  that  he 
loses  flesh  ;  that  his  strength  is  satisfactory ;  that  his  appetite  is  good 
and  digestion  perfect ;  that  he  has  no  elevations  or  oscillations  of  tem- 
perature ;  that  he  sleeps  well  at  night  and  awakes  refreshed ;  and  that 
he  is  in  no  manner  troubled  with  any  nervous  symptoms,  even  slight. 
If,  in  short,  a  man  shows  signs  of  doing  well,  has  no  mouth,  stomach, 
or  intestinal  troubles,  and  it  is  evident  that  his  lesions  and  symptoms 
are  being  bettered,  the  physician  may  know  that  he  is  on  the  right 
track,  and  should  go  ahead,  but  should  always  be  on  the  lookout  for  the 
mouth  and  the  gastro-intestinal  tract.  When  mercury  is  thus  intro- 
duced through  the  skin,  it  is  thought  that  it  enters  not  by  the  lungs, 
but  by  way  of  the  sweat,  hair,  and  sebaceous  follicles,  into  the  lymph- 
spaces,  and  then  it  becomes  albuminized  and  ready  for  absorption.  We 
then  have  the  stomach  free  for  food,  tonics,  or  the  iodide  of  potassium 
if  it  is  indicated.  Thus  we  may  improve  digestion  and  nutrition  by 
agents  such  as  iron,  quinine,  strychnine,  coca,  hypophosphites,  etc. 
This  coincident  tonic  course  is  often  very  beneficial  in  improving  the 
condition  of  the  syphilitically  affected  tissues,  and  in  rendering  them 
more  amenable  to  the  specific  action  of  the  mercury.  In  this  connection 
it  is  to  be  prominently  remembered  that  a  decided  tonic  action  is  pro- 
duced by  generous,  nutritious  diet,  which  does  so  much  to  engraft  upon 
the  tissues  the  power  of  resistance  to  the  syphilitic  poison.  This  fact 
has  recently  been  well  brought  out  by  Dymnicki,^  who  strongly  advises 
quinine  in  weak  and  debilitated  syphilitic  persons  whose  temperature 
and   weight  are   subject   to   great  oscillations.     By  its  use  the   bodily 

^  "  Action  of  Quinine  in  some  Grave  Cases  of  Syphilis  treated  by  Inunction,  affect- 
ing Temperature,  Pulse,  and  Weight  of  Body,"  Gaz.  Lekarska,  1889,  2,  8,  ix.  pp.  388 
et  seq. 


862  SYPHILIS. 

weight  is  increased  and  general  improvement  follows.  Dymnicki  found 
— and  my  experience  is  in  accord  Avith  his — that  in  many  cases  the  use 
of  quinine  enables  us  to  increase  the  quantity  of  mercurial  ointment. 
Schwimmer  ^  advises  in  weakly  and  anaemic  persons  a  preliminary  course 
of  the  syrup  of  iodide  of  iron  before  beginning  the  inunction-treatment. 
In  my  own  practice  I  have  often  derived  benefit  from  a  similar  course. 

The  next  consideration  is  the  preparation  of  the  skin  for  the  inunction- 
treatment.  The  circumstances  and  conditions  are  rather  different  when 
the  treatment  is  received  at  home  from  that  administered  at  thermal  baths 
and  at  health  resorts.  When  the  patient  undergoes  the  frictions  at  home 
he  must  first  have  a  local  or  general  bath.  As  a  rule  in  city  life,  the 
inunctions  are  of  necessity  taken  in  the  evening,  whereas  in  health  resorts 
it  is  well  that  they  should  be  taken  in  the  morning.  The  home  patient 
may  take  a  bath  at  a  temperature  of  96°  to  98°  F.,  after  which  he  should 
be  well  rubbed  with  a  towel.  When  possible,  in  warm  weather  one  or  two 
Turkish  baths  a  week  may  be  taken  in  alternation  with  the  regular  baths. 
But  of  these  baths  the  physician  must  be  very  watchful,  and  if  they  in 
any  way  tend  to  debilitate  the  patient,  who  under  the  circumstances  sleeps 
poorly  and  awakes  unrefreshed,  stiff,  and  weak,  they  should  be  discon- 
tinued. Under  these  circumstances,  and  when  it  is  impossible  to  have 
bathing  facilities,  the  part  to  be  anointed  should  be  carefully  washed  with 
warm  water  and  soap,  and  then  sponged  with  a  2  or  3  per  cent,  solution 
of  carbolic  acid.  This  latter  application  should  also  always  be  used  after 
the  general  bath.  By  strict  attention  to  the  aseptic  condition  of  the  skin 
we  can  almost  always  avoid  dermal  inflammatory  complications.  When  it 
is  urgently  necessary  to  treat  parts  covered  with  hair,  they  may  be  clipped, 
or  even  shaved,  and  then  thoroughly  washed  with  the  carbolic  solution. 
Upon  parts  sparsely  supplied  with  hairs  great  care  should  be  taken  that  an 
aseptic  condition  be  produced.  By  means  of  this  care  many  unpleasant 
drawbacks  may  be  avoided. 

It  is  always  best  that  the  inunctions  should  be  made  by  a  professional 
rubber  or  a  trained  nurse,  if  possible.  If,  owing  to  circumstances,  the 
patient  must  be  his  own  rubber,  he  should  be  made  clearly  to  understand 
the  technique.  In  the  first  place,  the  physician  must  see  that  the  dose  is 
made  precise,  and  if  the  ointment  is  put  up  in  packets  of  oiled  paper 
allowance  must  be  made  for  the  loss  occasioned  by  the  adherence  of  some 
of  the  ointment.  Then  no  glove  or  pads  or  protective  coverings  to  the 
hands  should  be  used.  It  is  a  mistaken  idea  that  persons  administering 
the  inunctions  are  liable  to  salivation,  for  they  are  not,  provided  they  take 
ordinary  precautions.  I  have  employed  many  trained  rubbers  and  nurses 
in  this  treatment,  and  I  have  never  seen  any  untoward  condition  of  the 
hands  result.  Brandis,^  Wilson,^  and  others,  who  have  had  much  experi- 
ence at  Aix-la-Chapelle  and  at  our  own  Hot  Springs  of  Arkansas,  also 
speak  of  the  immunity  to  local  and  general  mercurialization  enjoyed  by 
professional  rubbers.  The  simple  procedure  of  anointing  the  hands  with 
oil  or  with  a  stiff  simple  cerate,  or  even  with  soap,  will  effectually  prevent 
the  absorption  of  the  mercurial  ointment. 

The  ointment  should  be  divided  into  several  portions,  and  each  one 
should  be  firmly  rubbed  into  the  skin,  employing  the  two  palms  when  the 

1  Loc.  cit.,  p.  79. 

^  "  On  the  Treatment  of  Syphilis,"  Lancet,  March  27  and  April  5,  1886. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     863 

anatomical  arrangement  of  the  parts  will  admit  of  it.  Combined  with  the 
friction,  a  moderate  amount  of  massage  may  be  practised.  In  this  Avay  all 
the  ointment  must  be  rubbed  in,  so  that  no  lumps  are  left,  and  the  surface 
of  the  skin  will  then  look  as  if  it  had  been  lightly  pot-leaded.  As  a  gen- 
eral rule,  from  twenty  to  thirty  minutes  are  necessary  for  an  inunction. 
After  this  operation  suitable  night-clothes  should  be  put  on  to  protect  the 
bed-linen,  and  the  patient  should  retire.  When  the  preliminary  general 
bath  cannot  be  taken,  it  is  well  to  let  the  patient  drink  directly  after  the 
rubbing  a  pint  or  more  of  pure  hot  milk,  and  then  cover  himself  up  well 
with  blankets  in  order  to  induce  perspiration.  According  to  his  case  and 
to  the  whim  of  the  patient,  hot  lemonade  or  hot  tea  (and  in  some  cases  a 
little  brandy,  whiskey,  or  gin  may  be  added)  may  be  taken  to  produce 
diaphoresis  after  the  inunction.  For  this  purpose  hypodermic  injections 
of  pilocarpine  have  been  used,  but,  according  to  my  observation,  they 
are  not  beneficial  in  any  way.  Lewin  and  Zeissl  also  found  pilocarpine 
inefficient,  and  even  harmful,  in  the  treatment  of  syphilis. 

At  thermal  springs  the  patient  has  his  hot  bath  early  in  the  morning, 
then  his  inunction,  followed  by  a  period  of  repose  and  sweating.  After 
that  he  is  ready  for  his  walk,  and  during  the  day  may  partake  of  the 
mineral  waters  of  the  place.  In  my  judgment  (as  I  state  elsewhere),  no 
specific  effect  is  produced  by  the  waters,  either  taken  internally  or  used 
for  baths,  at  the  Hot  Springs  of  Arkansas,  at  Aix-la-Chapelle,  or  at  any 
other  thermal  resort.  The  beneficial  effect  is  largely  derived  from  a  variety 
of  conditions,  such  as  climate,  rest,  recreation,  and  abstinence.  It  is  very 
certain  that  at  all  springs  and  health  resorts  the  inunction-treatment, 
vigorously  pushed,  is  well  supported.  This  applies  to  patients  who  pursue 
the  method  at  our  seaside  resorts  and  use  hot  salt-water  baths,  and  also 
those  at  thermal  and  mineral  springs.  The  same  tolerance  of  mercury 
may  be  obtained  in  the  mountains  and  in  rural  districts  if  patients  are 
subjected  to  rigid  rules  of  hygiene  and  regimen.  It  is  a  matter  of  con- 
gratulation that  at  our  own  Richfield  Springs  all  the  benefits  so  much 
vaunted  at  Aix-la-Chapelle  and  Uriage  may  be  obtained.  When  patients 
are  stopping  at  sulphur  or  mineral  springs  they  instinctively  desire  to  drink 
the  waters,  but  they  should  do  so  only  under  medical  advice  and  super- 
vision. It  is  claimed  that  sulphur  waters  exert  a  depurative  action  and 
carry  ofi"  the  mercury  and  effete  products  through  the  kidneys  and  intes- 
tines. This  contention  is  not  clearly  settled ;  therefore  I  usually  tell 
patients  to  try  the  sulphur  waters  in  moderation,  and  if  they  agree  with 
them  and  they  are  seemingly  benefited,  they  may  continue  their  use.  But 
very  often  these  waters  produce  dyspepsia  and  gastro-intestinal,  and  even 
cystic,  irritation,  and  it  is  necessary  to  abandon  them.  The  other  mineral 
waters  at  our  resorts  should  be  employed  only  under  proper  advice. 

Among  many  of  the  laity,  and  among  some  physicians,  there  is  an 
impression  that  the  use  of  sulphur  baths  and  waters  internally  may  have 
a  revealing  influence  in  rendering  evident  a  latent  or  dormant  syphilitic 
condition,  and  some  physicians  at  the  thermal  springs  put  patients  through 
what  they  term  a  test  or  proof  cure  or  treatment.  In  my  judgment,  this 
opinion  is  incorrect,  and  I  agree  with  Spillman,^  Brandis,  and  others  that 
the  instances  in  which,  after  sulphur-water  treatment,  a  latent  syphilis  is 

^  "  Influence  des  Eanx  sulphureiises  d.ans  le  Traitement  de  la  Sypliilis,"  Comptes  Ren- 
dus  de  la  Sociele  de  Medicine,  de  Nancy,  1882. 


864  SYPHILIS. 

called  into  activity  are  either  mere  coincidences  or  the  result  is  due  to  the 
same  influences  which  ordinary  vapor  or  hot-water  baths  may  produce. 
It  has  been  claimed  by  Guntz^  and  others  that  the  waters  and  salts  of 
sulphur  springs  may  be  used  with  benefit  in  combination  with  the  inunc- 
tion-treatment followed  at  patients'  homes.  I  have  given  this  method  a 
careful  trial,  and  I  have  seen  it  followed  in  the  practice  of  other  physi- 
cians, and  my  opinion  is  that  no  perceptible  good  is  gained,  though  much 
trouble  and  expense  is  entailed.  In  every  large  city  the  facilities  for 
obtaining  sulphur  baths  are  ample,  and  it  is  advisable  in  those  cases  in 
which  the  inunctions  seem  to  be  backward  in  their  effects  to  alloAV  the 
patient  to  take  a  few  of  them  as  an  experiment.  In  general,  one  or  two 
sulphur  baths  a  week  during  an  inunction-treatment  may  be  a  benefit. 
They  certainly  have  a  decidedly  happy  moral  effect  on  some  patients.  In 
cases  of  ulcerative  lesions  particularly,  and  also  in  those  of  the  papular 
and  tubercular  forms,  sulphur  baths  and  simple  hot-water  and  vapor  baths 
are  often  of  much  aid  by  reason  of  their  stimulation  of  the  skin. 

Within  the  past  ten  years  I  have  seen  the  wisdom  of,  and  the  neces- 
sity for,  a  more  extended  and  comprehensive  application  of  mercurial 
ointment  in  the  treatment  of  syphilis ;  and  my  observations,  worked  out 
upon  a  clinical  basis,  have  been  confirmed  by  certain  pathological  studies 
made  by  Neumann.^  This  observer  has  shown  that  several  months  (four 
to  eight)  after  the  disappearance  of  visible  syphilitic  lesions  there  may 
remain  in  the  skin  in  and  around  its  glands  and  follicles,  and  around  its 
vessels,  morbid  products  consisting  of  exudation  cells.  This  infiltration 
of  small  round-cells  is  not  as  copious  and  extensive  as  it  is  in  very  early 
syphilis,  but-  its  occurrence  certainly  shows  how  the  disease  may  remain 
latent  in  the  system.  On  this  subject  I  may  quote  with  benefit  from  my 
own  paper :  ^  "  There  is  one  fact  that  the  surgeon  should  always  keep 
in  mind  in  the  treatment  of  syphilis — namely,  that  all  syphilitic  lesions, 
even  the  most  minute,  are  to  be  feared  as  possible  sources  of  continuous 
or  intermittent  reinfection  of  the  system.  The  morbid  cells  contained  in 
these  lesions  are  capable  of  great,  even  infinite,  multiplication,  and  the 
so-called  syphilitic  relapses  are  due  to  the  continual  recurrence  of  these 
cell-proliferations,  which  occur  from  morbid  foci  left  over  at  an  earlier 
date.  While  all  deposits  of  syphilitic  new-growths  in  any  part  or  tissue 
are  of  much  danger  in  their  ultimate  results,  those  which  occur  in  the 
lymphatic  ganglia,  in  the  lymphatic  vessels,  and  around  blood-vessels  are 
especially  so  by  reason  of  the  activity  of  growth  of  these  organs,  and  of 
their  very  ready  transposition  to  all  parts  of  the  body  by  means  of  the 
lymph  and  blood  circulation." 

Pathological  facts  like  these  prove  to  us  very  forcibly  that  besides  the 
general  mercurial  action  through  the  blood,  Ave  should,  whenever  it  is 
possible,  bring  mercury  into  direct  contact  with  the  syphilitic  processes 
by  what  is  termed  the  local  or  regional  method.  For  this  purpose  the 
inunction-treatment  is  especially  adapted,  since  by  the  absorption  of  mer- 
cury through  the  skin  morbid  processes  there  latent  are  cured  without  in 
any  way  impairing  the  general  constitutional  results. 

^  Die  Einreibunr/smr  bei  Syphilis  in  Verbindung  mil  Schwpfel-wmtsern,  Dresden,  1873. 
*  "Welches  Siiid  die  Anatomischen  Veriinderungen  der  leutischen  Plant  nach  Ablauf 
der  Klinischen  Erscheinnngen,"  Wein.  med.  Wochenschrift,  1885,  xxxv.  p.  825. 

3  "  Some  Practical  Points  in  the  Treatment  of  Sypliilis,"  Med.  News,  Dec.  7,  1889. 


THE  GENERAL   METHODICAL   TREATMENT  OF  SYPHILIS.      865 

It  is  very  possible  that  even  with  a  supposed  well-regulated  inunction 
course  after  the  older  plans,  some  lesions  may  escape,  and  thus  the  per- 
petuation of  the  disease  be  allowed.  This  fact  is  forcibly  shown  by  a  case 
reported  by  Kobner '  in  a  valuable  paper  on  the  local  and  regional  treat- 
ment of  syphilis,  of  a  man  who  was  covered  Avith  an  unusually  extensive 
and  abundant  papular  syphilide,  who  had  upon  the  back  a  molluscum, 
pendulum  as  large  as  a  nut,  upon  which  there  were  two  papules.  After 
six  weeks  of  treatment,  due  to  enormous  induration  of  the  lymphatic 
ganglia,  in  which  no  less  than  sixty  drachms  of  mercurial  ointment  were 
used,  all  the  papules  underwent  involution  except  the  two  upon  the  mol- 
luscous tumor,  which  had  escaped  the  inunction  process.  This  striking 
case  is  only  a  conspicuous  example  of  what  we  constantly  see  when  inunc- 
tions are  not  universally  made  over  the  whole  body.  Thus  even  with 
toxic  symptoms  of  mercurialization  present,  syphilitic  lesions  about  the 
anus  and  head  and  elsewhere,  which  have  not  been  brought  into  direct 
contact  with  the  mercurial  ointment,  will  very  frequently  be  seen  to  per- 
sist. Yet  in  these  cases  the  patient  (and  I  have  very  often  found  his 
physician  to  agree  with  him)  thinks  that  he  has  been  undergoing  a  most 
thorough  cure,  and  they  both  marvel  that  in  spite  of  such  seemingly  ener- 
getic measures  that  the  disease  should  persist. 

Therefore,  I  say  that  we  should  carry  out  the  inunction  treatment  in  a 
far  more  systematic,  thorough,  and  minute  manner  than  has  been  gener- 
ally done.  To  this  end  I  divide  the  body  into  eleven  subdivisions,  each 
of  which  is  to  be  submitted  to  its  own  mercurial  friction.  They  are  as 
follows : 

1.   The  neck  and  head. 

2  and  3.  The  arms,  palms,  and  axillae. 

4  and  5.  The  legs  and  soles. 

6  and  7.  The  thighs,  with  groins  and  Scarpa's  triangle. 

8  and  9.  The  breast  and  abdomen. 

10  and  11.  The  back  from  the  root  of  the  neck  to  lower  part  of  the 
gluteal  region. 

In  non-hairy  persons  there  is  little  trouble  in  anointing  the  neck.  In 
those  whose  necks  are  densely  covered  with  hair  we  may  be  forced  to  con- 
fine the  inunctions  to  the  parts  not  covered.  In  urgent  cases  and  where 
the  lesions  are  copious  it  is  necessary  to  have  the  hair  clipped  or  shaved. 
If  there  are  scalp  lesions  or  any  in  the  beard  an  ointment  composed  of 
Avhite  precipitate  30  grains  and  vaseline  1  ounce  may  be  used  freely.  In 
this  case  it  may  be  well  to  make  the  regular  dose  of  mercurial  ointment 
used  elsewhere  on  the  neck  smaller.  Prior  to  rubbing  the  ointment  into 
the  scalp  and  beard  shampoos  and  antiseptic  lotions  should  be  used. 

It  is  important  that  the  whole  surface  of  the  arms  should  be  acted 
upon  in  a  vigorous  manner.  If  there  are  any  lesions  of  the  palms,  these 
parts  should  receive  careful  attention,  and  in  any  case  it  is  well  to  anoint 
them  several  times  during  the  treatment.  It  is  most  important  to  bring 
the  ointment  into  contact  with  the  contents  of  the  axill?e  ;  and  this  can 
be  done  with  impunity,  provided  care  is  taken  that  the  parts  are  rendered 
aseptic. 

^  "Ueber  therapeutische  Verwerthung  der  localen  antisyphilitischen  Wirkung  des 
Qiiecksilbers,"     Tageblatt    der    Versamml.   Ueutsch.  Naturf.  und   Aerzte ;   and   Deut.  med. 
Wochenschrift,  1884,  pp.  757  et  seq. 
55 


866  SYPHILIS. 

The  legs  and  the  soles  should  be  well  rubbed  with  both  hands,  and 
any  lesions  upon  the  latter  parts  should  receive  especial  attention.  In 
like  manner  the  thighs  should  be  treated,  and  the  groins  and  the  surface 
over  Scarpa's  triangle  should  be  firmly  rubbed  for  a  sufficient  time.  If 
the  ganglia  in  the  groins  are  unusually  swollen,  it  may  be  necessary  to 
apply  a  layer  of  mercurial  ointment  on  lint  or  one  of  the  mercurial  plas- 
ters.     Care  need  not  be  taken  to  keep  the  ointment  from  the  scrotum. 

Sometimes  the  inunctions  produce  irritation  upon  the  breast  and 
abdomen,  and  the  method  is  pursued  with  difficulty.  Under  these  cir- 
cumstances all  means  toward  the  avoidance  of  dermatitis  and  follicular 
inflammation  should  be  adopted. 

Patients  rarely  have  any  difficulty  in  administering  to  themselves 
inunctions  upon  the  buttocks,  but  it  is  impossible  for  them  to  reach  their 
backs.  Therefore  it  is  necessary  to  get  outside  aid,  which  in  most  cases 
I  have  found  possible.  By  this  method  the  whole  body  is  treated  in 
eleven  seances.  In  many  cases,  when  we  use  from  40  to  60  grains  of 
the  ointment  for  each  rubbing,  we  can  give  the  whole  series  of  eleven  on 
successive  days.  But,  as  I  have  said  before,  Ave  can  never  be  positive 
that  we  can  do  so  ;  therefore  the  patient  must  be  watched  and  ques- 
tioned each  day  as  to  his  condition.  In  this  way  we  feel  our  way  along, 
and  continue  or  suspend  the  inunctions  as  the  indications  of  the  case 
teach  us. 

In  giving  a  regular  treatment  by  inunctions  it  is  well  to  omit  them  for 
a  few  days,  according  to  the  indications,  and  then  to  go  over  the  same 
ground  again.  In  a  systematic  treatment  we  may  give  fifty  to  eighty,  or 
even  a  hundred,  inunctions  with  proper  intermissions,  and  then  it  is  well 
to  desist  for  a  short  or  long  time.  In  ordinary  cases,  where  the  inunction 
method  is  used  as  a  regular  mode  of  treatment,  it  may  or  may  not  be 
necessary  to  administer  the  iodide  of  potassium'  at  the  same  time.  In 
most  cases  it  will  not  be  necessary  to  employ  a  large  dose  of  this  salt. 
But  in  old  and  untreated  cases  it  will  be  necessary  to  use  stronger  doses 
of  the  ointment,  perhaps  employ  them  more  uninterruptedly,  and  com- 
bine them  with  large  doses  of  the  iodide,  given  internally.  This  ques- 
tion of  the  conjoint  use  of  inunctions  and  iodide  of  potassium  will  be 
considered  farther  on  in  the  section  upon  Special  Medication. 

It  sometimes  happens  that  we  desire  to  keep  up  a  mild  mercurial 
action,  and  the  circumstances  of  the  patient  will  not  admit  of  the  employ- 
ment of  frictions.  In  these  cases  the  ointment  may  be  spread  upon  a 
canton-flannel  belt,  which  may  be  worn  around  the  body.  In  cases  of 
enlargement  of  the  spleen,  tenderness  over  the  liver,  with  or  without 
jaundice,  pain  in  chest  (pleuritic  or  resembling  angina  pectoris),  and  in 
swollen  and  painful  joints,  these  mercurial  bandages  may  be  employed 
with  much  benefit.  This  method  is  also  useful  in  the  treatment  of  syph- 
ilitic infants  and  children. 

Though  the  inunction  treatment  is  uniformly  potent  and  beneficial,  it 
has  its  drawbacks  and  complications.  These  are — 1,  dermatitis  and 
follicular  inflammation;  2,  stomatitis  and  salivation;  3,  digestive  dis- 
turbances and  intestinal  complications ;  4,  sleeplessness ;  5,  inanition 
and  exhaustion ;  6,  tendency  to  congestion  of  the  head,  heart,  and 
lungs ;  7,  tendency  to  fever  and  perspiration ;  8,  pain  in  bones  and 
joints.     Though    this  list   looks   rather    formidable,   in   actual    practice 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      867 

the  cases  are  few  in  which  it  is  necessary  to  abandon  the  treatment  or  in 
which  modifications  and  expedients  fail  to  smooth  matters  over. 

With  careful  antiseptic  attention  to  the  condition  of  the  skin,  and 
with  the  employment  of  fresh  and  pure  ointment,  we  rarely  encounter 
such  an  amount  of  inflammation  in  it  that  the  patient  is  made  to  suffer  or 
that  the  treatinent  is  curtailed.  Zinc  ointment,  Lassar's  paste,  and 
dusting  powders,  with  protective  layers  of  cotton,  are  very  beneficial  in 
the  prevention  of  dermal  inflammation. 

Under  the  older  system  of  inunction,  when  a  larger  quantity  of  blue 
ointment  was  employed  it  was  not  uncommon  to  find  mouth  and  throat 
lesions.  When,  however,  the  treatment  is  carried  out  on  the  lines  here- 
tofore indicated,  the  occurrence  of  salivation  will  be  rather  rare.  Mouth 
lesions  from  inunction  are  similar  to  those  produced  by  the  internal  use 
of  mercury,  with  the  exception  that  their  onset  is  more  sudden  and 
abrupt  and  their  severity  greater.  It  is  therefore  necessary  to  follow  the 
directions  already  given  to  prevent  salivation  in  the  matter  of  attention 
to  the  teeth,  mouth,  and  throat.  It  is  also  well  to  make  the  patient  rinse 
the  mouth  well  with  solutions  of  chlorate  of  potassium  and  alum,  and 
also  with  a  mild  solution  of  sugar  of  lead  and  acetate  of  alumina  in 
peppermint-water.  This  precaution  is  particularly  necessary  when  for 
any  reason  we  are  compelled  to  push  the  treatment. 

Very  often  a  lowering  of  the  dose  or  its  temporary  suspension  will 
cause  the  disappearance  of  irritability  of  the  stomach.  The  trouble 
should  also  be  treated  symptomatically.  In  like  manner,  intestinal 
irritation  should  be  treated,  and  very  often  much  benefit  will  result  from 
a  full  dose  of  castor  oil. 

In  some  cases  sleeplessness  is  but  an  ephemeral  symptom.  It  may 
persist  and  necessitate  a  suspension  or  diminution  of  the  treatment.  The 
bromides,  sulphonal,  phenacetin,  and  perhaps  morphine  and  chloral,  may 
be  temporarily  resorted  to,  but  always  under  the  physician's  knowledo;e 
and  full  direction.  It  is  better  to  abandon  the  method  than  use  any  of 
these  drugs  for  a  long  time. 

In  women  particularly,  a  feeling  of  exhaustion  and  inanition,  perhaps 
w^ith  digestive  disturbance,  may  complicate  the  inunction  treatment.  The 
usual  expedients  of  lowering  the  dose,  of  allowing  intervals  of  repose,  of 
administering  tonics,  should  be  resorted  to.  If,  after  a  conscientious 
trial  of  the  method,  these  symptoms  continue,  it  must  be  given  up. 

Tendencies  to  congestion  of  the  head,  heart,  and  lungs  should  be 
treated  symptomatically,  and  the  frictions  carefully  pushed  and  watched. 

A  feverish  condition,  with  or  without  perspiration,  or  the  occurrence 
of  the  last  symptom  alone,  should  call  for  quinine  and  iron  tonics, 
generous  food,  and  perhaps  a  mild  malt  liquor,  or  even  claret  or  burgundy 
in  moderation. 

Pains  in  the  bones  and  joints,  fixed  or  fugitive,  may  give  more  or  less 
trouble.  They  usually  pass  away  by  cai'e  on  the  part  of  the  physician 
and  patient.  I  have  met  with  several  cases,  however,  in  women  in  which 
these  symptoms  were  so  severe  that  a  discontinuance  of  the  frictions  was 
made  necessary. 

A  mild  and  continuous  mercurial  effect  may  be  produced  by  the  appli- 
cation of  plasters  of  mercurial  ointment.  This  may  be  spread  on  chamois- 
skin,  and  adjusted  to  the  body  by  means  of  a  belt  made  of  flannel  or  of 


868  SYPHILIS. 

canton  flannel.  In  cases  of  lesions  of  the  spleen  or  liver  or  of  intratho- 
racic pains  in  early  syphilis  this  method  of  mild  mercurialization  is  very 
beneficial.  It  may  also  be  employed  in  cases  in  which,  for  any  reason, 
inunctions  are  contraindicated.  In  many  cases  of  hereditary  syphilis 
murcurial  ointment  may  be  kept  continuously  upon  one  or  more  regions 
of  the  body  with  decided  benefit. 

Akin  to  this  method  of  using  mercury  is  the  application  of  mercurial 
plasters.  The  old-time  emplastrum  de  Vigo,  in  which  Chassaignac  placed 
so  much  confidence,  may  be  used,  either  in  large  plaques  or  on  small  sur- 
faces for  local  treatment.  There  are  in  the  market  at  present  several 
mercurial  plasters  which  are  worthy  of  use. 

This  slow  and  prolonged  treatment  is  much  extolled  b}'^  Unna,^  par- 
ticularly for  commercial  travellers  and  those  very  desirous  of  secrecy. 
He  uses  a  mercurial  plaster-mull,  and  with  his  usual  ingenuity  has  devised 
a  frame  of  zinc  glue  which  serves  to  keep  the  plaster  in  place  and  to  pre- 
vent it  from  melting  at  the  edges,  with  its  inevitable  discoloration  of  the 
skin  and  the  underwear.  In  severe  cases  of  paralysis,  cranial  exostoses, 
etc.  Unna  girdles  the  entire  trunk  with  his  mercurial  plaster-mull. 

A  modification  of  the  foregoing  treatment  has  been  proposed  by 
Quinquaud,^  who  uses  a  calomel  plaster  made  as  follows : 

I^.  Emplast.  diachyli,  3000  parts ; 

Hydrarg.  chlorid.  mite,  1000     "     ; 

01.  ricini,  300     "     .— M. 

The  plaster  is  to  be  melted,  and  to  it  added  the  calomel  suspended  in  the 
castor  oil. 

This  quantity  is  to  be  spread  upon  linen,  so  that  fourteen  strips,  each 
nine  feet  by  seven  and  three-quarter  inches  are  produced.  Of  this 
plaster  a  square  of  two  and  a  half  inches  contains  18  grains  of  calomel. 
Analysis  of  the  urine  of  patients  treated  with  this  plaster  showed  the 
presence  of  mercury  in  from  six  to  ten  days.  The  plaster  is  to  be  applied 
over  the  region  of  the  spleen,  the  skin  having  previously  been  carefully 
washed.  It  may  be  applied  elsewhere  upon  the  body,  with  a  view  to  its 
general  mercurial  effect  and  also  for  the  cure  of  local  lesions.  Quinquaud 
says  that  the  use  of  tliis  plaster  is  free  from  danger  and  inconvenience, 
and  that  by  its  use  mercury  is  slowly  and  surely  introduced  into  the  sys- 
tem. My  own  experience  with  it  is  not  large,  but  I  regard  it  as  a  useful 
addition  to  our  therapeutic  measures. 

Within  the  past  decade  a  new  method  of  treatment,  which  is  really  a 
modification  of  the  inunction  plan,  has  been  introduced  by  Schuster  of 
Aix-la-Chapelle,^  and  used  by  others.  This  method  is  by  friction  of  the 
skin  with  a  mercurial  soap  made  in  Paris  and  called  savon  Napolitain. 
A  good  lather  is  made  with  water  and  allowed  to  dry  on  the  skin,  upon 
which  it  leaves  a  thin  film  of  mercury.     This  may  be  applied  over  a  more 

'  "  Ueber  die  Therapeutische  Verwendnng  von  Salben  und  Pflastermullpriiparaten," 
Berlin,  klin.  Wocherischrift,  No.  38,  1881,  and  "Die  Medicamentosen  Leime,"  Aerztlichen 
Fem"?isWa</,  1886,  No.  176. 

^  "Traiteraent  de  la  Syphilis  par  le  Sparadrap  au  Calomel,"  Bulletin  de  la  Societe 
Fran^aise  de  Dermal,  et.  de  Syphil.,  1890,  pp.  63  et  seq. 

'^  "  Die  Mercurseife,  Savon  napolitain,"  Vierteljahr.  fur  Derm,  und  Syphilis,  Heft  1. 
1882. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      869 

or  less  extensive  surface,  but  its  too  frequent  application  may  cause  der- 
matitis. The  lather  is  less  objectionable  in  odor  and  in  feeling  than  the 
mercurial  ointment ;  hence  iSchuster  thinks  this  method  is  more  elegant 
than  inunctions.  Improvement  in  cases  of  syphilis  thus  treated  was 
noted,  and  chemical  examination  revealed  the  presence  of  mercury  in  the 
urine.  Oberliinder^  endorses  the  method,  but  prefers  a  soap  originated 
by  himself,  which  is  composed  of  1  part  of  mercury  combined  with  3 
parts  of  green  soap,  perfumed  with  oil  of  lavender.  Oberlander  claims 
that  the  lather  made  from  this  soap  is  of  lighter  color  than  that  of  the 
French  preparation,  and  that  it  is  actually  absorbed  into  the  skin,  even 
without  much  friction. 

Spillmann  ^  advocates  a  soap  made  of  pure  olive  oil  and  caustic  potash, 
with  which  is  incorporated  50  per  cent,  of  mercury.  This  soap,  which 
may  be  perfumed  according  to  taste,  is  neutral  in  reaction  and  causes  no 
irritation.  A  portion  of  the  body  is  lathered  with  the  soap,  and  after 
drying  it  is  covered  with  thin  paper  or  some  suitable  garment.  After 
twenty-four  hours  the  part  is  washed  oflf  and  dusted  with  rice  powder. 

Watrazewski  ^  claims  that  calomel  soap  is  equally  as  efficacious  and 
more  cleanly  and  easier  of  use  than  mercurial  ointments.  He  advises  a 
pure  potash  and  olive-oil  soap  as  the  basis.  His  stronger  soap  consists 
of  1  part  of  calomel  to  2  parts  of  the  soap,  and  the  milder  is  composed  of 
1  part  of  calomel  to  3  of  the  soap  basis.  Of  these  soaps  he  uses  two  to 
three  grammes  daily,  employing  sufficient  water  to  make  a  lather  and  rub- 
bing it  well  into  the  skin  by  a  rotatory  movement  for  from  ten  to  fifteen 
minutes.  In  this  way  the  calomel  is  thoroughly  rubbed  in,  and  the  skin 
is  left  in  its  normal  color.  Watrazewski  claims  that  this  method  is  ex- 
peditious, unattended  with  discoloration,  not  disagreeable  to  the  sense  of 
smell,  not  followed  by  dermal  irritation,  and  is  equally  as  efficacious  as 
the  inunction  treatment.  Examination  of  the  urine  of  patients  thus 
treated  showed  the  constant  presence  of  mercury,  and  slight  gingivitis 
attested  the  fact  of  its  absorption. 

It  may  also  be  well  to  mention  Dietrich's  *  mercurial  soap,  which  is 
well  thought  of  by  Bronson.  In  my  judgment  the  use  of  these  soaps 
should  be  restricted  to  local  or  regional  therapeutics. 

Fumigation. 

The  mercurial  vapor-bath  is  a  method  of  treating  syphilis  which  was 
revived  and  perfected  by  Langston  Parker^  and  Henry  Lee."  It  is  use- 
ful in  very  many  cases  and  in  many  conditions  of  syphilis — not  as  a 
routine  treatment,  but  as  one  of  reserve  and  exigency.  Many  prepara- 
tions of  mercury  have  been  used  in  this  form  of  treatment,  but  calomel 
and  cinnabar  are  the  agents  upon  which  experience  has  shown  that  mogt 

^  "Die  Merciirseife  ein  Neues  und  Praktisches  Ersatzmittel  fiir  die  Mercursalbe," 
Vierieljahr.  fur  Derm,  und  Syphilis,  Heft  4,  1882. 

*  "  Le  Savon  mercuriel  comnie  succedan^  de  TOnguent  napolitain,"  Annates  de  Derm. 
et  de  Sijphibcjraphie,  1SS5,  pp.  496  and  497. 

^  Le  Savon  au  Calomel  dans  la  Traitement  de  la  Syphilis,"  Bull,  de  la  Soeiele  Fran^. 
de  Derm,  et  de  Syph.,  May,  1893,  pp.  136  et  seq. 

*  "Sapo  Unguiosus  und  Seine  Anwendung  als  Salben  Korper,"  Monatshe/lefur  Prak. 
Dermal olofjie,  1887,  pp.  1068  et  seq. 

^  The  Modern  Treatment  of  Si/phiUlic  Diseases,  London,  1871,  pp.  352  et  seq. 
^  Lectures  on  Syphilis,  Philadelphia,  1875,  pp.  93  et  seq. 


870  SYPHILIS. 

reliance  may  be  placed.  To  obtain  good  and  satisfactory  results  these 
drugs  must  of  necessity  be  perfectly  pure  and  free  from  admixture. 

When  calomel  alone  is  used,  from  20  to  40  grains  may  be  placed  upon 
the  lamp,  but  in  some  urgent  cases  even  60  grains  may  be  required.  As 
a  general  rule,  however,  the  smaller  quantities  are  most  serviceable,  and 
they  may  be  used  over  a  longer  period  of  time.  The  large  doses  of  calo- 
mel administered  by  moist  vapor  are  generally  used  in  cases  of  severity 
and  of  exigency,  and  are  not  frequently  repeated.  Cinnabar  may  be  used 
in  somewhat  larger  quantity  than  calomel,  but  in  general  my  practice  is 
to  combine  the  two  salts  in  one  bath.  As  an  average  dose  I  have  found 
that  20  grains  of  calomel  and  40  of  cinnabar  fused  simultaneously  in  con- 
nection with  moist  heat  produce  prompt  and  safe  results.  This  dose  may 
be  increased  or  diminished  according  to  the  condition  of  the  case.  In 
large  cities  there  are  usually  one  or  more  establishments  in  which  these 
baths  are  given  under  the  advice  of  physicians.  In  that  case  the  physi- 
cian need  only  prescribe  the  dose  and  the  number  of  baths  which  he  de- 
sires the  patient  to  take,  and  the  bath  attendants  will  carry  out  his 
wishes.  Unfortunately,  in  some  establishments  the  attendants,  having  a 
smattering  of  medical  knowledge,  think  they  know  more  than  the  doctor, 
and  proceed  to  treat  the  case  themselves.  As  Dr.  Bumstead  puts  it, 
their  "  inherent  tendency  would  seem  to  be  to  absorb  the  patient  at  the 
same  time  that  he  absorbs  the  mercurial  fumes." 

In  some  cases,  when  the  baths  are  unobtainable  or  when  the  patients 
object  to  go  to  the  bath  establishment,  this  method  may  be  pursued  at 
home.  For  this  purpose  it  is  necessary  to  use  either  Lee's  or  Maury's 
lamps,  by  means  of  which  the  mercurial  salt  is  volatilized  and  steam  gen- 
erated at  the  same  time.  The  patient  is  stripped  and  enveloped  in  one 
or  more  blankets  or  in  coverings  made  for  the  purpose  of  mackintosh  or 
India-rubber  lined  with  flannel,  and  then  the  flame  is  started.  In  a  few 
minutes  perspiration  is  induced,  and  the  evaporated  calomel  is  deposited 
upon  the  body.  Usually  the  protective  garments  fit  closely  at  the  neck, 
but  in  some  there  is  a  slight  opening,  through  which  some  of  the  fumes 
may  escape  and  may  be  absorbed  in  respiration.  When  deemed  necessary 
by  the  physician  the  patient  may  breathe  in  some  of  the  fumes,  but  it  is 
ahvays  well  to  allow  an  admixture  of  air  with  them.  Twenty  to  thirty 
minutes  are  sufiicient  for  a  bath,  after  which  the  patient  is  allowed  to  cool 
off  slowly.  When  practicable  the  patient  should  retire  at  once  to  bed, 
preferably  enveloped  in  the  garment  used  in  the  bath.  It  is  well,  if  the 
patient  has  to  dress  and  go  out,  that  as  little  friction  of  the  skin  as  pos- 
sible should  be  used,  in  order  not  to  rub  off"  the  minute  particles  of  mer- 
cury. In  cold  weather  due  care  should  be  taken  that  the  patient  is  prop- 
erly protected  when  he  goes  out  after  the  bath. 

These  baths  should  never  be  taken  directly  after  meals.  It  is  better 
that  they  should,  if  possible,  be  taken  just  before  going  to  bed  or  in 
the  evening,  but  in  any  case  fully  two  hours  should  elapse  after  a  meal. 
As  a  rule,  patients  should  be  in  good  condition  as  to  their  stomachs  and 
bowels  when  they  are  subjected  to  this  treatment,  and  they  must  be  rig- 
idly prohibited  from  using  alcoholics.  While  undergoing  mercurial  vapor 
treatment  the  patient  must  be  carefully  Avatched  in  order  that  no  draw- 
backs may  be  encountered.  Thus  if  he  complains  of  feeling  tired  and 
debilitated  after  a  bath,  it  will  be  necessary  to  reduce  the  quantity  of 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      871 

mercury  and  also  the  amount  of  water  to  be  evaporated.  In  many  cases 
harm  is  done  by  using  too  much  steam  vapor.  Some  patients  complain 
of  headache,  and  it  is  then  necessary  to  administer  a  purge  or  to  moderate 
the  amount  of  food  ingested. 

It  is  well  to  begin  by  giving  one  bath  every  other  day,  and  then  to 
increase  to  a  bath  daily  if  the  necessity  of  the  case  demands  it.  Some 
patients  bear  these  daily  baths  well,  while  others  experience  unpleasant 
symptoms  from  them.  As  a  rule,  after  one  or  two  baths  improvement 
is  observed,  but  in  some  cases  a  beneficial  effect  is  delayed  for  a  week  or 
two.  The  number  of  baths  to  be  taken  can  only  be  determined  by  the 
condition  of  the  case.  In  general  it  may  be  said  that  a  course  of  baths 
extending  over  one  or  two  months  will  be  sufiicient  for  that  time.  This 
period,  however,  may  be  lengthened.  In  many  cases  only  a  few  baths 
are  necessary,  they  being  employed  for  some  temporary  condition  or  as 
an  adjuvant  to  other  methods  of  treatment. 

While  a  patient  is  thus  being  treated  the  physician  should  carefully 
watch  the  state  of  his  gums  and  of  the  gastro-intestinal  tract,  and 
remedy  any  disturbance.  It  is  not  uncommon  to  observe  a  mild  form  of 
mouth  lesions  in  patients  taking  a  course  of  mercurial  baths.  This 
condition  may  be  cured  by  local  means  and  by  the  temporary  suspen- 
sion of  the  baths  or  by  diminishing  the  strength  of  the  mercurial  em- 
ployed. Sometimes,  when  large  doses  have  been  frequently  used,  a 
sudden  and  violent  colitis  is  developed.  This  condition,  painful  and 
sometimes  alarming,  is  readily  cured  by  rest,  cessation  of  treatment,  and 
the  use  of  opiates. 

Mercurial  baths  are  useful  in  the  whole  secondary  stage  of  syphilis, 
and  also  in  the  tertiary  period.  They  may  be  employed  to  remove  some 
obstinate  local  lesion  or  to  expedite  the  disappearance  of  a  general  rash. 
Late  secondary  rashes,  rebellious  to  other  methods,  are  frequently  dis- 
pelled by  this  one  with  promptitude.  Neuralgias,  rheumatoid  pains, 
cephalalgias,  pains  in  joints  and  fasciae  are  often  promptly  relieved  by 
mercurial  baths.  In  cases  in  which  for  any  reasons  other  methods  of 
treatment  are  contraindicated  we  can  frequently  resort  to  mercurial  fumi- 
gations Avith  marked  benefit. 

Wells  ^  has  proposed  a  very  simple  method  of  local  fumigation  for  cases 
of  syphilitic  lesions  of  the  palms.  A  hole  large  enough  to  admit  the 
hand  is  cut  in  an  ordinary  hat-box,  and  \  to  \  drachm  of  calomel  is  put 
underneath  on  a  tripod,  and  a  spirit-lamp  produces  the  fumes  which  form 
a  deposit  on  the  hand. 

Thyroid  Extract  and  Blood-serum  Therapy. — Thyroid  extract  has 
been  recently  recommended  by  J.  Duncan  Menzies  ^  for  the  treatment  of 
severe  cases  of  syphilis.  He  reports  four  cases  of  men  in  a  very  weak, 
sickly  state,  who  also-  suffered  from  malaria  and  bowel  complaints.  These 
men  presented  grave  rupial  and  ulcerative  lesions,  which  were  uninfluenced 
by  mercurial  treatment.  They  were  given  five  to  fifteen  grains  daily  of 
the  thyroid  extract,  specific  treatment  having  been  suspended,  and,  ac- 
cording to  his  report,  the  favorable  results  were  little  less  than  mar- 
vellous. 

'  Medical  Record,  May  13,  1891. 

'^  "A  Report  on  Some  Recent  Cases  of  'Malignant'  Indian  Syphilis  Treated  with 
Thyroid  Extract,"  British  Med.  Journ.,  June  7,  1894. 


872  SYPHILIS. 

Basing  their  theory  on  its  bactericidal  action,  a  number  of  observers 
have  used  subcutaneous  injections  of  the  serum  of  animals  and  of  the 
blood  of  syphilitics,  with  the  hope  of  discovering  a  true  specific  treatment 
for  syphilis.  It  will  be  noted  that  there  is  a  want  of  uniformity  of  success 
in  the  results  obtained.  Tommasoli  ^  used  lamb's  blood-serum,  and  claims 
that  he  cured  his  patients.  Sartori^used  ox  blood-serum  on  four  cases 
with  beneficial  efiect.  Bonaduce  employed  the  serum  from  hereditary 
syphilitic  children,  and  states  that  he  observed  good  results  in  his  cases. 
Pellizzari^  also  used  the  unfiltered  serum  of  syphilitic  subjects,  and  ob- 
tained the  best  results  when  the  injections  were  given  early  in  the  disease. 
He  thinks  that  serum  taken  from  persons  in  whom  the  infection  is  active 
is  best,  for  the  reason  that  it  contains  more  antitoxine.  Other  observers , 
have  written  more  or  less  enthusiastically  upon  this  new  method  of  treat- 
ment. It  is  interesting  to  know  that  Kollmann  ■*  followed  up  Tommasoli's 
work,  and  failed  utterly  in  curing  syphilis  with  the  blood-serum  of  sheep, 
calves,  dogs,  and  rabbits.  We  know  absolutely  nothing  on  this  subject 
as  yet. 

Hypoderviic  Injections. — Within  the  past  decade  the  use  of  mercury 
hypodermically  in  syphilis  has  been  largely  extended,  and  to-day  this 
method  is  held  in  high  repute  by  many  physicians.  As  I  shall  show  in 
the  sections  upon  Corrosive  Sublimate  and  Calomel,  this  method  of  em- 
ployment of  these  drugs  is,  within  certain  limitations  as  a  measure  of 
utility,  reserve,  and  exigency,  of  marked  benefit  in  many  cases.  It,  how- 
ever, should  never  be  adopted  as  a  routine  treatment. 

The  chief  claims  of  the  advocates  of  the  method  by  hypodermic  injec- 
tions of  calonael  and  other  mercurial  salts,  in  preference  to  the  older  and 
more  classic  modes  of  treatment,  are  as  follows : 

1.  It  is  simple,  more  exact,  more  convenient,  and  more  expeditious. 

2.  It  is  applicable  to  all  stages  of  the  disease  and  to  patients  of  all 
ages. 

3.  The  practitioner  remains  the  master  of  the  treatment  throughout. 

4.  It  spares  the  patient's  skin  and  stomach. 

5.  It  ensures  accuracy  and  precision  of  dose,  and  is  attended  with 
more  rapid  action  and  greater  potentiality  of  the  drug. 

6.  It  is  superior  to,  and  less  objectionable  than,  inunctions,  and  more 
permanent  in  its  eifects. 

7.  It  is  less  liable  to  be  followed  by  relapses,  and  gives  the  patient  a 
greater  immunity  against  the  ulterior  eff'ects  of  syphilis  than  any  other 
known  method. 

8.  It  eifects  a  cure  by  the  use  of  a  minimum  quantity  of  mercury,  and 
at  little  expense. 

9.  It  bothers  the  patients  very  little,  does  not  necessitate  change  in 
mode  of  life  or  regimen,  does  not  cause  them  to  see  their  physician  very 
often,  and  has  the  advantage  of  giving  them  a  holiday  of  eight  days,  or 
more  when  calomel  is  used,  during  which  they  have  no  medicine  to  take 
or  medical  procedure  to  undergo. 

These  claims,  it  must   be  remembered,  are  made  by  enthusiasts,  and 

»  Gaz.  Med.  drr/li  nxpitali,  Nos.  28  and  70,  1892. 

'^bid.,  Auff.  2,  1892. 

»  Oiornak  Ital.  delle  mnl.  ven.  e  delln  Pdlr,  1894,  pp.  398  and  469. 

*  Deut.  med.  Wochenschr.,  No.  36,  1892,  p.  806. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      873 

the  reader  must  not  be  misled  by  tbeir  scope  and  boldness.  It  has 
been  claimed  that  mercury  thus  administered  has  occult  curative  prop- 
erties hitherto  unknown,  but  of  this  there  is  really  no  evidence. 

Within  recent  years  much  has  been  written  eulogizing  the  eifect  of 
insoluble  preparations  of  mercury,  and  there  is  at  present  a  tendency 
to  the  disuse  of  the  soluble  preparations.  It  is  claimed  that  the  solu- 
ble salts  of  mercury  are  so  rapidly  absorbed  and  eliminated  that  their 
eifect  is  less  potent  and  much  more  ephemeral.  On  the  other  hand,  it 
is  claimed  that  insoluble  preparations  of  mercury  are  slowly  absorbed, 
are  retained  for  long  periods  in  the  system,  and  that  their  effect  is  more 
active  and  prolonged.  It  is  needless  for  me  to  discuss  these  questions 
here,  for  the  reader  can  gain  very  clear  ideas  by  a  perusal  of  the  follow- 
ing pages.  In  my  judgment,  the  soluble  salts  of  mercury  are  of  much 
benefit  in  many  cases,  and  their  hypodermic  use  is  not  attended  with  the 
serious  drawbacks  and  dangers  incident  to  the  use  of  insoluble  salts 
hypodermically.  In  certain  cases  and  with  marked  limitations  insolu- 
ble salts,  particularly  calomel,  thus  used  may  be  productive  of  benefit. 

In  former  years  injections  were  made  into  the  connective  tissues ; 
to-day  intramuscular  injections  (particularly  of  the  insoluble  salts)  and 
intravenous  are  largely  in  vogue.  In  my  opinion,  the  innovations  are 
neither  beneficial  nor  necessary. 

The  extent  of  the  literature  of  hypodermic  injections  in  syphilis 
contributed  within  the  past  ten  or  twelve  years  is  simply  appalling,  and 
in  it  there  is  really  very  little  which  is  of  practical  value.  In  a  chapter 
like  this,  in  which  completeness  is  aimed  at,  it  is  necessary  to  give  a 
survey  of  the  progress  made  in  the  treatment  of  syphilis.  To  that  end 
I  have  gone  over  and  condensed  this  huge  mass  of  literature,  and  I 
present  an  epitome  of  it  here  for  what  it  is  worth.  It  will  be  seen 
that  almost  every  preparation  of  mercury  has  been  experimented  with 
in  the  hypodermic-injection  treatment,  and  that  the  chemist's  art  has 
been  sorely  taxed  to  produce  new  preparations.  Each  new  preparation 
has  been  exploited  as  the  ideal  of  perfection,  and  in  most  cases  a  hearty 
welcome  has  been  accorded  it,  so  that  a  witty  German  reviewer  has  made 
the  following  paraphrase  of  an  old  maxim  applicable  to  the  subject: 
"  i>e  novis  nil  nisi  bonum."  After  all  is  said  and  done,  the  bare  fact 
remains  that  corrosive  sublimate  and  calomel  are  the  two  agents  worthy 
of  confidence,  and  they  are  not  excelled  in  any  way  by  any  others. 

For  convenience  of  description,  I  Avill  divide  the  preparations  of 
mercury  used  hypodermically  into  the  following  groups  :  1,  the  insolu- 
ble salts  ;  2,  the  soluble  salts  ;  3,  the  so-considered  antiseptic  group  ;  and 
4,  the  amide  group.  Iodide  of  potassium,  alone  and  in  combination 
with  mercury,  and  iodoform  has  also  been  employed  subcutaneously, 
and  the  essential  facts  of  their  use  will  be  presented. 

Insoluble  Salts. — Calomel — Of  the  insoluble  salts  of  mercury, 
calomel  is  the  one  most  extensively  used  and  most  uniformly  efficient. 
Subcutaneous  injections  of  the  salt  were  first  recommended  by  Scarenzio^ 
in  18G4,  and  in  1868  that  author  and  his  disciple,  Ricordi,"  published  a 

^  "  Primi  tentativi  di  cura  della  sifilide  constitutionale,"  Annuli  di  Medicina,  Aug.  and 
Sept.,  1864. 

^  La  Melhode  hypodermique  dmis  la  Cure  de  la  Syphilis,  translated  by  Dr.  Osicar  Max. 
van  Mons,  Brussels,  18G9. 


874     .  SYPHILIS. 

pamphlet  of  ninety-nine  pages  in  -which  they  claimed  brilliant  results 
in  the  cure  of  syphilis.  Since,  at  the  present  time,  there  is  a  revival 
on  the  part  of  some  physicians  in  various  countries  of  this  method,  it 
is  proper  that  a  synopsis  of  our  knowledge  should  be  here  presented. 
Though  this  treatment,  which  has  become  known  in  medical  literature 
as  the  method  of  Scarenzio,  was  used  in  Italy  and  in  Germany  princi- 
pally by  Sigmund,  it  had  not,  until  within  a  decade,  been  tried,  except 
in  isolated  instances,  in  other  countries.  In  the  year  1883  a  Russian 
physician  named  Smirnoff^  published  a  pamphlet  in  which  he  claimed 
to  have  modified  and  improved  Scarenzio's  method,  and  earnestly 
advocated  its  general  adoption.  In  the  year  1886  this  author  pub- 
lished a  second  pamphlet,^  in  Avhich  he  laid  greater  stress  upon  his 
former  claims.  These  writings  of  Smirnoff  have  resulted  in  a  more 
general  knowledge  and  employment  of  calomel  subcutaneously  in  syph- 
ilis, so  that  to-day  the  method  of  treatment  is  accepted  as  a  part  of  their 
armamentarium  by  a  large  number  of  observers. 

Scarenzio  claimed — and  others  have  endorsed  his  view — that  cal- 
omel introduced  under  the  skin  is  acted  upon  by  the  alkaline  chlorides 
of  the  blood,  and  slowly  transformed  into  the  bichloride,  which  in  its 
turn  is  absorbed  into  the  system.  This  author  thought  that  6  grains 
of  calomel,  administered  in  two  injections  at  varying  intervals  (eight, 
ten,  fourteen,  and  twenty-one  days)  into  two  different  portions  of  the 
body — and  he  preferred  the  outer  sides  of  the  arms  and  thighs — were 
sufficient  for  a  cure.  In  the  early  stages  of  the  trial  of  this  method  it 
is  stated  that  abscesses  invariably  folloAved  the  injections,  but  this  com- 
plication Avas  thought  little  of.  Glycerin  and  mucilage  of  acacia  were 
the  vehicles  in  which  the  calomel  was  suspended. 

The  views  of  Sigmund^  on  the  treatment  of  syphilis  are  generally 
worthy  of  close  attention,  and  it  is  interesting  to  note  that  after  a  pro- 
longed trial  of  Scarenzio's  method  he  reached  the  conclusion  that  we 
can  only  assign  very  narrow  limits  to  the  employment  of  the  hypoder- 
mic method,  and  can  only  recommend  it  in  the  milder  and  more  simple 
forms  of  secondary  syphilis.  Sigmund  saw  very  clearly  that  syphilis 
could  not  be  cured  in  the  rapid  and  high-pressure  manner  claimed  by 
the  Italian  syphilographer,  and  in  his  employment  of  the  latter's  method 
he  made  radical  modifications.  Sigmund  used  smaller  doses  of  calomel : 
instead  of  3  grains  injected  once  in  eight  days  or  at  a  longer  interval, 
he  used  f  of  a  grain  twice  a  week,  and  extended  the  treatment  over  a 
longer  period.  He  preferred  the  sides  of  the  chest  and  the  belly  as  the 
sites  of  the  injections. 

In  the  light  of  existing  knowledge  of  the  treatment  of  syphilis  by  hypo- 
dermic injections  of  calomel,  the  following  general  summary  may  be  given 
as  to  dose,  technique,  indications,  and  results  : 

The  calomel  must  be  perfectly  pure  and  reduced  by  steam  sublimation. 
Some  authors  go  so  far  as  to  recommend  that  it  be  Avashed  in  boiling 
alcohol  and  dried.  It  may  be  suspended  in  pure  glycerin,  glycerin  and 
water,  mucilage  of  acacia,  or  in  vaseline  oil.      Some  observers  use  equal 

'  Om.  behandling  af  Syfilis  medelsl  subkuiana  Kalomel  injectioner,  af  Georg  Smirnoff, 
Helsingfors,  1883. 

'■*  Developpemeni  de  la  Methode  de  Scarenzio,  Helsingfors,  1886. 

^  Vorlesungen  ilber  neuere  BehancUungsweisen  der  Syphdis,  3d  ed.,  Vienna,  1883. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      875 

quantities  of  sodium  chloride  and  calomel  mixed  in  water.  It  is  better 
that  each  dose  should  be  freshly  prepared,  and  in  the  weighing  of  the 
drug  and  in  its  trituration  with  pestle  and  mortar  every  precaution  should 
be  taken  to  prevent  contamination.  As  a  rule,  1  grain  of  calomel  is 
sufficient  for  a  dose ;  and  this  should  be  suspended  in  10  or  12  drops  of 
the  vehicle  used.  In  urgent  cases  2  grains  may  be  injected,  but  rarely 
is  this  much  required.  When  the  dose  is  mixed  freshly  for  each  injection 
it  is  necessary  to  prepare  from  four  to  five  times  the  quantity  in  order  to 
be  certain  that  a  full  dose  is  drawn  up  in  the  syringe. 

In  certain  rare  cases,  particularly  of  lesions  of  the  eye,  ear,  and  cere- 
bro-spinal  system,  in  which  a  decided  action  was  needed,  I  have  employed 
injections  of  calomel  suspended  in  water  which  contained  chloride  of 
sodium  in  solution,  Krecke  ^  has  used  this  treatment  on  these  lines  in 
Striimpell's  clinic.  His  formula  is  a  good  one,  and  is  as  follows :  Calo- 
mel and  chloride  of  sodium,  of  each  5  parts,  to  distilled  water  50  parts. 
Of  this  liquid  the  contents  of  a  Pravaz  syringe  may  be  injected  every 
eight  or  ten  days.  This  combination  has  been  used  by  many  observers, 
notably  Rona,  Matthes,  Sterne,  Neumann,  Kopp  and  Chotzen,  Dellen, 
and  Finger. 

Smirnoff  is  certainly  correct  in  insisting  upon  thorough  antisepsis  in 
the  administration  of  these  injections  ;  therefore  I  am  careful  to  enter 
fully  into  the  necessities  of  the  technique.  The  hands  of  the  operator 
should  be  thoroughly  cleansed,  and  the  parts  to  be  injected  should  be 
washed  with  soap  and  water  and  scrubbed  gently  with  a  brush.  After 
this  they  should  be  well  saturated  with  a  5  per  cent,  carbolic  solution, 
and  then  dried.  The  syringe  must  be  kept  perfectly  clean,  after  having 
been  rendered  aseptic  after  its  last  employment.  It  should  have  a  rather 
larger  needle  than  usual,  one  having  a  calibre  about  twice  as  large  as  that 
of  those  generally  used,  and  it  should  be  nearly  an  inch  and  a  half  long. 
The  working  of  the  syringe  should  be  easy  and  perfect,  and  its  adjust- 
ment to  the  needle  should  be  accomplished  without  hitch  or  delay.  Pre- 
vious to  introduction  it  should  be  ascertained  that  no  air  has  lodged  either 
in  the  needle  or  the  syringe.  The  injections  are  to  be  made  at  a  right 
angle  to  the  surface  of  the  skin,  and  not  in  an  oblique  manner.  The 
needle  is  to  be  slowly,  but  firmly,  pushed  in  until  the  subcutaneous  tissues 
are  reached,  and  then  the  piston  is  to  be  very  slowly  pushed  down.  The 
idea  is  to  produce  as  little  violence  as  possible  to  these  delicate  tissues. 
Then  the  needle  is  to  be  carefully  withdrawn  between  two  finger-tips, 
pressing  carefully  but  firmly  on  the  injected  spot.  There  is  no  necessity 
for  light  massage  or  for  the  application  of  plaster  or  collodion  over  the 
site  of  injection,  though  there  is  no  objection  to  the  latter. 

The  site  of  injection  preferred  by  Smirnoff,  Jullien,  Watrazewski, 
Klotz,  and  others  is  the  depression  in  the  buttocks,  an  inch  behind  the 
posterior  border  of  the  great  trochanter.  Here  the  connective  tissue  is 
very  lax  and  abundant,  and  pressure  is  not  felt  in  any  of  the  attitudes  of 
our  daily  life.  It  is  always  better  that  patients  should  be  selected  who 
have  but  a  moderate  quantity  of  fatty  tissue ;  therefore  in  very  fiit  and 
closely-knit  subjects  fear  of  abscesses  resulting  from  a  want  of  diffusion 
of  the  injected  fluid  is  to  be  entertained.     In  this  limited  area  of  course 

^  "  Ueber  die  Eehandlung  der  Syphilis  mit  Subcutanen  Calomel  injectionen,"  Munchen 

med.  Wochenschrift,  1877,  No.  6. 


876  SYPHILIS. 

only  a  few  injections  can  be  made,  but  it  is  to  be  remembered  that  the 
advocates  of  this  treatment  speak  of  cures  of  syphilis  by  the  use  of  6 
grains  of  calomel.  Other  parts  of  the  body  may  also  be  selected,  but  it 
should  ahvays  be  remembered  that  there  must  be  plenty  of  loose  cellular 
tissue,  that  bony  prominences  are  to  be  avoided,  and  that  places  liable  to 
be  subjected  to  pressure  during  the  day  or  in  sleep  must  be  spared.  In 
some  cases  of  active  and  grave  intra-ocular,  aural,  and  cerebral  lesions  the 
nucha,  temples,  and  scalp  have  been  and  may  be  selected  with  advantage 
as  sites  of  injection.  Experience  has  shown  that  the  thighs  are  prone  to 
undergo  abscess-formation  from  the  injection  of  insoluble,  and  even 
soluble,  preparations  of  mercury.  Therefore,  these  regions,  as  well  as  the 
arms  and  forearms,  should,  unless  under  urgent  circumstances,  be  avoided. 
I  have  found  that  injections  of  calomel  and  of  corrosive  sublimate  may 
be  made  in  the  hypogastrium  when  care  is  taken  not  to  go  down  to  the 
groins  or  the  mons  veneris.  The  lateral  portions  of  the  chest  have  also 
been  used,  particularly  by  Sigmund. 

By  some  it  is  advised  that  the  patient  should  lie  down  when  the  injec- 
tion is  made,  and  it  is  a  good  rule  in  the  administration  of  all  forms  of 
mercurial  injection  to  place  the  patient  in  such  a  position  that  tension  is 
not  exerted  upon  the  part  to  be  injected.  Though  some  observers  state 
that  they  allow  patients  to  go  about  their  business  after  injection,  I  am 
strongly  of  the  opinion  that  it  is  well  for  them  to  be  quiet  for  at  least  an 
hour  or  two,  or  to  lie  down  for  several  hours  if  possible. 

Until  within  the  present  decade  calomel  injections  were  made  into  the 
subcutaneous  connective  tissues,  and  this  site  of  deposit  is  preferred  by 
some  authors.  Following,  however,  a  suggestion  of  Soffiantini,  a  disciple 
of  Scarenzio,  a  number  of  experimenters  have  thrown  the  mercurial  salt 
deep  into  the  muscular  tissue,  where  it  is  claimed  in  an  acid  medium 
absorption  is  more  rapid  and  certain.  In  my  own  practice,  with  the  limi- 
tations which  I  observe  as  to  this  method  of  treatment,  I  have  always 
injected  into  the  connective  tissues,  preferring  to  have  a  superficial  to  a 
very  deep  subfascial  abscess  if  that  unpleasant  complication  should 
develop.  Whichever  site  of  deposit  is  chosen  by  the  physician,  the 
greatest  care  must  be  observed  to  get  the  needle  well  into  the  soft  tissues. 
It  is  very  unfortunate  to  throw  the  injection  into  the  deep  corium  ;  there- 
fore the  point  of  the  needle  should  be  well  below  this  layer.  An  injec- 
tion should  never  be  throAvn  into  the  connective  tissues  over  the  bony 
surfaces,  nor  anyAvhere  near  the  periosteum. 

Symptoms  of  two  varieties  are  observed  after  these  injections — those 
which  develop  at  once,  and  those  Avhich  appear  more  or  less  remotely  after 
the  operation.  In  some  cases  pain  in  the  track  of  the  needle  and  in  the 
injected  focus  is  complained  of.  This  symptom  may  be  severe  and  it  may 
be  mild.  It  is  often  ephemeral  in  duration,  and  again  it  may  last  one  or 
more  hours.  As  a  rule,  women  complain  of  it  much  more  bitterly  than 
men. 

In  some  cases  a  disk  of  redness  and  inflammatory  hypergemia  of  the 
skin  is  seen  around  the  point  of  puncture.  If  proper  antisepsis  has  been 
attained,  the  inflammatory  plaque  in  most  cases  gradually  pales  and  dis- 
appears. If,  however,  any  particles  of  dirt  have  been  left  in  the  track 
of  the  injection  an  abscess  of  that  part  is  very  apt  to  form. 

Within  a  few  hours  or  within  a  day  or  two  in  very  many — I  may  say 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      877 

in  most — cases  a  moderate  swelling  can  be  felt  well  under  the  skin  at  the 
injected  focus.  This  nodule  may  be  circumscribed  and  unattended  with 
surrounding  inflammation,  or  it  may  go  on  to  the  formation  of  a  large  and 
brawny  swelling  limited  to  the  deep  tissues,  or  perhaps  complicated  with 
inflammatory  exudation  into  the  derma.  The  onset  of  these  sequelae  indi- 
cates the  necessity  of  rest  and  quiet,  and  perhaps  the  use  of  cooling  lotions. 
In  some  instances  the  nodules  will  gradually  undergo  resorption,  but  in 
very  many  softening  takes  place  slowly  after  the  subsidence  of  the  imme- 
diate inflammatory  symptoms.  It  seems  to  be  the  general  opinion  that 
when  softening  has  occurred  it  is  better  to  refrain  from  opening  the  mass, 
for  even  when  marked  fluctuation  is  felt  resorption  may  occur,  or  at  the 
worst  the  abscess  will  point  and  burst.  In  the  latter  event  it  rarely  causes 
much  trouble  in  healing,  and  very  seldom  leaves  sinuses  through  the  skin. 
These  abscesses  may  become  encysted  or  they  may  undergo  cheesy  de- 
generation and  subsequent  absorption.  Whereas  before  Smirnoif 's  time 
abscesses  were  of  inevitable  occurrence,  with  the  improved  technique  of 
to-day  they  may  be  rendered  very  much  less  numerous  than  formerly. 
Even  in  Sigmund's  experiments  the  number  of  abscesses  was  reduced. 

To  the  eye  these  nodular  masses  Avhen  excised  look  like  a  cellular 
adipose  lump  well  saturated  with  a  rather  thick  fluid  of  chocolate  color, 
and  in  their  centre  a  necrosed  nucleus.  According  to  Kopp  and  Chotzen, 
there  were  no  bacteria  found  in  the  specimens  examined  by  them.  Under 
the  microscope  these  calomel  abscesses  are  found  to  contain  blood,  leuco- 
cytes, fatty  matter  and  crystals  of  fatty  acids,  and  the  mercurial  salt  not 
yet  absorbed.  They  are  really  necrotic  and  not  septic  abscesses.  The 
fact  of  the  absorption  of  the  mercurial  salt  thus  injected  is  proved  by  the 
prompt  disappearance  of  syphilitic  lesions  and  symptoms,  and  the  demon- 
strable presence  of  mercury  in  the  urine,  faeces,  and  saliva.  Balzer's 
observations,  based  on  autopsies,  go  to  prove  that  three  weeks  or  a  month 
are  required  for  the  absorption  of  the  mercury. 

Though  it  is  claimed  by  the  most  ardent  advocates  of  the  calomel  injec- 
tions that  salivation  is  not  frequently  produced,  and  even  if  developed 
that  it  is  mild,  according  to  my  reading  and  experience  this  accident  is 
not  uncommon,  particularly  when  as  large  a  quantity  as  3  grains  have 
been  injected  every  eight  or  ten  days.  The  truth  is,  that  one  should 
be  always  on  the  alert  and  watchful  of  the  condition  of  the  mouth  when 
these  injections  are  employed.  Salivation  complicating  this  method  of 
treatment  may  appear  after  the  second  or  third  injection,  and,  though 
rarely,  even  after  the  first.  Cases  are  on  record  in  which  during  a  seem- 
ingly auspicious  course  of  injections  alarming  salivation  has  set  in.  To 
explain  this  fulminating  form  of  ptyalism  the  view  has  been  expressed 
that  the  drug  has  a  cumulative  eff'ect,  or  that  its  absorption  was  slow  at 
first,  and  that  under  unknown  conditions  it  suddenly  became  very  active 
and  resulted  in  an  explosion.  Such  facts  carry  with  them  their  own 
teaching. 

In  the  Paris  hospitals,  in  the  services  of  Besnier,  Balzer,  and  Du 
Castel,  cnterorrhoea  and  colitis  of  varying  degrees  of  severity  and  per- 
sistence have  been  observed.  The  imminence  of  these  complications 
teaches  us  that  we  should  never  proceed  in  a  bold  manner  in  using  these 
injections  by  throwing  under  the  skin  large  quantities  of  calomel  at  short 
intervals.     Cosati  injected  8  grains  of  the  salt,  which  caused  a  phlegmon- 


878  SYPHILIS. 

ous  abscess,  produced  gangrenous  stomatitis,  and  such  a  general  morbid 
state  that  the  patient  nearly  died. 

Lesser^  reports  a  case  of  mercurial  erythema  following  a  calomel  injec- 
tion. He  further  says  that  he  has  seen  abscess  less  frequently  follow  the 
subcutaneous  use  of  calomel  than  of  yellow  oxide. 

Runeberg^  reports  the  case  of  an  anaemic  woman,  thirty-four  years 
old,  recently  syphilitic,  to  whom  three  injections  of  1|-  grains  each  of 
calomel  were  given  at  intervals  of  eight  and  twenty-four  days,  and  who 
became  so  debilitated  and  suffered  so  much  from  diarrhoea  and  ulcerations 
of  the  mouth  that  she  died.  At  the  autopsy  great  destruction  of  the 
mucous  membrane  of  the  intestines  and  softening  of  the  spleen  were 
found.  Vogeler^  reports  a  case  in  which  calomel  injected  deep  into  the 
glutei  muscles  produced  such  a  severe  abscess  that  an  incision  was  required, 
together  with  free  curetting  of  the  walls.  He  further  details  a  case  in  which 
salivation  and  diarrhoea,  together  with  prostration  and  even  collapse,  were 
so  severe  that  life  was  threatened.  The  patient  was  saved  by  opening  the 
injected  spots,  scraping  them  out,  and  applying  Paquelin's  cautery.  In 
a  third  case  very  alarming  symptoms  were  only  controlled  by  the  adoption 
of  this  procedure. 

The  following  case,  reported  by  Kraus,^  is  worthy  of  attention :  A 
healthy  man,  aged  thirty  years,  was  injected  twice,  with  an  interval  of 
seven  days,  with  1^  grains  of  calomel.  He  was  soon  after  attacked  with 
salivation,  bloody  diarrhoea,  and  anuria.  He  died  on  the  sixth  day  after 
the  last  injection,  and  at  the  autopsy  severe  dysentery  with  perforation  of 
the  gut,  diffuse  bronchitis,  parenchymatous  nephritis,  and  ulcerative  stoma- 
titis were  found.  There  was  no  urine  in  the  bladder.  Overbeck  claimed 
that  anuria  is  a  symptom  of  mercurial  intoxication. 

Klotz  ^  details  a  case  in  which,  after  a  calomel-and-oil  injection,  his 
patient  felt  a  sensation  of  heaviness  in  the  leg  near  the  spot  injected,  and 
was  attacked  with  alternating  chills  and  fever.  He  had  severe  pain  in 
the  left  side  of  the  chest,  difficulty  of  breathing,  and  slight  and  painful 
cough.  Examination  showed  a  temperature  of  102°  Fahr.,  in  the  axilla 
and  symptoms  of  pneumonia.  In  a  few  days  the  bad  symptoms  passed 
off.  Klotz  is  led  to  think  that  "  embolism  of  the  oil  forming  part  of  the 
injected  fluid  into  the  lung  had  taken  place."  He  speaks  of  another  case 
in  which  similar  phenomena,  but  of  a  milder  character,  were  observed. 

It  is  also  well  to  remember  the  experience  of  Staderini^  in  the  case  of 
a  syphilitic  man,  suffering  from  neuro-retinitis.  This  observer  injected 
into  the  temporal  region  of  each  side  of  the  head  one  gramme  (15  grs.) 
of  a  1  to  10  suspension  of  calomel,  in  order  to  bring  the  mercury  as  close 

^  "  Ueber  Nebenwirkungen  bei  Injectionen  unloshlicher  Quecksilber  verbindungen," 
Vierteljahr.  fiir  Demi,  und  Syphilis,  1888,  pp.  909  et  seq.    • 

^  "Quecksilber-intoxication  rait  toedtlichen  ausgang  nach  subcutanen  Calomel-injec- 
tionen,"  Dnil.  med.   Wochenschrift,  1889,  pp.  4  ct  seq. 

^  "  Zur  Behandhing  der  Sypliilis  mit  subcutanen  Calomel-injectionen,"  Berliner  klin. 
Wochenschrift,  1890,  No.  27,  pp.  940  et  seq. 

*  "  Ein  Beitrag  zur  Kenntniss  der  Wirkung  des  Quecksilbers  auf  den  Darm,"  Deutsche 
med.  Wochenschrift,  1888,  No.  12. 

*  "  Clinical  Observations  on  Intramuscular  Injections  of  Insoluble  Mercurial  Salts  in 
Syphilis,"  Jonrnnl  of  Oidaneous  and  Genit.o-urinary  Diseases,  Feb.,  March,  and  April,  1890. 

^  "  Injezione  di  calamelanos  alia  tempia  consequente  embolia  della  arteria  temporale 
superficiale  e  gangrene  locale,"  Bollet.  del  Scz.  d.  Cult,  del  Scienz.  med.,  1887,  6,  and  Viertel- 
jahr. J'iir  Derm,  und  Syphilis,  vol.  xix.  1156  and  1157. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     879 

as  possible  to  the  lesion,  and  thus  to  obtain  the  most  active  local  effect. 
As  a  result,  on  one  side  a  gangrenous  spot  was  produced  which  laid  bare 
the  temporal  artery  and  destroyed  one  of  its  two  twigs.  The  author  very 
properly  calls  attention  to  the  small  quantity  of  connective  tissue  in  the 
temporal  region,  and  to  the  firm,  bound-down  condition  of  the  overlying 
integument.  Injections,  if  used  in  these  parts,  must  be  made  with  the 
greatest  care,  and  not  in  too  large  a  quantity,  and  vessels  must  be  avoided. 

Scattered  in  the  literature  of  this  subject  we  find  many  claims  of  bril- 
liant results  and  cures.  Flarer  by  means  of  three  injections  of  IJ  grains 
of  the  salt  cured  a  case  of  condylomata  (gummy  tumors)  of  the  iris  with 
posterior  synechia.  Scarenzio  cured  a  case  of  cerebral  syphilis  with  two 
injections,  while  iodide  of  potassium  was  taken  internally.  Soresina 
reports  eight  cases  of  specific  eye  diseases,  such  as  complete  paralysis  of 
third  nerve,  keratitis  punctata,  retino-hyaloiditis,  amaurosis,  amblyopia, 
and  neuro-retinitis,  thus  cured  ;  while  Stephanini  produced  brilliant  results 
in  a  severe  case  of  gummous  infiltration  into  the  pharynx.  In  eight  cases 
Quaglino,  by  means  of  one,  two,  and  three  injections  of  3  grains  of  cal- 
omel into  the  temporal  region  and  arms,  promptly  cured  paralysis  of  the 
third  nerve,  iritis,  and  keratitis  punctata,  retinitis,  neuro-retinitis,  and 
progressive  atrophy  of  the  optic  nerves.  Magri  gives  similar  results  in  six 
similar  cases,  the  injections  being  made  into  the  temples  and  arms.  Many 
other  cases  are  to  be  found  in  medical  literature  in  which  conspicuously 
brilliant  results  have  been  claimed  in  the  cure  of  the  cerebral  and  ocular 
lesions  of  syphilis  by  Scarenzio's  method.  Sigmund's  cures  by  this  method 
were  those  of  the  mild  early  manifestations  of  the  disease,  which  of  course 
readily  yield  to  mercury  administered  subcutaneously,  as  indeed  they  would 
if  the  remedy  had  been  given  by  the  mouth.  Smirnoff  claims  that  he 
cured  cases  of  tertiary  syphilis,  gummy  tumors,  tubercular,  ecthymatous, 
and  serpiginous  syphilides,  nocturnal  pains,  rheumatism,  lesions  of  the 
bones,  and  insomnia.  Other  observers  have  failed  to  see  benefit  in  the 
pains  of  syphilis,  bone  lesions,  or  insomnia.  Smirnoff  significantly  remarks 
that  if,  during  a  course  of  injections  in  tertiary  syphilis,  aggravation  of 
the  symptoms  occurs,  they  should  be  stopped  at  once,  and  that  the  iodide 
of  potassium  should  be  substituted.  Klotz^  claims  very  satisfactory  results 
from  calomel  and  yellow-oxide-of-mercury  injections,  administered  to 
private  patients  for  primary,  secondary,  and  tertiary  lesions.  It  must  be 
remembered  that  while  patients  are  undergoing  this  method  of  treatment, 
as  indeed  under  any  form  of  mercurialization,  they  should  be  placed  in 
the  best  possible  hygienic  conditions  of  all  kinds.  Though  it  is  claimed 
that  relapses  are  less  frequent  and  less  severe  after  this  treatment  than 
after  any  other,  there  is  really  no  substantial  evidence  to  prove  the  asser- 
tion. 

It  is  also  important  to  bear  in  mind  that  in  old  age,  in  cases  of  anaemia, 
of  cachexia,  of  weak  heart,  of  chronic  visceral  diseases  in  general,  in 
persons  having  a  bad  state  of  the  mouth  and  bad  teeth,  this  treatment  is 
contraindicated.  Though  the  same  ardent  advocates  consider  it  a  method 
suitable  for  infants,  young  children,  and  pregnant  women,  I  am  f\ir  from 
their  way  of  thinking. 

From  an  experience  of  this  method  of  treatment  dating  over  twent}^- 
five  years  (having  seen  the  original  trials  of  it  by  my  colleague,  Dr.  Bum- 

1  Op.  cit. 


880  SYPHILIS. 

stead,  in  1866),  and  from  a  study  of  all  that  has  been  written  upon  it,  I 
can  but  reiterate  what  I  have  often  said  in  medical  debates — that  it  is  a 
method  of  treatment  of  utility  in  emergency.  It  may  prove  useful  in 
some  cases  spoken  of  elsewhere  in  this  essay,  such  as  those  of  ocular,  aural, 
and  cerebral  syphilis,  when  given  very  cautiously  and  only  in  a  few  doses. 
That  it  never  will  be  used  as  a  systematic  treatment  extending  over  a 
period  of  years,  as  Neisser  and  Leloir  suggest,  I  am  firmly  convinced.  It 
is  a  treatment  which  is  generally  irksome  and  repulsive  to  patients,  always 
attended  with  more  or  less  discomfort  and  pain,  and  often  producing 
destructive  subcutaneous  lesions  over  the  body,  which  cause  mental  and 
physical  suffering,  and  Avhich  of  necessity  must  impair  the  patient's  health 
and  strength.  In  some  cases,  as  we  have  seen,  it  has  been  known  to 
imperil  and  to  destroy  life. 

In  the  foregoing  section  prominent  mention  has  not  been  made  of  the 
combination  of  calomel  with  oil  of  almonds,  olive  oil,  or  oil  of  vaseline. 
The  clinical  facts  relating  to  this  modification  of  Scarenzio's  method  can 
be  more  clearly  and  briefly  brought  out  as  an  addendum  to  the  section 
upon  gray  oil  as  a  remedy  in  syphilis. 

Metallic  Mercury. — The  administi'ation  of  metallic  mercury  has  not 
been  extensively  tried  in  the  treatment  of  syphilis,  and  it  must  be  con- 
fessed that  the  advantages  claimed  by  those  who  have  thus  employed  the 
agent  are  not  conspicuously  brilliant.  Fiirbringer  ^  was,  according  to 
my  reading,  the  first  to  inject  metallic  mercury  under  the  skin,  using  the 
following  liquid  :  mercury,  2  parts  ;  mucilage  acacia  with  glj^cerin,  10 
parts ;  of  which  the  dose  is  the  contents  of  a  Pravaz  syringe.  At  the 
time  of  injection  little  pain  is  experienced,  but  in  about  twenty-four 
hours  symptoms  of  inflammation  appear,  which  may  end  in  abscesses. 
If  the  skin  is  rubbed  after  these  injections  at  intervals,  mercury  may  be 
found  in  the  urine  quite  early,  but  when  simply  deposited  under  the  skin 
it  may  there  remain  and  produce  no  effect.  Fiirbringer  thinks  this 
method  of  treatment  should  only  be  used  when  inunctions  are  contra- 
indicated  and  when  the  mercurial  is  not  well  borne  by  the  mouth.  To 
Luton,^  however,  belongs  what  credit  there  may  be  in  another  innovation 
in  the  employment  of  metallic  mercury  in  syphilitic  therapeutics.  This 
observer  claims  that  if  mercury  in  its  pure  state  be  injected  into  the 
muscular  tissues,  it  will  there  undergo  peptonization  and  digestion  by 
means  of  the  acid  fluids.  In  a  limited  experience  of  these  injections  he 
found  that  syphilitic  patients  grew  fat,  and  that  their  disease  was  favor- 
ably influenced. 

Prokhoroff  ^  states  that  he  has  thus  treated  forty  cases,  and  that  he 
considers  this  method  of  treatment  superior  to  inunctions  or  to  injections 
with  any  other  mercurial.  He  injects  from  6  to  30  grains  (0.5  to  2.0 
gm.)  of  the  metal  at  a  time  once  a  week,  and  employs  hot  baths  to 
accelerate  absorption.  Symptoms  pi-omptly  disappeared  and  no  toxic 
effects  were  produced.  Prokhoroff  thinks  that  the  mercury  traverses  the 
system  in  a  pure  state  in  the  form  of  very  minute  particles. 

^ "  Zur  localen  iind  resorptiven  Wirkungaweise  einiger  merciirialien  bei  Syphilis 
insbesondere  des  subcutan  injicirten  Metallischen  Quecksilbers,"  Deut.  Arcliiv  fur  kiln. 
Med.,  1879,  24,  pp.  129-157. 

2  "  Des  Milieux  Hypodermiques,"  Archiv.  gen.  de  Medicine,  1882,  vol.  ii.  pp.  526  etseq. 

3  Vrach,  No.  40,  1887,  p.  766. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      881 

lakovlefF^  used  5  to  20  grains  of  pure  mercury  in  weekly  injections, 
which  Avere  followed  by  daily  kneading  and  rubbing  of  the  injected  spot 
and  by  hot  baths  every  two  or  three  days.  This  author  claims  a  minimum 
number  of  relapses  in  cases  in  which  on  an  average  83f  grains  of  metallic 
mercury  Avere  injected  over  a  period  of  ninety-three  days.  The  pain  is 
said  by  him  to  be  trifling,  and  to  disappear  quickly  under  local  massage 
and  hot  baths,  and  indurated  nodules  and  abscesses  were  not  produced, 
lakovleff  mentions  the  fact  that  in  cases  previously  treated  by  frictions 
mercurialism  appeared  after  these  injections. 

Von  During^  also  injected  pure  mercury  into  the  buttocks  of  seven 
patients,  using  one-half  the  contents  of  a  Pravaz  syringe,  more  or  less. 
When  small  doses  were  injected  the  effect  was  delayed,  but  large  doses 
were  promptly  followed  by  such  severe  mercurial  intoxication  that  ex- 
cision of  the  injection-nodule  in  the  glutei  muscles  was  rendered  neces- 
sary. In  a  patient  injected  in  the  forearm  a  movable,  sharply  defined, 
fluctuating  tumor  of  the  size  of  a  pigeon's  egg  was  formed,  and  over  it 
the  skin  was  of  a  deep  red  and  traversed  by  sinuses,  through  which 
metallic  mercury,  but  no  pus,  exuded.  The  microscopical  examination 
of  this  mass  when  removed  showed  a  picture  strikingly  resembling 
spindle-celled  sarcoma.  Von  During  therefore  thinks  that  metallic  mer- 
cury is  unsuitable  for  subcutaneous  injection,  for  the  reason  that  small 
doses  act  too  slowly,  while  large  ones  are  apt  to  produce  too  intense  and 
continuous  an  action.  On  the  other  hand,  the  following;  case  of  AuD-as:- 
neur  seems  to  prove  that  mercury  may  become  encysted,  and  from  time 
to  time  be  absorbed  into  the  system.  Augagneur's  ^  case  presented  a 
tumor  of  the  thigh  which  folloAved  two  injections  of  metallic  mercury.  A 
peculiarity  of  the  case  was  that  intermittent  salivation  occurred,  and  that 
on  one  occasion  it  seemed  to  follow  a  blow  upon  the  thigh.  The  tumor 
Avas  very  large,  and  an  incision  into  it  down  to  the  muscle  revealed  the 
fact  that  a  great  part  of  the  mercury  injected  had  not  been  absorbed. 

Oleum  Cinereum,  or  Gray  Oil. — Oleum  cinereum,  or  gray  oil,  is  a 
semifluid,  fatty,  mercurial  liquid  introduced  into  medicine  by  Professor  E. 
Lang  of  Vienna  in  1886.*  This  author  claimed  exceptional  merit  for 
this  therapeutic  agent,  and  in  his  last  essay,^  after  an  experience  of  five 
years  in  its  use,  he  states  that  his  earlier  convictions  have  been  strongly 
confirmed.  It  is  uro;ed  that  this  oil  is  Avell  borne,  and  that  the  usual 
draAvbacks  to  the  use  of  mercury  are  very  slight,  and  that  even  Avhen 
they  do  occur  they  are  mild  and  ephemeral  in  character.  Lang  con- 
siders this  combination  to  be  superior  to  mercurial  frictions.  Before  it  is 
used  upon  patients,  however,  he  insists  that  the  condition  of  their  mouth 
and  teeth  shall  be  carefully  attended  to. 

Gray  oil  is  prepared  as  folloAvs  :  A  given  quantity  of  lanolin — 1  or  2 
drachms — is  rubbed  up  Avith  considerable  chloroform  to  emulsify  it.      This 

'  Proceed inr/ii  of  the  Riga  Russian  Med.  Society,  1889,  p.  87,  and  British  Journal  of 
Dermatology,  1889,  vol.  i.  p.  481. 

"^ "  Die  Einwirkung  des  Regiillnisohen  Quecksilbers  auf  tierische  Gewebe,"  Monats- 
hefle  fib-  Prak.  Dermatolof/ie,  Nov.,  1S8S,  pp.  ]0o9  et  seq. 

•^"Tumeiir  d'origine  therapeutique  de  I'injection  de  mercure  metallique,"  Lmn 
medical,  March  30, 1890,  p.  455. 

*  "Zur  Sypliilis-tlierapie,"   Wien.  mrd.  Wochenschrift,  Ncs.  34  and  35,  1886. 

*  "  Behandlung  der  Syphilis  mit  Subkutanen  Injectionen  von  grauem  oele,"  ihid., 
Nos.  48  and  oO,  1889. 

56 


882  SYPHILIS. 

mixture  is  to  be  thoi'oughly  triturated,  during  which  operation  the  chloro- 
form will  evaporate.  While,  however,  the  mixture  is  still  in  a  fluid  state, 
metallic  mercury  to  the  amount  of  double  the  quantity  of  the  lanolin  is 
to  be  added,  and  the  trituration  further  kept  up.  As  a  result,  a  pomade 
of  mercury  is  left,  which  represents  mercury  two  parts  and  lanolin  one 
part.  This  is  called  strong  lanolin  gray  ointment.  From  this  salve- 
basis  a  50  per  cent,  oleum  cinereum  or  gray  oil  may  be  obtained  by  mix- 
ing three  parts  of  it  with  one  part  of  olive  oil.  A  mild  gray  lanolin  oint- 
ment may  be  made  in  the  same  manner  as  the  strong  by  taking  equal 
parts  of  lanolin  and  mercury  and  thoroughly  mixing  them.  From  this 
salve-basis  a  30  per  cent,  gray  oil  may  be  made  by  mixing  six  parts  of  it 
with  four  parts  of  fresh  almond  or  olive  oil. 

Lang  uses,  therefore,  two  forms  of  gray  oil,  the  one  containing  50 
per  cent,  and  the  other  30  per  cent,  of  mercury.  These  preparations 
should  be  kept  in  small  quantity  in  glass-stoppered  bottles  and  in  a 
cool  place.  With  care  they  may  be  kept  in  perfect  condition  for  many' 
months. 

Neisser  ^  uses  a  modification  of  Lang's  gray  oil,  made  as  follows : 
Mercury,  twenty  parts ;  ethereal  tincture  of  benzoin,  five  parts ;  and 
liquid  vaseline  forty  parts.  This  compound  should  be  thoroughly  tritu- 
rated for  a  long  time  (care  being  taken  that  an  aseptic  condition  is  ob- 
served) until  a  homogeneous  liquid  is  produced.  This  observer  thinks 
that  the  gray  oil  has  a  large  sphere  of  usefulness,  and  that  it  may  even 
be  used  during  pregnancy. 

Balzer  ^  and  Reblaub  have  used  Neisser's  gray  oil  in  preference  to 
that  of  Lang,  but  were  not  very  favorably  impressed  with  its  results. 
They  noted  pain  and  tumefaction  after  the  injections  into  the  buttocks, 
and  that  a  lameness  was  produced  which  passed  off"  after  rest. 

Althaus  ^  has  lately  advocated  for  the  treatment  of  syphilitic  nervous 
aff"ections  a  modification  of  Lang's  gray  oil,  made  as  follows :  Metallic 
mercury,  one  part ;  pure  lanolin,  four  parts ;  and  five  parts  of  a  2  per 
cent,  carbolic  oil.  This  is  said  to  be  a  homogeneous  gray  cream  which 
has  no  tendency  to  decomposition.  The  dose  is  about  five  minims  for  an 
injection. 

It  is  always  necessary  to  warm  the  gray  oil,  either  over  a  spirit-lamp 
or  in  hot  water,  and  then  thoroughly  shake  it  before  using  it.  Lang 
injects  three-quarters  of  a  grain  (0.05)  to  one  grain  and  a  half  (0.1)  of 
the  50  per  cent,  solution  twice  in  the  first  week  in  two  places,  and  half 
as  much  the  next  week.  Such  is  the  claimed  enduring  efficacy  of  the 
remedy  that  Lang  does  not  administer  another  injection  for  two  or  four 
weeks.  Double  the  quantity  of  the  30  per  cent,  solution  may  also  be 
employed.  In  the  subsequent  injections  Lang  is  explicit  in  stating  that 
they  should  not  be  made  stronger,  but  that  they  may  be  given  at  various 
intervals,  according  to  the  urgency  of  the  case,  of  one  or  two  weeks  in- 
definitely.    It  thus  happens  that  no  pause,   as  indicated   just    now,   is 

'  Harttimg :  "  Die  Verwendung  des  oleum  cinereum  benzoatum  (Neisser)  zur 
Syphilis-behandlung,"  Vierteljahresschrifi  filr  Dermaiologie  und  Si/phiUs,  1888,  pp.  367 
et  seq. 

'^  "Traitement  de  la  Syphilis  par  les  Injections  intramusculaires  d'huile  grise  ben- 
zoin^e,"  Bulletin  medical,  No.  74,  1888. 

^  27(6  Treatment  of  Syphilis  of  the  Nervous  System,  London,  1891. 


THE  GENERAL  METHODICAL  TREATMENT  OF  SYPHILIS.      883 

observed,  but  that  a  continuous  treatment  is  followed.  Increased  rapidity 
of  action  is  produced  by  making  injections  into  two  spots,  and  a  more 
enduring  action  results  than  from  one  injection  of  a  similar  quantity. 
Lang  says  that  his  treatment  may  be  used  according  to  the  views  of  the 
experimenter,  either  continuoush'',  by  intermissions,  or  even  symptomati- 
cally.  He  speaks  of  its  efficacy  in  local  and  regional  therapy,  in  cases 
of  circumscribed  infiltrations,  and  of  ganglionic  enlargement. 

In  the  nervous  afi"ections  of  syphilis  and  the  neurasthenia  produced 
by  that  disease  Lang  claims  that  injections  of  gray  oil  are  most  effica- 
cious, and  that  a  notable  improvement  in  appetite  and  health  is  soon 
experienced. 

The  sites  of  injections  are  the  back,  a  few  inches  on  each  side  of  the 
spine,  beginning  about  the  scapula  and  ending  at  the  buttocks.  In  the 
regional  therapy  the  injection  should  be  made  near  the  lesion  to  be  acted 
upon.     The  injections  are  made  into  the  subcutaneous  connective  tissues. 

Certain  observers,  notably  Hallopeau  and  Kaposi,  have  reported 
cases  of  very  alarming  mercurial  intoxication  (great  asthenia  and  in- 
tractable colitis)  as  being  caused  by  injections  of  the  gray  oil.  In  his 
latest  communication  Lang  analyzes  these  cases  in  full,  and  claims  that 
they  resulted  from  an  excessive  and  intemperate  use  of  the  mercurial 
compound,  and  that  they  should  not  stand  as  evidences  of  its  dangerous 
character. 

It  is  claimed  by  Lang  that  local  pain  is  seldom  caused  by  these 
injections,  and  that  when  it  exists  it  is  mild  in  character;  also,  that 
little  if  any  inflammatory  oedema  or  infiltration  of  the  tissues  is  pro- 
duced. In  these  assertions  he  is  borne  out  by  Trost,^  who  instituted 
comparative  tests  between  gray  oil  and  a  lanolin-olive-oil-combination 
of  calomel.  On  the  other  hand,  Lindstroem ^  states  that  Lang's  injec^ 
tions  are  slow  in  action,  attended  with  relapses,  accompanied  and  fol- 
lowed by  pain,  and  frequently  give  rise  to  difiuse  infiltrations.  Stomati- 
tis is  frequent  and  severe,  and  accompanied  by  profound  anaemia  and 
diarrhoea.  Lindstroem  further  says  that  these  injections  may  give  rise 
to  embolism — that  in  one  case  he  observed  a  consecutive  paralysis  of 
the  right  side  of  the  face,  and  in  another  intense  oedema  of  the  right 
upper  limb  and  pneumonia  of  the  right  side.  If,  now,  we  compare  the 
drawbacks  noted  as  following  injections  of  calomel  and  gray  oil,  we  may 
reach  the  conclusion  that,  notwithstanding  all  that  is  said  in  their  favor, 
they  sometimes  give  rise  to  very  unpleasant  symptoms,  and  rather  ex- 
ceptionally to  conditions  which  threaten  and  even  compromise  life. 
Therefore,  I  think  that  their  use  should  be  restricted  to  well-selected 
cases  in  which  other  remedies  are  contraindicated  or  are  impracticable  of 
employment.  When  used  much  care  and  observation  is  required  of  the 
person  who  administers  them.  In  my  reading  I  have  been  struck  forci- 
bly by  the  fact  that  the  most  serious  results  have  almost  invariably  fol- 
lowed injections  in  which  fatty  matters  have  been  the  vehicle  of  suspen- 
sion.    Then,  besides  the  cases  already  cited,  the  case  of  Lesser^  may  be 

^  "Ueber  das  Oleum  Cinerenm  im  Vergleiclie  zur  den  Calomel-priiparaton,"  Wiener 
med.  Wochemchrifl,  1888,  No.  38,  pp.  1374  et  seq. 

■■^"Treatment  of  Syphilis  by  Subcutaneous  Injections  of  Oleum  Cinereum,"  Meditz- 
inskoi'e  Obozrevie,  1890,  xxxiii.  pp.  7  et  seq. 

^  Op.  cit.,  pp.  913-915. 


884  SYPHILIS. 

mentioned :  A  man,  thirty-eight,  had  received  five  injections  of  a  minute 
quantity  of  tannate  of  mercury  in  olive  oil,  and  after  the  last  one  the 
patient  was  seized  with  a  convulsive  cough  and  became  cyanotic.  He 
then  had  diarrhoea  and  dulness  at  the  base  of  his  lung,  with  crepitant 
rales  and  rough  breathing.  He  luckily  escaped  with  his  life.  Therefore 
I  think  that  these  methods  of  treatment  should  never  be  largely  em- 
ployed as  routine  therapeutics. 

It  may  be  of  interest  to  add  that  Watrazewski  recently  reported  that 
he  had  made  experiments  upon  animals  which  convinced  him  that  injec- 
tion of  oily  substances  without  the  addition  of  mercury  may  give  rise  to 
embolism  of  the  lung.  In  the  section  on  Calomel  Injections  it  is  noted 
that  Klotz  ^  had  such  an  experience  after  a  calomel-oil  injection.  It  is 
certain,  therefore,  that  there  is  danger  in  hypodermic  medication  when 
the  mercurial  is  suspended  in  any  oily  substance  or  liquid. 

Yellow  Oxide  of  Mercury. — The  yellow  oxide  of  mercury  owes  its 
introduction  into  the  therapeutics  of  syphilis  to  Watrazewski,^  whose 
advocacy  of  its  worth  has  been  the  means  of  its  adoption  in  prefer- 
ence to  other  mercurial  preparations.  It  is  the  salt  to-day  most  gene- 
rally used  hypodermically,  having  largely  replaced  calomel.  Watrazewski 
had  used  calomel  on  a  large  scale,  and  was  led  to  abandon  it  by  reason 
of  the  many  drawbacks  to  its  use  (see  section  on  Calomel),  and  chiefly  by 
reason  of  the  intense  pain  caused  by  the  injection  of  it,  and  of  the 
weakness,  fever,  diarrhoea,  want  of  appetite,  and  insomnia  which  it 
produces.     His  formulae  are  as  follows : 

No.  1.  I^.  Hydrarg.  oxid.  flav.,  1.50 ; 

Acacise,  0.30 ; 

Aq.  destillat.,  •        30.00.— M. 

No.  2.  I^.  Hydrarg.  oxid.  flav.,  1.00 ; 

Acacise,  0.25 ; 

Aq.  destillat.,  30.00.~M. 

He  begins  with  the  second  or  milder  solution,  and  injects  a  Pravaz, 
syringeful.  Three  to  six  injections  are  sufficient  for  a  cure,  which,  it 
must  always  be  remembered,  means,  in  the  minds  of  most  exploiters  of 
hypodermic  mercurial  preparations  in  syphilis,  the  disappearance  of  a 
given  set  of  symptoms  or  lesions. 

The  yellow  oxide  of  mercury  is  promptly  absorbed,  and  its  presence 
can  be  detected  in  the  urine  within  a  day  or  two.  It  seems  to  linger  in 
the  system  also,  and  whereas,  many  of  the  mercurial  preparations  soon  dis- 
appear from  the  urine  upon  the  cessation  of  the  injections,  when  the 
yellow  oxide  is  discontinued,  mercury,  according  to  several  observers,  may 
be  found  in  the  urine  for  three  weeks  or  more.     The  usual   claims  are 

1  Op.  cit.,  p.  135. 

^  "  Ueber  Behandlung  der  Syphilis  mit  Injektionen  von  Kalomel  und  Quecksilbers- 
oxyden,"  Wiener  med.  Presse,  1886,  Nos.  42  and  44;  "Ueber  die  Behandlung  der 
Syphilis  mit  Injektionen  unloeslicher  Quecksilber-salze,"  Movafshefle  fur  Prak:  Der- 
matologie,  1887,  pp.  989  et  seq. ;  "Etude  comparative  sur  I'Effet  therapeutique  des 
Injections  mercurielles  insolubles  dans  la  Syphilis  et  sur  les  Accidents  qui_  peuvent 
accompagner  leur  emploi,"  Journal  des  Med.  cutanees  ei  aypldliliques,  1890,  vol.  i.  pp.  193 
et  seq. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     885 

made  by  WatrazeAvski  as  to  the  prompt  action,  the  mild  and  ephemeral 
local  reactions,  and  the  comparatively  rare  occurrence  of  mouth  and  intes- 
tinal complications  after  injections  of  yellow  oxide. 

Many  observers  have  used  Watrazewski's  salt,  and  speak  in  high  terms 
of  it,  among  them  Dr.  Klotz  of  New  York.^  Rosenthal^  endorses  its 
use  quite  warmly,  and  considers  it  next  to  inunctions  in  value.  This 
observer  used  the  following  formula : 

^i.  Hyd.  oxid.  flav.,  0.5; 

01.  amygdal.  vel  olivse,  15. — M. 

Of  this  the  dose  is  two  grammes,  injected  every  eight  days  into  the  glutei 
muscles. 

Kuhn  ^  put  this  agent  to  the  test  in  comparison  with  calomel.  He 
concludes  that  it  is  less  active  than  that  of  salt,  but  has  the  advantage  of 
being  less  painful,  of  causing  mild  and  ephemeral  indurations,  and  being 
attended  with  no  local  or  constitutional  complications.  TchernogUboff  * 
employed  the  yellow  oxide,  using  one  or  two  injections  of  2  grains  each, 
into  the  cellular  tissues  in  early  cases,  at  intervals  of  eleven  days,  and  in 
older  cases  at  longer  periods.  This  observer  as  will  be  seen,  uses  large 
doses,  and  says  that  they  are  beneficial  in  tertiary  syphilis  and  in  early 
gummata.  Men  and  women,  it  is  claimed,  bear  these  large  doses  well,  and 
children  are  said  to  be  benefited  by  doses  of  1  grain.  TchernogUboff 
thinks  this  remedy  is  contraindicated  in  angemia,  exhaustion,  alcohol- 
ism, and  visceral  diseases.  Perhaps  it  may  be  well  to  add  that  any 
mercurial  preparation  should  be  used  with  great  caution  in  patients  suf- 
fering from  these  grave  disorders.  It  is  interesting  to  remember  that 
Lesser  ^  observed  abdominal  pains,  vomiting,  and  bloody  and  mucoid  diar- 
rhoea after  injections  of  yellow  oxide,  and  never  after  calomel.  The  con- 
clusion, therefore,  is  warranted  that  we  can  only  get  at  the  truth  as 
regards  the  advantages  and  drawbacks  peculiar  to  any  and  all  prepara- 
tions by  a  study  of  the  experience  of  many  men.  It  is  never  well  to 
fully  rely  upon  the  assertions  of  the  exploiter  of  a  new  mercurial  prepa- 
ration or  combination.  Thus  we  find  that  Dampekoff^  used  the  yellow 
oxide  upon  179  syphilitic  women,  and  that  neither  intense  pain  nor  sup- 
puration was  produced.  Yet  these  women  absolutely  refused  to  allow  the 
continuation  of  the  treatment  by  reason  of  the  severity  of  the  pain. 
Then,  on  the  other  hand,  Reshetnikoff^  in  the  course  of  1800  injections 
of  yellow  oxide  suspended  in  vaseline  oil  and  made  into  the  gluteal 
regions,  never  met  with  an  instance  of  local  suppuration,  and  only  once 

1  Op.  cit.,  p.  99. 

"^  "Die  Behandlung  der  Syphilis  niittelst  Einspritzung,  von  Hydrarg.  oxyd  flav," 
Vierteljah.  fiir  Derm,  unci  Syphilk,  1887,  pp.  1101  et  seq.;  and  "  AUgemeine  Gesichtspunkte 
bei  der  Behandlung  der  Syphilis  mittelst  Quecksilbereinspritzungen,"  Ibid.,  pp.  1107 
et  seq. 

^  "  Zur  Behandlung  der  Syphilis  mit  Injektionen  von  Hydrarg-oxyd-flav.  im  Ver- 
gleiche  znm  Calomelol,"  Deut.  med.  Wochevschrifl,  1888,  pp.  635  et  seq. 

*  Transaction!^  of  the  Third  General  Meeting  of  Russian  Medical  Men,  No.  5,  p.  100,  St. 
Petersburg,  1889. 

^  Op.  cit. 

^  Dnevnik  Kazanskaho  Obslitehcstva  Vratchei,  .Jan.  and  May,  1889,  p.  11;  and  British 
Journal  of  Dermalology,  vol.  i.,  1889,  p.  .381. 

'  Vestnik  Obshtch.  High.  Sudebnoi  i  Praktitcheskoi  Meditziny,  Jan.,  1889,  pp.  1-17;  and 
British  Journal  of  Dermatology,  vol.  i.,  1889,  p.  349. 


SYPHILIS. 

saw  a  diffuse  sanguinolent  infiltration,  Avhich  disappeared  without  any 
bad  result.  A  quite  recent  essay  on  the  value  of  yellow  oxide  of  mercury 
hypodermically  in  syphilis  is  contributed  by  Selenew,^  of  Stukovenkofi"s 
clinic  m  Kiew.  This  observer  reaches  the  conclusion  that  this  treatment  is 
to  be  preferred  to  all  others  as  offering  a  more  energetic  and  more  pro- 
longed influence  of  the  mercurial  upon  the  syphilitic  virus.  Selenew 
thinks  that  cerebral  lesions,  old  age,  exhaustion,  anaemia,  and  alcoholism 
are  not  contraindicating  conditions  to  its  use.  He  noted  a  mild  character 
in  the  sequelae  of  the  injections,  and  occasionally  a  mild  and  ephemeral 
rise  in  the  temperature. 

My  own  conclusion  as  to  this  agent  is  that  in  certain  exceptional  cases, 
where  regional  or  local  mercurial  therapy  is  required,  it  may  be,  if  used 
carefully,  of  decided  benefit.  I  have  no  leaning  to  the  routine  use  of 
any  insoluble  salt  of  mercury  employed  hypodermically. 

Many  other  contributions  upon  the  use  of  yellow  oxide  of  mercury 
have  been  published,  but  they  contain  nothing  more  than  has  been  here 
presented. 

Black  Oxide  of  Mercury. — Black  oxide  of  mercury,  used  largely  in 
homoeopathic  practice,  has  been  extolled  as  a  remedy  for  syphilis  when 
administered  subcutaneousl3\  Abend  ^  used  a  suspension  of  this  drug 
in  gum  and  water,  employing  in  all  six  hundred  and  eighty-three  intra- 
muscular injections,  of  Avhich  two  to  fourteen  are  necessary  in  each  case. 
He  noted  the  early  disappearance  of  secondary  and  tertiary  lesions. 
Pain  and  infiltration  were  moderate,  there  Avere  no  abscesses,  and  rarely 
was  stomatitis  observed. 

Hartmann  ^  also  claims  for  the  black  oxide  especial  advantages. 
He  used  the  following  formula : 

^.  Hydrarg.  oxidi  nigri,  1.0; 

Glycerinse, 
Aquae  destillat.  da.  5.0. — M. 

Of  this  the  contents  of  a  Pravaz  syringe  should  be  injected  into  the 
buttocks. 

Hartmann  also  uses  a  10  per  cent,  oil  emulsion.  Three  to  six  injec- 
tions are  considered  sufficient.  They  produce  some  pain,  slight  irrita- 
tion, and  sometimes  stomatitis.  It  is  claimed  that  this  drug  is  indicated 
in  the  treatment  of  hereditary  syphilis. 

WatrazcAvski  also  used  both  black  and  red  oxides  of  mercury  in  a 
10  per  cent,  gum  solution.  He  found  that  they  exhibited  considerable 
action,  comparable  to  that  of  calomel,  but  that  they  caused  less  jDain 
than  that  drug.  He  thinks  that  the  oxides  mix  more  readily  Avith 
liquids  than  calomel.  The  resulting  nodosities  are  smaller  and  less 
lasting  than  those  produced  by  calomel. 

It  need  only  be  mentioned  that  protoiodide  of  mercury,  tannate  of 
mercury,  red  oxide  of  mercury,  sulphate  of  mercury,  and  turpeth  min- 
eral have  all  been  tried  hypodermically  in  syphilis,  and  their  promoters 

^  Meditzinskoie  Obozreni'e,  1890,  p.  1 ;  and  British  Journal,  of  Dennatolofjy,  vol.  ii.,  p.  190. 

*  "  Behandlung  der  Syphilis  durch  Subcutanen  Injectionen  von  Hydrargyrum 
oxydulatum  nigrum,"  Inaugural  Disiicrtation,  Wiirzburg.  1887. 

*  "  Behandlung  der  Syphilis  mit  Injectionen  von  Hydrarg.  oxydulatum  nigrum,"  St. 
Petersburg  mecl.  Wochen.,  1890,  3. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      887 

have  usually  found  them  efficacious.  The  truth  is,  that  they  all  come 
under  the  head  of  insoluble  salts,  and  that  none  of  them  possess  any 
advantag-e  whatever  over  calomel,  while  some  are  more  irritatiuo;  and 
others  less  efficient. 

Cinnabar. — Cinnabar  (hydrargyrum  sulphuratum  rubrum)  is  con- 
sidered by  Dr.  A.  A.  SUkhoff^  of  Cronstadt  the  best  mercurial  prepa- 
ration for  subcutaneous  use.  He  prefers  the  so-called  artificial  cinna- 
bar, a  fine  bright-red  salt,  which  mixes  very  evenly  with  oil  of  sweet 
almonds.  One  drachm  of  the  powder  is  mixed  with  an  ounce  of  oil  of 
sweet  almonds,  and  of  this  one  syringeful,  representing  about  one  and  a 
half  grains  of  the  agent,  is  injected  into  each  buttock  every  one  or  two 
weeks.  The  average  number  of  injections  required  varies  between  two 
and  ten,  and  the  sojourn  of  the  patients  in  the  hospital  averaged  between 
twelve  and  forty  days.  Sukhoff  claims  that  these  injections  are  pain- 
less, and  cause  no  local  or  general  reaction,  and  that  they  are  suitable 
for  ambulatory  cases.  He  makes  the  significant  remark  that  in  rare 
malignant  forms  of  syphilis  this  agent  is  less  energetic  than  the  classi- 
cal mercurials. 

Corrosive  Suhlimate. — Though  Hebra^  in  1861  employed  hypodermic 
injections  of  corrosive  sublimate  upon  two  cases  of  syphilis,  and  Berke- 
ley HilP  in  1866  upon  eleven  cases,  it  was  not  until  after  the  appear- 
ance of  the  monograph  of  Lewin^  of  Berlin  upon  the  subject  that  this 
mode  of  treatment  took  a  prominent  place  in  the  therapeutics  of  syphilis. 
The  first  important  contribution  to  this  subject  published  in  France  was 
by  Li^gois,^  and  after  this  very  many  articles  appeared  in  various 
countries  detailing  the  experience,  favorable  or  the  reverse,  of  different 
observers.  In  1871,  I  published  the  results  of  my  experience  ^  in  the 
treatment  of  50  cases  of  syphilis  by  this  method,  and  I  have  employed 
it  since  within  the  limitations  yet  to  be  brought  out.  From  the  expe- 
rience of  many  observers  it  is  made  clear  that  doses  of  from  ^  to  ^  of 
a  grain  of  this  salt,  dissolved  in  from  10  to  15  drops  of  distilled  water, 
injected  into  the  subcutaneous  tissues,  have  a  prompt  effect  upon  sec- 
ondary syphilitic  manifestations.  Whereas  in  earlier  days  the  claim 
was  made  that  this  treatment  was  applicable  to  all  forms  and  stages  of 
syphilis,  the  conviction  has  gradually  gained  ground  that  it  is  a  method 
(valuable  in  very  many  instances)  of  reserve,  emergency,  utility,  or  ex- 
pediency. Thus  in  cases  in  which  mercury  is  badly  borne  by  the 
stomach,  and  by  that  method,  acts  as  a  depressant  and  impairs  nutrition, 
it  is  very  common  to  observe  that  these  injections  are  well  borne,  and 
that  an  era  of  improvement  is  inaugurated.  Again,  in  cases  of  intes- 
tinal disorder,  in  which  pain  and  diarrhoea  always  follow  the  stomach- 
dose,  the  subcutaneous  injections  come  to  our  aid.     In  many  cases  when 

^  "  Treatment  of  Syphilis  bv  Injection  of  Cinnabar,"  Protok.  Rusch.  Sif  i  Dei-mat.  Obst. 
St.  Petersburgh,  1890,  iv.  51-57'; 

^"Ueber  die  Behandlung  der  Syphilis,"  Allgemeine  Wiener  mccl.  Zeiiunci,  July  23, 
No.  30,1861. 

^  "Subcutaneous  Injection  of  Mercury  in  Syphilis,"  Lancet,  May,  18G6. 

*  Behandhmg  drr  Si/philis,  mil  subcuianen  Snblimat-injeciioncn,  Berlin,  1869. 

^  "  Des  Resultats  cliniques  et  scientifiques  obtenus  avec  les  Injections  sous-cutan^es 
de  sublime  a  petites  doses,"  Annales  de  Derm,  et  de  Syph.,  tome  2,  1869-70,  pp.  1,  90, 
and  272. 

^  "  On  the  Treatment  of  Syphilis  by  the  Hypodermic  Injections  of  Corrosive  Sub- 
limate,"  Medical  Gazette,  May"  13,  1871. 


SYPHILIS. 

by  stomach  ingestion  a  mild  or  severe  stomatitis  or  salivation  is  pro- 
duced, or  when  local  medication  is  powerless,  the  substitution  of  hypo- 
dermic injections  Avill  often  be  followed  by  full  toleration  of  the  drug. 
The  injections  are  often  of  much  value  in  local  and  regional  therapy,  as, 
for  instance,  in  cases  of  localized  syphilitic  neoplasms,  resisting  internal 
treatment,  in  eye,  ear,  and  cerebral  affections,  and  hyperplasia  of  the 
lymphatics  and  the  ganglia.  In  the  past  few  years  I  have  observed 
much  benefit  from  the  hypodermic  injection  of  corrosive  sublimate  in 
patients  who  were  suifering  from  the  grip,  and  in  whom  the  secondary 
manifestations  of  syphilis  coincidently  showed  themselves.  In  many  of 
these  cases  mercury  by  the  stomach  was  badly  borne  and  produced  de- 
bility and  great  nervousness ;  in  others  the  stomach  was  fully  taxed  by 
the  antigrip  remedies ;  and  in  still  others  it  seemed  to  have  no  effect. 
In  these  conditions  I  resorted  to  the  sublimate  injections,  with  a  promptly 
beneficial  effect  and  ultimate  good  results  upon  the  syphilitic  diathesis. 
It  is  well  to  bear  these  facts  in  mind,  for  they  will  be  the  means  of  help- 
ing many  a  sorely-tried  patient  over  some  very  rough  spots. 

In  many  cases  of  secondary  syphilis  it  will  happen  that  by  reason  of 
colds,  of  intercurrent  acute  affections  of  the  throat,  lungs,  liver,  and  intes- 
tines, and  of  gastric  derangements,  mercury  by  the  mouth  is  temporarily 
contraindicated ;    and  in  these  exigencies  a  resort  may  be  had  to  hypo- 
dermic medication.     Patients  sometimes  become  tired  and  complain  of 
the  dosing  by  pills,  and  circumstances  do  not  favor  the  use  of  inunctions 
or  fumigations  ;    and  in  these  cases  very  often  quiet  and  contentment 
may  be  produced  by  using  the  mercury  subcutaneously.    In  some  cases, 
happily  rare,' the  evolution  of  the  secondary  period  of  syphilis  is  ushered 
in  with  fever  and  deep  debility  and  malaise ;  in  fact,  a  pseudo-typhoid 
state  is  produced.     In  such  cases  there  is  very  often  stomach  intoler- 
ance of  mercury,  and  the  patient  is  too  weak  to  stand  mercurial  inunc- 
tions.    In  this  emergency  we  can  use  hypodermic  injections  of  sub- 
limate  with    confidence,  and   employ   the    stomach    for    symptomatic 
remedies.     Even  at  this  late  day  I  think  I  can  do  no  better  than  quote 
in  the  main  the  conclusions — somewhat  modified  and  elaborated,  how- 
ever— which  I  reached  upon  this  subject  in  1871.     They  are  as  follows: 
1.   That  the  use  of  bichloride  of  mercury  by  hypodermic  injections, 
though  a  method  of  treatment  possessing  certain   advantages,  is  for 
various  reasons  of  limited  application.     2.  It  is  useful  in  the  whole 
secondary  period  of  syphilis,  in  roseola,  in  the  papular  syphilides,  and 
in  the  small  miliary  pustular  syphilide.     Its  action  upon  newly-appear- 
ing syphilides  is  sometimes  almost  marvellous.     This  effect  is  always 
strikingly  well  marked  upon  lesions  in  the  vicinity  of  the  injections, 
which  disappear  in  a  few  days.     Thus  in  cases  of  disfiguring  and  com- 
promising syphilitic  eruptions  on  the  face,  neck,  or  hands,  these  injec- 
tions made  as  near  as  possible  to  the  seat  of  the  lesions,  will  always 
bring  about  a  prompt  and  satisfactory  result.     When  syphilides  have 
grown  old,  they  are  often  slow  to  yield  to  these  injections,  which  have 
little  if  any  effect  upon  scaling  lesions,  Avhether  of  early  or  late  evolu- 
tion.     3.   It   very   rapidly   cures   all   syphilitic    neuroses,   cephalalgias, 
pleurodynias,  and   angina,  even   when   they   are   slow   to   yield   to   the 
internal  use  of  mercury  and  morphine.    4.  In  the  cachexias  of  syphilis, 
early  and  late,  and  in  the  anaemia  with  concomitant  gastric  weakness, 


THE  GENERAL  METHODICAL  TREATMENT  OF  SYPHILIS.      889 

these  injections,  used  for  a  time  as  a  treatment  of  utility,  will  prove 
very  efficacious.  5.  It  possesses  no  advantages  over  other  methods  in 
the  treatment  of  mucous  patches  and  condylomata  lata,  or  in  the  hard 
oedema  accompanying  primary  or  secondary  lesions.  6.  It  may  be 
beneficial  in  the  mild  and  even  severe  forms  of  cerebral  and  spinal 
lesions,  in  combination  with  iodide  of  potassium  internally,  particularly 
in  those  cases  in  which  the  use  of  mercurial  frictions  is  for  any  reason 
impossible.  Under  like  conditions  in  eye  and  ear  syphilis  these  injec- 
tions may  be  resorted  to.  7.  In  the  early  tertiary  lesions,  and  even  in 
the  late  forms  if  not  of  an  ulcerated  character,  these  injections  are 
often  beneficial,  but  they  then  require  the  internal  use  of  the  iodide  of 
potassium  as  an  adjuvant.  8.  This  treatment  is  frequently  well  borne 
by  men,  but  is  much  objected  to  by  women  as  a  rule,  and  in  children 
and  infants  it  is  contraindicated  except  under  conditions  of  severe 
emergency. 

Rosolimos,^  who  has  used  sublimate  injections  upon  a  large  scale, 
calls  attention  to  a  fact  which  I  have  also  observed — namely,  that  the 
method  is  often  extremely  efficacious  in  cases  of  buccal  lesions  without 
the  aid  of  topical  treatment.  He  attributes  this  efficient  action  not 
only  to  the  curative  influence  of  the  injections,  but  also  to  the  fact  that 
they  very  rarely,  if  ever,  cause  stomatitis  or  any  form  of  mouth  lesions, 
which  so  often  lead  to  the  development  of  syphilitic  processes  on  these 
parts. 

It  is  of  the  utmost  importance  that  the  patient  should  be  not  only 
intelligent,  but  at  the  same  time  impressed  with  the  gravity  of  his  dis- 
ease, in  order  that  he  may  comprehend  the  advantages  he  is  to  derive, 
otherwise  he  will  not  submit  to  the  pain  and  inconveniences  of  the 
treatment.  In  some  cases  in  private  practice  the  treatment  is  inadmis- 
sible by  reason  of  the  cost  of  the  frequent  injections.  In  dispensary 
practice  patients  soon  tire  of  this  treatment,  and  they  fail  to  appear  for 
its  continuance.  It  is  well,  therefore,  for  physicians  not  to  put  down 
in  their  records  cases  as  being  cured  for  the  reason  that  they  did  not 
come  back,  since  it  is  very  probable  that  they  may  have  sought  other 
and  more  agreeable  methods  of  treatment. 

Within  the  limits  of  expediency,  emergency,  and  utility  these  injec- 
tions possess  the  advantages  of  smallness  and  precision  of  dose  and  ease 
of  administration,  a  promptly  satisfactory  therapeutic  action,  and  the 
absence  of  systemic  disturbance. 

The  quantity  of  mercury  for  initial  injections  should  be  about  ^  or 
-|  of  a  grain  of  the  sublimate  for  persons  in  good  health.  In  weakly 
individuals  -jl^-  of  a  grain  may  be  used.  Therefore  it  is  well  to  have 
several  solutions  on  hand,  always  in  small  quantity,  kept  in  a  cool 
place  and  secluded  from  the  light.  After  many  years'  experience  I 
have  reached  the  conclusion  that  10  or  12  drops  of  water  are  sufficient 
for  the  amount  of  injection  fluid.  Thus  Ave  may  have  a  solution  in 
which  -^  of  a  grain  of  sublimate  is  dissolved  in  10  drops  of  water, 
another  of  ^  of  a  grain  in  the  same  quantity,  and  for  exceptional  in- 
stances "I"  or  ^  of  a  grain  to  the  same  amount.  As  a  rule,  it  will  be 
found  that  as  an  all-around  solution  the  one  containino;  ^  grain  to  10 

'  "  Les  Syphilides  secondaires  de  la  Bouche,  trait^es  par  les  Injections  merciirielles," 
Annales  de  Demi,  et  de  Syph.,  1888,  pp.  525  et  seq. 


890  SYPHILIS. 

drops  will  be  the  most  used  and  the  most  effective.  For  a  few  injections 
a  greater  strength  may  be  required  by  reason  of  emergency  or  the 
severity  of  symptoms,  and  in  most  instances  benefit  will  result.  These 
solutions  must  be  made  with  great  care  and  with  distilled  water,  and  then 
they  should  be  filtered.  Whenever  they  show  signs  of  turbidity  they 
should  be  rejected. 

White  ^  of  Guy's  Hospital  has  reported  his  marked  success  in  the 
treatment  of  syphilis  of  the  nervous  system  with  the  sublimate  injection. 
He  first  injects  deeply  into  the  gluteal  muscles  |-  of  a  grain  of  muriate  of 
morphine,  then,  withdrawing  and  recharging  the  syringe,  he  injects  \  of 
a  grain  of  the  mercurial.  He  speaks  of  one  case  in  which  daily  injections 
for  nearly  ten  weeks  were  made.  In  this  connection  it  should  be  remem- 
bered that  by  such  a  treatment  we  are  liable  to  induce  a  craving  for  mor- 
phine.    It  is  always  better  for  the  patient  to  stand  the  pain. 

CruyP  has  modified  the  use  of  sublimate  hypodermically  by  using 
olive  oil  as  the  means  of  suspension.  A  given  quantity  of  sublimate  is 
dissolved  in  ether,  and  then  incorporated  with  the  oil.  The  dose  is  the 
same  as  in  watery  solutions.  No  bad  effects  are  produced  by  these  injec- 
tions. 

A  further  modification  of  the  sublimate  treatment  is  in  the  form  of 
emulsions  with  vaseline  oil,  which  Tchistiakoff  ^  considers  very  valuable 
in  severe  cases,  and  not  attended  with  bad  results.  This  same  observer 
has  made  a  number  of  experiments  ^  in  order  to  find  a  combination  with 
sublimate  which  does  not  give  rise  to  pain,  and  concludes  that  the  follow- 
ing combination  answers  the  purpose  well : 

^.   Hydrarg.  chlorid.  corros.,  gr.  x; 

Aquae  destillat.,  ■        5J ; 

Acidi  tartarici,  3ss. — M. 

Method  of  Injection. — The  syringe  should  be  made  of  India-rubber, 
and  should  hold  10  or  12  drops,  or  if  larger  should  be  accurately  gauged 
for  those  amounts.  The  needles  should  be  of  very  fine  calibre,  of  steel, 
and  fully  an  inch  and  one-eighth  or  one-quarter  long.  The  greatest 
care  should  be  taken  to  keep  the  syringe  and  needles  (for  it  is  Avell  to 
have  quite  a  number)  in  a  state  of  perfect  cleanliness  and  removed  from 
any  chance  of  dust  contamination.  When  the  syringe  is  charged  with 
the  sublimate  solution  and  the  needle  is  affixed,  the  instrument  should 
be  placed  in  a  saucer  or  tray  containing  a  5  per  cent,  carbolic  solution. 
In  the  operation  the  utmost  asepsis  should  be  aimed  at,  and  the  injected 
part  should  be  carefully  washed  with  soap  and  water,  and  after  that  sopped 
and  wiped  with  carbolic  water  (5  per  cent.).  The  skin  being  pinched  up 
in  a  fold,  the  needle  is  to  be  pushed  gently,  slowly,  but  firmly  deep  into 
the  subcutaneous  connective  tissues,  and  then  the  fluid  is  to  be  expelled 
slowly  and  Avith  care,  in  order  that  the  tissues  may  not  be  bruised  more 

1  "  On  the  Treatment  of  Syphilis,  especially  of  the  nervous  system,  by  the  Subcu- 
taneous Injection  of  Perchloride  of  Mercury,"  Lancet,  June  6,  1891. 

^  "Une  Nouvelle  Injection  mercurielle  sous  cutanee,"  Annales  de  Deii/ii.  et  de  Syph., 
1890,  p.  35. 

^  Transactions  of  the  Third  General  Meetincj  of  Russian  Med.  Men  in  St.  Petersburg, 
1889,  No.  5,  p,  158. 

*  Voenno-Meditzinsky  JUrnal,  No.  28,  1889,  p.  45G. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      891 

than  necessary.  Slight  massage  over  the  injection  will  aid  in  its  diffu- 
sion into  the  tissues.  It  must  always  be  borne  in  mind  that  the  fluid 
should  not  be  thrown  into  the  deep  parts  of  the  derma  proper,  for  the 
reason  that  if  there  deposited  it  is  very  prone  to  produce  an  eschar, 
Avhich  Avill  result  in  the  destruction  of  the  whole  thickness  of  the  skin. 
Then,  again,  great  care  must  be  exercised  that  the  point  of  the  needle 
is  not  lodged  in  a  vein,  in  which  case  dizziness,  syncope,  a  feeling  of 
suffocation,  pain  in  the  heart  and  lungs,  and  other  alarming  symptoms 
Avill  be  observed.  To  avoid  this  accident  the  surgeon  must  watch  the 
piston  of  the  syringe  while  he  is  injecting.  If  there  is  a  moderate  but 
mild  resistance  to  the  injected  fluid,  as  will  be  the  case  if  the  tip  is  in 
the  subcutaneous  tissues,  he  may  know  that  he  is  all  right.  If,  however, 
the  injection  seems  to  pass  out  of  the  syringe  without  any  or  with  very 
little  resistance,  there  is  fear  that  the  tip  is  in  a  vein.  Under  these  cir- 
cumstances it  is  well  to  push  down  farther  or  withdraw  the  needle  a  little 
until  the  normal  resistance  shall  be  felt,  and  then  no  untoward  symp- 
toms will  threaten.  A  very  moderate  amount  of  practice  in  the  use 
of  hypodermic  injections  will  teach  the  surgeon  to  know  when  he  is  in 
danger  of  doing  harm. 

Various — indeed  almost  all — parts  of  the  body  have  been  selected  for 
this  method  of  treatment.  The  arms  and  legs  have  been  used  and  aban- 
doned, for  the  reason  that  much  discomfort,  pain,  and  muscular  inability 
is  generally  produced.  The  back  in  a  line  from  the  shoulders  to  the 
hips,  at  a  distance  of  about  six  inches  on  either  side  of  the  spinal 
column,  was  utilized  by  Lewin,  and  may  occasionally  be  used  when 
other  parts  fail  to  offer  a  proper  site  for  injections.  It  is  always  import- 
ant, when  using  any  form  of  subcutaneous  injection  of  mercury,  to 
avoid  parts  liable  to  be  compressed  over  bony  ridges  or  prominences,  or 
where  extra  pressure  of  the  garments  is  exerted.  After  many  years' 
experience  I  have  come  to  look  upon  the  gluteal  regions  as  the  most 
advantageous  sites  for  mercurial  injections.  Smirnoff  first  called  atten- 
tion to  the  depressions  just  behind  the  great  trochanters  as  eligible  sites 
for  injections,  and  I  think  that  no  parts  of  the  body  lend  themselves  to 
our  purpose  as  well  as  these.  Injections  made  here,  as  a  rule,  cause 
little  if  any  pain  and  but  small  and  ephemeral  nodosities.  In  this  region 
quite  a  number  of  injections  may  be  given,  and  in  most  instances  suffi- 
cient surface  is  offered  for  the  requisite  injection-treatment.  We  can 
resort  also  to  the  hypogastric  regions  and  to  the  parts  near  the  inguinal 
lymphatics,  above  and  below  ;  but  whenever  the  upper  parts  of  the 
thighs  are  used  great  care  must  be  exercised,  in  order  that  we  can  con- 
tinue the  treatment.  As  it  is  very  often  important  to  act  locally  upon 
lesions  of  the  penis  and  of  the  lymphatics  arising  therefrom,  we  may 
have  to  utilize  the  tissues  in  their  vicinity.  It  must  always  be  remem- 
bered that  injections  should  not  be  made  into  the  mons  veneris  or  under 
the  skin  of  the  penis.  The  region  of  the  neck,  particularly  its  back 
portions,  may  be  used  in  some  extreme  cases  requiring  local  or  regional 
therapy.  Care  must  be  exercised  that  vessels  and  nerves  are  not  punc- 
tured or  injured.  Whenever  mercurial  injections  are  employed  for 
localized  deposits  of  new  growths,  the  anatomical  peculiarities  of  the 
parts  must  be  taken  into  consideration. 

As  a  rule,  the  injection  of  ^-  or  ^  of  a  grain  of  sublimate  every  second 


892  SYPHILIS. 

day  "will  be  attended  with  no  bad  or  annoying  results,  and  even  a  daily 
injection  may  be  well  borne  and  may  produce  good  results.  No  absolute 
rule  can  be  given  as  to  the  dose  or  its  frequency.  As  has  already  been 
said,  each  case  is  a  problem,  and  when  treated  Avith  injections,  as  with 
all  methods  of  antisyphilitic  therapy,  it  must  be  carefully  watched.  If 
the  general  condition  of  the  patient  is  improved,  if  his  lesions  show 
signs  of  yielding  to  treatment,  and  if  the  annoyances  and  discomforts 
of  his  disease  are  ameliorated,  the  physician  may  be  assured  that  he  is 
on  the  right  track,  and  he  can  increase  the  dose  or  the  frequency  of  the 
injections  according  to  the  indications  presented.  It  is  astonishing  how 
seldom  stomatitis  or  intestinal  troubles  are  produced  even  when  massive 
doses  of  the  sublimate  are  injected. 

The  unpleasant  local  effects  are  as  follows :  Pain  at  the  point  of 
puncture  ;  pain  at  the  site  of  the  injection  ;  an  erythematous  condition 
of  the  skin,  with  heat  and  itching  or  burning ;  infiltration  in  the  sub- 
cutaneous tissues  and  localized  firm  nodosities. 

The  pain  at  the  point  of  puncture  is  usually  trifling,  and  is  seldom  seen 
in  this  era  of  asepsis. 

The  pain  at  the  site  of  the  injection  may  be  severe,  and  even  lasting 
in  some  few  instances,  but  as  a  rule  it  ceases  in  a  few  hours.  It  may  last 
one  or  more  days,  and  give  way  to  a  sensation  of  tenderness  and  soreness 
of  varying  degrees.  In  many  cases  it  will  be  observed  that  pain  is  felt 
after  the  first  few  injections,  and  that  thereafter  it  is  not  complained  of. 
The  temperament  of  the  patient  in  this  ordeal,  as  in  disease  in  general, 
has  much  to  do  with  the  presence  or  absence  of  pain  following  injections. 

An  erythematous  halo  of  greater  or  less  extent  may  often  be  observed 
even  when  tht  utmost  care  has  been  taken  with  the  injection.  As  a  rule, 
this  hypergemia  is  slight  and  ephemeral,  and  causes  little  annoyance.  In 
some  cases  the  redness  is  deep  and  the  burning  and  itching  are  severe.  It 
is  a  condition  readily  cured  by  rest  and  cooling  lotions. 

Infiltration  into  the  subcutaneous  tissues  may  be  of  various  grades  of 
severity.  In  somewhat  exceptional  cases  it  presents  many  of  the  objec- 
tive features  of  erythema  nodosum.  We  may  also  find  more  or  less 
extensive  induration  of  a  brawny  character,  which  may  be  painful  or  the 
reverse.  In  some  instances  prompt  involution  occurs,  and  in  others  the 
thickened  condition  is  very  persistent,  so  that  patients  present  large  sur- 
faces of  skin  the  seat  of  brawny  swelling  and  thickening.  The  nodosities 
are  usually  the  sequelse  of  diffuse  infiltrations.  In  some  cases  each  injec- 
tion gives  rise  to  a  localized  marginated  subcutaneous  tumor  which  pre- 
sents a  feeling  of  firm  structure.  These  nodosities  remain  in  an  indolent 
condition  for  a  time,  and  then  disappear. 

In  the  sense  in  which  we  understand  the  abscesses  which  follow  calo- 
mel injections,  it  may  be  said  that  these  complications  are  not  observed 
in  sublimate  injections.  During  more  than  twenty  years  I  have  seen  but 
two,  or  perhaps  three,  subcutaneous  abscesses.  They  are  certainly  of 
great  rarity.  I  have  seen  in  my  own  practice  and  in  that  of  another  sur- 
geon a  localized  gangrene  of  the  skin  occur  in  consequence  of  the  injec- 
tion not  having  been  thrown  into  the  subcutaneous  tissues,  but  rather  into 
the  deep  parts  of  the  derma.  In  these  cases  the  whole  skin  for  an  area 
corresponding  to  the  extent  of  the  injection  is  killed.  The  process  of 
decay  is  a  rather  slow  one,  and  the  morbid  tissue  is  thrown  off  and  a 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      893 

clearly  punched-out  wound  is  left.  With  ordinary  care  this  troublesome 
accident  may  be  avoided. 

Intravenous  Injections  of  Bichloride  of  Mercury. — The  latest  modifi- 
cation of  the  injection-treatment  is  that  of  Baccelli,^  who  advocates  the 
injection  of  the  solution  directly  into  the  veins.  He  was  so  successful  in 
the  treatment  of  malaria  by  the  intravenous  injection  of  quinine  that  he 
was  led  to  try  the  method  in  the  treatment  of  syphilis.  As  usual  when 
a  new  fad  is  exploited,  the  results  are  not  less  than  brilliant.  This  treat- 
ment has  the  endorsement  of  W.  L.  Pyle.^ 

In  this  connection  it  is  well  to  remember  that  Ullmann^  has  reported 
some  experiments  upon  the  lower  animals  in  which  he  injected  mercurial 
salts  into  their  veins,  and  produced  death  particularly  promptly  when  he 
used  the  bichloride.  It  will  be  well  to  think  twice  before  resorting  to  this 
dangerous  procedure. 

Sal  alemhroth,  the  double  chloride  of  mercury  and  ammonium,  was 
introduced  into  the  therapeutics  of  syphilis  by  Bloxam*  of  London  as 
being  preferable  to  all  other  mercurial  preparations  for  hypodermic  use. 
The  solution  found  by  the  author  most  efficient  was  one  which  did  not 
contain  an  excess  of  chloride  of  ammonium,  and  was  made  by  dissolving 
32  grains  of  sublimate  and  16  of  chloride  of  ammonium  in  sufficient 
water  to  make  2  ounces.  The  dose  of  this  solution,  which  is  not  liable 
to  decompose,  is  10  minims,  and  it  should  be  injected  deep  into  the  glutei 
muscles  once  a  week.  By  this  agent  the  author  claims  that  he  has  been 
very  successful  in  the  treatment  of  syphilis,  using  the  injections  weekly, 
bimonthly,  and  monthly  for  a  period  of  eighteen  or  twenty-three  months. 

Comjjosite  Preparations  of  Mercury. — Early  in  the  history  of  subli- 
mate injections  efforts  were  made  to  obtain  a  salt  or  a  combination  which 
should  be  so  bland  as  to  cause  no  pain  or  irritation,  and  which  would  be 
more  promptly  absorbed  and  readily  assimilated  than  the  bichloride.  The 
search  for  this  panacea  began  in  1871,  and  it  still  continues.  To  Staub  ^ 
may  be  given  the  credit  of  first  proposing  a  chloro-albuminous  solution  of 
mercury.     He  used  the  following  formula  : 

I^.  Hydrarg.  bichlor.,  1.25  ; 

Ammon.  chlor.,  1.25; 

Sodii  chlor.,  4.15 ; 

White  of  one  egg. 

Distilled  water,  250.00.— M. 
Secundem  artem. 

Staub 's  fluid  was  not  used  largely,  even  in  France,  where  the  bi- 
chloride solution  was  preferred.      In  1876,  Bamberger*^  introduced  an 

^  Gaz.  Med.  Roma,  vol.  xix.,  1893,  pp.  241  et  seq. 

2  Med.  News,  Feb.  23,  1895. 

^  Annates  de  Derm,  et  de  Syph.,  1895,  p.  67. 

*  "On  the  Intramnsciilar  Injection  of  Mercury  in  Syphilis,"  Lancet,  April  28,  1888; 
and  "  On  Syphilis  and  its  Treatment,"  ibid.,  May  5,  1888. 

=»  Traitement  de  la  Syphilis  par  les  Injections  hypodermique  de  Sublime  d  I'elat  de  Solution 
chlor n-albumineiise,  Paris,  1872. 

^  "  Ueber  Hypodermatische  Anwendiing  von  loslichen  Quecksilber-albuminat," 
Wiener  med.  Wnclmischrift,  No.  11,  1S76 ;  and  "  Nachtriigliche  Bemurknng  uher  die 
darstellung  der  loslichen  Quecksilber-albuminat,"  ibid. 


894  SYPHILIS. 

albuminous  mercuric  compound  which  was  largely  used,  and  is  even  em- 
ployed at  this  time.  Bamberger's  solution  is  made  as  follows  :  To  100 
c.c.  of  a  filtered  solution  of  white  of  egg  (containing  40  c.c.  of  albumin 
and  60  c.c.  of  water)  there  are  added  60  c.c.  of  a  solution  of  mercuric 
chloride  (containing  5  per  cent,  or  3  grm.  Hyd.  Clg)  and  60  c.c.  of  a 
solution  of  sodium  chloride  (containing  20  per  cent.)  ;  finally,  80  grm.  of 
distilled  water  are  added,  which  brings  the  bulk  of  the  solution  up  to 
300,  containing  0.010  sublimate  in  every  cubic  centimetre.  Upon  the 
hypothesis  that  in  stomach  ingestion  sublimate  is  first  converted  into  an 
albuminate,  which  in  its  turn  is  readily  absorbed,  Bamberger's  fluid  was 
accorded  an  extensive  use  in  Germany.  But  by  reason  of  the  more  or 
less  prompt  deterioration  of  this  fluid  (in  its  becoming  turbid  and  pre- 
cipitating a  white  substance  consisting  chiefly  of  calomel)  it  gradually  fell 
into  disfavor — a  result  which  was  accelerated  by  the  fact  that  its  injec- 
tion produced  nearly  if  not  as  much  pain  as  the  sublimate  injections.  I 
used  this  solution  in  many  cases  over  a  considerable  period  of  time,  and 
abandoned  it  by  reason  of  the  uncertainty  of  the  dosage  from  precipita- 
tion, and  from  the  fact  that  it  possessed  no  advantage  over  the  sublimate 
solution.  My  colleague,  the  late  Dr.  Bumstead,  reached  a  similar  con- 
clusion. 

With  the  death  of  the  mercuric  albuminate,  phoenix-like  a  new 
preparation  was  heralded.  For  this  therapeutic  novelty  the  world  is 
indebted  to  the  late  L.  Martineau^  of  Paris,  who  in  season  and  out  of 
season,  wrote  in  journals  and  in  societies  spoke  words  of  praise  about  his 
pejjtone  mecufique  ammonique.  According  to  this  enthusiastic  physician, 
the  syphilitic  panacea  had  at  last  been  found,  which  was  readily  absorbed, 
caused  no  pain  or  inconvenience,  and  cured  promptly  every  case.  The 
formula  of  the  preparation  is  as  follows  : 

^.     Hydrarg.  bichlor.,  10 ; 

Peptone  dry  (Catillon),  15  ; 

Ammon.   chlor.,  15. — M. 

One  gramme  of  this  preparation  contains  25  centigrammes  of  sublimate. 
It  was  diluted  in  water  alone  and  in  a  mixture  of  water  and  glycerin, 
and  was  injected  in  doses  of  from  -^  of  a  grain  upward.  Though  so 
much  vaunted^  the  preparation  was  not  largely  used,  and  since  the 
death  of  its  introducer  it  has  passed  into  the  limbo  of  therapeutical 
curiosities. 

A  number  of  observers  have  also  published  papers  on  peptone- 
mercury  in  various  forms  and  modifications  in  syphilis.  Though  numer- 
ous, these  essays  contain  nothing  worth  recording,  and  they  themselves 
may  well  be  speedily  forgotten. 

Hydrochloric  Grlutin-Peptone  Sublimate. — This  newly-elaborated 
compound  has  been  recently  much  praised  by  Hiifier,^  who  contends  in 
favor  of  soluble  preparations  of  mercury  for  hypodermic  use  in  syphilis. 

^  "  Des  Injections  sous  cutanees  de  Peptone  merciirique  Ammonique  dans  le  Traite- 
ment  de  la  Syphilis,"  Union  medicale,  1881,  od  series,  vol.  xxxiii.  pp.  97,  125,  136,  149, 
174  and  186  ;  and  "Le9ons  sur  la  Therapeutique  de  la  Syphilis,"  io  France  medicale,  1882, 
tome  2,  Kos.  27  to  34. 

^  "  Ueber  die  Behandlung  der  Syphilis  mit  Salzauren  Glutinpeptone  Sublimat  (nach 
Dr.  Paal),"  Therap.  Monatshejle,  Sept.,  1890,  pp.  437  et  seq. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      895 

In  Strumpell's  clinic  sixty  patients  were  treated  by  this  new  compound. 
It  is  claimed  by  Hiifler  that  the  remedy  is  prompt  and  efficient,  that  it 
causes  no  local  reaction,  and  that  relapses  are  no  more  frequent  than 
when  other  treatments  are  followed.  It  may  be  remarked  that  such 
poly  pharmaceutic  refinements  as  the  one  just  mentioned  should  be  looked 
upon  only  as  therapeutical  curiosities,  to  be  used  by  those  seeking  novelty 
rather  than  true  scientific  results.  This  preparation  is  said  to  have  been 
patented  by  its  inventor.  Dr.  Paal.  It  is  scarcely  probable  that  he  will 
be  annoyed  with  the  prosecution  of  many  infringement  suits. 

Bockhart  ^  introduced  into  medicine  a  preparation  which  he  calls  blood- 
serum  mercury,  which  he  thinks  is  better  than  any  other  combination  of 
mercury  and  albumin.  It  is,  he  claims,  of  fixed  composition,  and  when 
injected  under  the  skin  causes  little  if  any  pain  or  inconvenience,  even 
when  injected  into  the  thighs.  It  is  prepared  as  follows  from  the  blood 
of  sheep,  horses,  or  oxen :  lOJ  drachms  of  blood-serum,  sterilized  after 
Koch's  method,  are  placed  in  a  graduated  glass,  and  then  mixed  with  a 
solution  of  45  grains  of  bichloride  of  mercury  dissolved  in  1  ounce  of 
boiling  distilled  water.  The  precipitate  formed  is  redissolved  by  the 
addition  of  105  grains  of  chloride  of  sodium  dissolved  in  5  drachms  of 
distilled  water.  This  compound  is  then  a  3  per  cent,  solution  of  blood- 
serum  mercury.  By  adding  enough  distilled  water  to  make  the  whole 
measure  6  fluid  ounces  and  5  drachms  we  have  the  solution  generally 
used,  containing  1^^  per  cent,  of  the  mercurial  salt.  In  every  detail  of 
preparation  the  most  scrupulous  care  must  be  taken  to  preserve  an  aseptic 
condition.  Fifteen  minims  of  this  solution  contain  ^  of  a  grain  of  sub- 
limate combined  with  albumin.  Injections  should  be  made  daily  or  every 
second  day.  This  liquid  is  of  a  yellowish  opalescent  color,  and  shows 
little  tendency  to  decomposition  if  kept  in  a  dark  bottle  in  a  cool  place. 

Bockhart  employed  this  preparation  in  many  cases  of  early  syphilis, 
of  condylomata,  gumma  of  the  tongue,  gumma  of  the  skin,  of  syphilitic 
ozoena,  and  of  scaling  syphilitic  eruptions  of  the  palm,  and  found  excel- 
lent results.  Lipp,  however,  thinks  that  the  remedy  is  less  efficacious 
and  more  painful  and  uncertain  in  its  action  than  the  utterances  of  Bock- 
hart would  lead  us  to  expect.  Hallopeau  ^  says  that  the  experiments 
made  with  this  preparation  at  the  Hopital  St.  Louis  did  not  realize  his 
expectations.  All  the  patients  thus  ti'eated  complained  so  bitterly  of  the 
pain  produced  that  the  remedy  was  of  necessity  given  up.  Rona,^  on 
the  other  hand,  though  he  concedes  that  the  remedy  has  some  drawbacks 
in  the  way  of  local  and  general  reaction,  thinks  that  it  is  a  valuable  one 
and  worthy  of  trial. 

Oyanide  of  Mercury  was  brought  prominently  forward  by  the  late 
Tilbury  Fox*  as  a  very  efficient  and  satisfactory  preparation  in  the  treat- 
ment of  syphilis ;  and  it  has  again  recently  been  advocated  as  a  most  ex- 
cellent antiseptic  by  Chibret.^     Fox  employed  it  in  the  form  of  pills,  with 

'  "  Blut-seriim-Qiiecksilber,  ein  neues  prilparat  zur  Injections-behandlung  der  Syph- 
ilis," Monatshefte  fiir  Prakfische  Dennatolof/ir,  1885,  No.  5,  pp.  137  et  seq. 

^  Revue  des  Sciences  medicales,  vol.  xxvii.  1886,  p.  241. 

^  "  Blut  serum  Quecksilber  (Bockhart)  gegen  Lues,"  Monaishtjte  fur  Prak.  Dermat., 
June,  1886,  pp.  287  et  seq. 

*  Skin  Diseases,  London,  1873,  pp.  306  and  307. 

^"  Etude  comparative  des  pouvoirs  Antiseptiques  du  Cyanure  de  Mercure,  etc.," 
Compt.  rendus  de  I' Acad,  des  Sciences,  Paris,  1888,  cvii.  119. 


896  SYPHILIS. 

the  initial  dose  of  -^  of  a  grain  thrice  daily.  This  agent  was  first 
employed  by  the  hypodermic  method  by  Cullingworth,^  who  reached  the 
conclusion  that  it  was  superior  to  the  sublimate  b}^  reason  of  the  mildness 
of  pain  and  of  local  reaction  and  of  its  stability  in  solution.  Therapeu- 
tically, he  found  it  very  efficient,  and  employed  the  following  formula : 

^.  Hydrarg.  bicyanidi,  gr.  xij  ; 

Glycerinse,  §ss ; 

Aquae  destillat.,  ad  5iv. — M. 

The  medium  dose  was  10  drops  (-jlg-  grain),  injected  every  day,  but  double 
the  quantity  can  be  used  in  appropriate  cases  under  careful  surveillance. 
This  agent  was  not  extensively  adopted  as  an  antisyphilitic  remedy, 
and  little  was  then  heard  of  it  until  the  year  1876,  when  Sigmund^ 
praised  it,  and  placed  it  next  to  sublimate  and  calomel  in  its  potency. 
This  observer  regarded  it  as  beneficial  in  mild  cases,  and  noticeable  for 
its  slight  disturbance  of  the  tissues  after  injections.  Sigmund's  opinion 
was  endorsed  by  Mandelbaum^  of  Odessa,  who  regarded  it  as  a  good 
remedy  in  public  practice  for  many  reasons,  particularly  its  cheapness. 
It  would  seem  that  in  Mandelbaum's  experience  this  agent  causes  pain, 
for  he  has  since  published  a  formula  which  contains  cocaine,  as  follows : 

^.   Cocaini  muriat.,  0.05  gm. ; 

Hydrarg.  bicyanidi,  0.01    " 

Aquae  destillat.,  1.00.— M. 
This  quantity  is  sufficient  for  one  injection. 

As  showing  how  one  man's  experience  in  the  use  of  a  drug  is  diamet- 
rically opposed  to  that  of  another,  it  is  interesting  to  give  the  views  of 
Giintz  *  of  Dresden  upon  the  eff'ects  of  the  cyanide  hypodermically  used. 
This  observer  says  that  the  solution  is  very  unstable  and  should  be  used 
up  quickly,  and  that  its  use  causes  much  pain,  vertigo,  noises  in  the  ears, 
nausea  and  syncope.  It  is  very  probable  that  he  selected  for  his  injec- 
tions places  which  are  particularly  sensitive,  and  that  when  he  observed 
syncope,  etc.,  these  alarming  "symptoms  were  due  to  the  fluid  being 
injected  directly  into  a  vein.  Giintz  convinced  himself  of  the  very  rapid 
action  of  the  remedy,  and  that  by  its  hypodermic  use  salivation  might  be 
induced.  The  infiltration  of  the  skin  was  less  than  after  the  employment 
of  the  bichloride. 

Cyanide  of  mercury  was  first  used  in  syphilitic  eye  aff"ections  by  Gale- 
zowski,^  who  injected  from  5  to  10,  and  even  15,  milligrammes  in  men. 
The  author  reports  cures  in  seven  cases  of  iritis  with  interstitial  infiltra- 

^  "On  the  Subcutaneous  Injection  of  Mercury,"  Lancet,  vol.  i.,  1874,  May  9,  16, 
and  23. 

2  Op.  cii. 

^  "  Ueber  die  Behandlung  der  Syphilis  mit  Subcutanen  Tnjectionen  von  Bicyanuretum 
Hydrargyri,"  Vierieljahr.  fiir  Derm,  unci  Syphilis,  1878,  201  et  seq. ;  and  "  Kokain  als 
Schinerzstillendes  Mittel  bei  der  Hypodermatischen  Syphilis  Behandlung,"  Monatshefte 
fiir  Prakt.  Derviat.,  vol.  vi.  pp.  241  et  seq. 

■*  "  Ueber  Subkutane  Injectionen  von  Bicyanuretum  Hydrargyri  bei  Syphilitischen 
Erkrankungen,"  Wien.  ined.  Presse,  1880,  xxi.  pp.  563,  598. 

*  "Des  Injections  hypodermiques  du  Cyanure  de  Mercure  dans  la  Syphilis  oculaire," 
Progrh  medical,  April  15,  1862,  pp.  279  et  seq. 


gr-  ^•; 

gr- 1 ; 

m  15.- 

-M, 

Tif^  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      897 

tion  into  the  cornea,  iritis  and  condylomata,  iritis  and  keratitis  punctata, 
irido-choroiditis,  interstitial  keratitis,  and  neuro-retinitis.  Isolated  cases 
in  support  of  Galezowski's  claims  have  appeared  from  time  to  time  in 
medical  journals. 

It  is  needless  to  mention  a  number  of  papers  published  within  the  last 
ten  years  upon  the  therapeutic  effects  of  this  drug,  since  they  all,  in  the 
main,  endorse  what  has  already  been  said.  The  most  important  recent 
paper  is  by  Boer^  of  Berlin,  who  used  the  cyanide  upon  thirty  cases  of 
syphilis  in  men  and  women,  and  who  thinks  that  it  has  an  antibacterial 
action.  Besides  its  promptness  of  action  and  mild  local  irritating  effect, 
Boer  thinks  the  cyanide  beneficial  for  the  following  reasons  :  1,  it  does  not 
coagulate  albumin,  and  has  a  neutral  or  alkaline  reaction ;  2,  it  is  less 
irritating  than  sublimate ;   3,  and  does  not  become  decomposed  by  light. 

lodo-Tannate  of  Mercury  was  prepared  by  Nourry^  with  the  idea  of 
obtaining  a  preparation  to  which  the  stomach  is  not  intolerant.  Dujardin- 
Beaumetz,  who  tried  this  salt  in  practice,  thinks  that  it  fulfils  the  hopes 
of  its  inventor.     It  is  used  hypodermically  in  the  following  solution : 

^.   Hydrargyri,  gr.  1 ; 

lodini, 

Acid,  tannic, 
Glycerinae, 

This  quantity  is  said  to  be  rather  too  large,  and  liable  to  produce  saliva- 
tion, therefore  but  half  of  it  should  be  used. 

Its  action  is  said  to  be  very  rapid,  and  the  injection  is  attended  with 
neither  pain,  nodosities,  nor  abscesses. 

Bichloride  of  Mercury  and  Potassium. — This  compound  was  first  used 
hypodermically  by  Aime  Martin,^  who  used  the  following  formula: 

I^.   Hydrarg.  biniodidi,  .4  ; 

Potassii  iodidi,  .4 ; 

Aquae  destillat.,  3j. — M. 

Of  this  solution  as  much  as  half  a  drachm  was  injected  at  a  dose.  Martin 
described  a  severe  case  of  generalized  syphilides,  which  had  been  treated 
in  vain  for  two  years,  which  was  cured  by  two  of  these  injections.  In  the 
second  case  syphilis  had  existed  for  six  months  and  was  rebellious  to  mer- 
cury by  the  mouth.  The  usual  dermal,  mucous,  and  glandular  lesions 
were  promptly  caused  to  disappear  by  one  injection. 

Bricheteau*  considered  that  the  iodide  of  potassium  is  irritant  to  the 
tissues,  and  after  many  experiments  adopted  a  formula    containing    the 

'  "  Injectionen  von  Quecksilber  Oxycyanid  gegen  Syphilis,"  Therapeut.  Monalshefte, 
1890,  pp.  332  et  seq. 

^  "Sur  les  Injections  liypodermiques  a  I'lodo-tannate  d' Hydrarg.  soluble,"  Bull.  gen. 
de  Therapevtique,  1888,  pp.  364  et  seq. 

^  "Snr  I'Emploi  des  Injections  liypodermiques  d'lodure  de  Mercure  et  de  Potassium, 
dans  le  Traitement  de  certains  accidents  de  la  Syphilis  sccondaire  et  tertiare,"  Gazelle  des 
Hopitaux,  Sept.  12,  1868. 

*  "On  the  Application  of  the  Ilypodermic  Method  to  the  Treatment  of  Syphilis  by 
Mercury,"  PractUmner,  vol.  ii.,  1869,  pp.  141  et  seq.;  and  Bidl.  gen.  de  Therapeutiqur,  vol. 
Ixvii.,  1869,  pp.  297  et  seq. 

57 


898  SYPHILIS. 

double  iodide  of  mercury  and  sodium,  which  he  thought  free  from  that 
objectionable  quality.     His  formula  was  as  follows: 

I^.   Double  iodide  of  mercury  and  sodium,  gr.  xxiij  ; 

Distilled  water,  5iij . — M. 

The  dose  by  hypodermic  injection  is  10  drops,  which  may  be  increased  to 
20.  The  author  advises  the  use  of  this  formula  in  cases  where  rapidity 
of  action  is  necessary,  as  in  iritis  and  severe  cases  of  syphilis. 

The  So-coxsidered  Antiseptic  Group. — Salicylate  of  Mercury. — 
Introduced  into  pharmacy  by  Lajoux  and  Grandval  in  1881,  salicylate 
of  mercury  was  first  recommended  as  an  antisyphilitic  remedy  by  Silva 
Araujo^  in  1887,  and  since  that  date  it  has  been  used  by  a  number  of 
observers,  who  claim  for  it  exceptional  merit.  It  is  used  in  pill  form,  and 
in  suspension  it  is  injected  into  the  muscles. 

It  is  claimed  for  this  remedy  that  it  is  much  more  promptly  absorbed 
than  any  other  mercurial  preparation  ;  that  it  is  well  borne  by  the  stomach, 
does  not  produce  gastro-intestinal  disturbances  or  diarrhoea ;  and  that  it 
rarely,  if  ever,  causes  stomatitis.  Used  by  stomach  ingestion,  salicylate 
of  mercury  may  be  given  in  pill  form  in  doses  of  from  ;^  to  f  of  a  grain 
three  times  daily.  If  very  prompt  action  is  desired,  the  large  dose  of  1 
grain  three  times  daily  may  be  administered,  but  Szadek  says  that  if 
pushed  too  vigorously  the  remedy  may  cause  intolerance  on  the  part  of 
the  stomach.  In  doses  of  2  grains  daily  it  has  been  used  with  benefit  for 
periods  of  from  two  to  three  months,  without  any  cause  for  interruption. 
It  is  claimed,  to  be  of  especial  benefit  in  the  early  secondary  period,  of  the 
lesions  and  symptoms  of  which  it  causes  involution  and  disappearance. 
In  relapsing  secondary  lesions  of  the  skin  and  mucous  membranes  it  also 
proves  very  effective.  In  late  tertiary  forms  of  syphilis,  particularly  those 
affecting  the  skin,  it  is  also  claimed  to  act  promptly  and  efficiently. 

Salicylate  of  mercury  has  been  used  in  the  form  of  subcutaneous  and 
intramuscular  injection  by  a  number  of  observers,  notably  by  Szadek.^ 
The  latter  uses  the  following  solution  : 

^.  Hydrarg.  salicylat.,  gr.  xvj-xxiv  ; 

Mucil.  acaci?e,  gr.  viij  ; 

Aquge  destillat.,  fsvss. — M. 

The  dose  of  this  liquid  is  the  contents  of  a  Pravaz  syringe,  which  may 
be  administered  into  the  gluteal  region  beneath  the  muscular  fasciae  every 
third  day.  The  number  of  injections  used  in  various  cases  was  from 
four  to  twelve.  Epstein  employed  this  salt  in  oil  emulsion,  and  Hahn 
in  suspension  with  vaseline  oil.  When  used  in  the  form  of  an  injection 
it  is  claimed  that  little  harm  is  produced,  that  the  local  reactions  are  much 
less  severe  than  by  the  use  of  other  mercurial  salts,  and  that  the  resulting 
nodule  gives  little  inconvenience  and  is  soon  absorbed.     Jadassohn  and 

^  "  Du  Traitement  de  la  Syphilis  par  le  Salicylate  de  Merciire,"  Bull.  gen.  de  Tliernpeuf., 
Paris,  1888,  cxiv.,  pp.  175  et  seq. ;  and  "El  Salicylate  de  Mercuric  y  sus  Applicaciones 
en  la  Sifilis  y  en  Algunas  Dermatitis,"  Bevista  de  Medicina  y  Farmacia,  1887,  ii.  2,  pp.  12 
and  14. 

^"Ueber  behandlung  der  Syphilis  niit  Intra-niusculiiren  Injectionen  von  Queck- 
silbersalicylat,"  Wien.  klin.  WochenschriJ't,  No.  13,  1S90. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      899 

Zeissig,  Welander,  Petersen,  Tschistiakoff,  and  others  speak  in  praise  of 
this  mercurial  salt. 

It  is  interesting  to  note  that  Touton  ^  reports  the  case  of  a  man  in 
whom  zoster  femoralis  followed  the  third  injection  of  salicylate  of  mer- 
cury. Touton  is  of  the  opinion  that  this  skin  lesion  was  of  reflex  origin, 
and  due  to  trauma  of  a  nerve.  This  may  be  considered  a  very  unusual 
complication  of  hypodermic  medication  in  syphilis. 

Oarholate  or  Phenate  of  Mercury  was  introduced  into  the  therapeutics 
of  syphilis  by  Gamberini,^  who  regards  it  both  as  an  effective  form  of 
mercury  and  as  being  valuable  by  reason  of  the  supposed  antimicrobic 
action  of  the  carbolic  acid.  This  salt  belongs  to  the  group  of  mercurial 
compounds  which  have  been  prepared  and  exploited  as  possessing  a  dis- 
tinct antimicrobic  effect — a  group  which  is  composed  of  the  thymolate, 
the  benzoate,  and  the  salicylate.  It  is  well  known  that  we  are  wholly 
lacking  in  positive  knowledge  of  any  micro-organism  of  syphilis ;  con- 
sequently the  claim  that  an  agent  possesses  a  specific  parasiticidal  effect 
on  the  disease  is  based  on  pure  assumption.  This  particular  prepara- 
tion is  claimed  to  be  as  potent  as  any  other  mercurial  preparation. 
Carbolate  of  mercury  may  be  given  in  pill  form,  each  pill  containing 
one-sixth  of  a  grain  of  the  salt  covered  with  gelatin  or  balsam  tolu. 
The  doSe  at  first  is  two  pills  daily,  which  may  be  increased  to  six  pills. 
In  some  cases  six  pills  produced  mild  gastro-enteritis,  and  in  one  case 
the  remedy  was  abandoned  on  account  of  intestinal  colic.  In  two  cases 
of  papular  syphilides  ^  of  a  grain  of  this  salt,  dissolved  in  15  drops  of 
water,  was  injected  during  a  period  of  two  months  without  good  results. 
In  the  hospital  at  Wlirzburg  this  preparation  was  tried  by  Happel.^  He 
injected  about  one-third  of  a  grain  every  day  or  two,  using  on  an  average 
fifteen  injections.  He  saw  no  abscesses  and  very  slight  nodules.  In  a 
few  women  malaise,  headache,  and  chills  were  produced. 

This  new  remedy  was  (as  might  be  supposed)  tried  by  Szadek,*  who 
was  well  pleased  with  its  action  in  pill  form  in  mild  cases  and  in  relapses, 
administered  to  adults  and  young  infants.  By  hypodermic  injection  into 
the  subcutaneous  tissues  and  the  muscles  he  also  used  it  with  gratifying 
results.  He  found  that  it  was  readily  absorbed,  and  that  the  injections 
caused  little  local  and  rarely  any  general  disturbance. 

Lexer  ^  made  comparative  studies  of  the  effects  of  injections  of  various 
mercurial  preparations,  and  arrived  at  the  following  results :  That  re- 
lapses occurred  after  inunctions  in  9  per  cent.  ;  after  sublimate,  in  13 ; 
after  the  salicylate  of  mercury,  in  15 :  after  formamide,  in  16  ;  after  the 
peptonate,  in  16  ;  after  the  gray  oil,  in  16  ;  after  the  tannate,  in  18,  and 
after  the  carbolate,  in  27  per  cent.  By  this  showing  the  carbolate  of 
mercury  is  among  the  least  efficient  of  mercurial  preparations. 

^  "Zoster  femoralis  im  Auschluss  an  eine  intra-musculiire  Salicylqueeksilber  Injec- 
tion,"  Archiv  fiir   Derm,  vnd  Syph.,  1889,  pp.  775  et  seq. 

^  "II  Phenato  di  Mercuric,  nuova  medicamento  per  la  cura  della  Sifilide,"  Giornale 
delle  Malat.  Vener.  e  della  Pelle,  1886,  p.  241. 

^  "  Die  Behandlung  der  Syphilis  mit  Subcntauen  Injectionen  von  Hydrargyrum 
Oxydatuni  Carbolicum,"  Inanr/.  7>('.s.sr/-/.,  Wiirzburg,  1888. 

■•  "  Innerliche  Anwendnnf?  des  Hydrargyri  Carholici  Oxydati  bci  Syphilis,"  Monatn- 
hefle  fur  Prak.  Dermat.,  1887,  pp.  195  et  seq.,  and  "  Ueber  hypodermatische  Anwend- 
ung  von  Hyd.  Carbol.  Oxydat.  bei  Syphilis,"   ibid.,  343. 

•^  "  Beitrag  7Air  Benrtheilung  der  Wertbes  der  Verschiedenen  Quecksilber  priiparate 
in  der  Syphilis-therapie,"   Archiv  fiir  Derm,  und  Syphilis,  1889,  pp.  715  et  seq. 


900  SYPHILIS. 

De  Luca^  also  experimented  Avith  this  salt,  of  which  he  administered 
pills  containing  about  ^  of  a  grain  three  to  six  times  a  day.  The  results 
were  no  better  than  those  of  other  mercurial  preparations,  and  Avere 
comparable  to  those  of  the  tannate  of  mercury.  Diarrhoea  and  intes- 
tinal pains  were  noted  in  some  cases. 

It  must  be  remembered  that  the  carbolate,  the  bicarbolate,  or  diphe- 
nate  of  mercury,  above  considered,  must  not  be  confounded  with 
diphenyl  mercury,  Avhich  is  a  deadly  poison. 

Szadek^  also  used  the  carbolate  of  mercury  by  injections  into  the 
subcutaneous  tissues  and  muscles  in  the  form  of  a  2  per  cent,  solution 
in  water  and  gum  arable.  He  states  that  no  pains  were  produced,  but 
sometimes  the  muscles  became  stiff  after  the  injections.  Complications 
are  very  rare,  and  the  action  of  the  drug  is  rapid.  Ten  injections  are 
usually  necessary.  Troitzky,  who  took  part  with  Szadek  in  these  expe- 
riments, entertains  the  latter's  views  as  to  the  efficacy  of  the  mercurial 
agent. 

A  survey  of  the  results  thus  far  experienced  in  the  use  of  this  remedy 
convinces  me  that  it  has  no  striking  qualities,  and  that  it  is  not  to  be 
preferred  to  the  classic  preparations. 

Thymolate  0/ Jf^rcwr^  (hydrargyrum  thymolo-aceticum,  Merck)  is  an 
insoluble  salt  which  was  first  used  in  the  treatment  of  syphilis  in  Neisser's 
clinic,  the  details  of  which  are  given  by  his  assistants,  Jadassohn  ^  and 
Zeissig.  These  observers  used  a  10  per  cent,  suspension  of  the  drug  in 
fluid  paraffine,  and  injected  for  a  dose  from  1  of  a  grain  to  one  grain 
into  the  muscular  tissues.  They  think  they  have  seen  in  its  action 
results  not  attainable  with  any  other  mercurial  salt,  without  the  usual 
drawbacks  of  pain,  infiltration,  and  abscesses.  Thymolate  of  mercury, 
used  hypodermically,  exerts  a  rapid  and  energetic  action  iipon  syphilitic 
manifestations,  less  pronounced  than  that  of  calomel,  but  greater  than 
that  of  gray  oil.  Six  or  eight  injections  are  sufficient  for  a  cure.  Wel- 
lander*  of  Stockholm,  having  tried  the  remedy  in  forty -four  cases,  en- 
dorses the  encomiums  of  Jadassohn  and  Zeissig,  though  he  states  that  it 
does  not  attain  the  ideal  of  perfection  in  syphilitic  therapy.  He  used 
larger  doses  of  the  drug  than  his  predecessors,  going  as  high  as  a  grain 
and  a  half,  and  injecting  into  the  subcutaneous  tissues  as  well  as  into 
the  muscles.  In  his  experience  the  local  inflammatory  phenomena  were 
greater  than  those  observed  in  Neisser's  clinic.  Szadek^  has  published 
his  results  with  thymolate  of  mercury.  This  experimenter  uses  the  fol- 
lowing formula : 

'Sf.  Hydrarg.  thymolo-acetic,  1.5; 

Mucil.  acaciae,  0.5 ; 

Aq.  destillat.,  20.— M. 

1  La  Biforma  Med.,  1888. 

2  Meditzin.  Obozrenie,  No.  6,  1887  ;  and  Bull.  gen.  de  Thempeutique,  1887. 

=*  "  Einspritzungen  von  Salicyl-  nnd  Thvmol-qnecksilber  zur  Syphilis  Behandlung," 
Vierteljahr.fur  Derm,  und  Syphilis,  1888,  pp.  781  et  seq. 

*  "'Ueber  die  Behandhing  der  Syphilis   mit  Injectionen  von  Thymol-  und  Salicyl- 
quecksilber,"  ibid.,  1889,  pp.  458  et  seq. 

*  "  Zur  Behandlung  der  Syphilis  mit  intra-musruliiren  Injectionen  von  Hydrargyrum 
Thymolo-aceticum,"   Wiener  vied.  Woche7ischrift,  1S90, 'No.  22. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      901 

Of  this  liquid  the  contents  of  a  Pravaz  syringe  was  injected  into  the 
thighs  every  three  or  four  days.  The  maximum  number  of  injections  was 
eight  or  ten,  and  the  duration  of  treatment  averaged  twenty-seven  days. 
The  local  reaction  was  mild,  there  were  no  indurations,  no  nodosities,  and 
never  was  an  abscess  produced.  These  results  induced  Lowenthal  ^  of 
Senator's  clinic  to  use  the  drug  suspended  in  glycerin  and  combined 
with  muriate  of  cocaine.  Improvement  was  noted  after  one  or  more 
injections  ;  no  abscess  occurred  in  the  course  of  two  hundred  and  ninety- 
three  injections.  Salivation  was  only  observed  in  one  patient,  having 
bad  teeth,  and  in  another  nausea  and  rigors  were  produced.  Lowenthal 
thinks  that  the  drug  has  a  future  as  an  antisyphilitic  remedy. 

Cehak  ^  also  has  used  thymolate  of  mercury  on  a  large  scale  with 
excellent  results.  He  injected  a  5  and  a  10  per  cent,  emulsion  in  par- 
affin oil  into  the  buttocks  every  second  or  fourth  day.  No  unpleasant 
sequelae  were  observed. 

Benzoate  of  Mercury. — This  preparation  was  introduced  into  medi- 
cine by  Professor  Stukobenkoff,^  is  known  as  hydrargyrum  benzoicum 
oxydatum,  and  contains  43  per  cent,  of  mercury.  It  is  slightly  soluble 
in  cold  water,  and  readily  so  in  alcohol  or  a  weak  solution  of  chloride 
of  sodium.  Stukobenkoff  has  used  it  extensively  in  syphilis,  employing 
a  solution  containing  4  grains  of  the  mercurial,  2  grains  of  salt,  1  grain 
of  muriate  of  cocaine,  in  1  ounce  of  water.  Of  this  mixture  a  Pravaz 
syringeful  is  injected  daily  into  the  buttock  muscles.  It  may  also  be 
used  as  a  10  per  cent,  solution  in  liquid  vaseline.  This  drug  is  said  to 
act  very  rapidly  upon  early  and  late  secondary  lesions.  A  sensation  of 
slight  burning,  which  lasted  two  or  three  days,  was  observed,  as  well  as 
mild  gingivitis  and  salivation.  It  may  also  be  administered  in  pill  form 
(gr.  ^  to  f),  but  the  recorded  results  of  its  action  are  not  striking.  Its 
sponsor  also  used  it  in  its  purity,  and  in  liquid  form  as  an  application 
for  chancroids  and  for  gonorrhoea  and  gonorrhoeal  cystitis  as  an  in- 
jection. 

Stukobenkoff's  preparation  has  been  used  at  the  Lourcine  Hospital  in 
Paris  by  Balzer  and  Thiroloix,  and  their  results  are  given  in  the  thesis 
of  Cochery.^  The  formula  already  given  was  used  by  the  French  ob- 
servers, who  found  that  it  was  a  very  unstable  compound,  in  that  in 
fifteen  days  two-fifths  of  the  mercury  was  lost  by  decomposition  and 
precipitation.  The  objection  which  applies  to  all  soluble  salts  of  mer- 
cury, that  the  dose  needs  daily  repetition,  is  urged  against  this  salt.  Its 
sole  advantage,  according  to  these  experimenters,  is  the  mildness  of  the 
pain  following  the  injections.  Their  conclusion  is  terse  and  to  the  point : 
"  En  resume,  une  nouvelle  formule  fV injection  d  ajouter  au.v  autres  mats 
U7i  progr^s  bien  minime  sil  existe  mhne.'' 

The  Amide  Group. — Formamide  of  Mercury. — Formamide  of 
mercury,  hydrargyrum  formamidatum,  was    introduced    as  an  antisyph- 

'  "  IntramuscuUire  Einspritzungen  von  Hydrargyrum  Thymolo-aceticuni  bei  Syph- 
ilis," Deutsche  med.  Wochenschrift,  1890,  xvi.  p.  .544. 

'^  "  Ueber  Thymolqiiecksilber-Injectionen,"  Alh/.  Wien.  med.  Zeitunc/,  1890,  No.  7. 

^  "  Ein  Neues  Hg-Salz-Hydrarg.  henzoiciim  oxydatum  zur  Behandlung  der  Syphilis," 
Vruch,  No.  4,  1889,  p.  93;  and  Vkrleljahr.  fur  Denn.  and  Si/pkilis,  1889,  vol.  xxi. 
p.  439. 

*  Trailemeni  de  la  Syphilis  par  les  Injections  sous-culanees  de  Benzoate  de  Mercure,  Paris, 
1890. 


902  SYPHILIS. 

ilitic  remedy  by  Liebreich.^  This  observer,  impressed  with  the  view 
that  the  amides  of  the  body — of  which  urea  may  be  taken  as  the  prin- 
cipal one — pass  out  of  the  system  in  an  undecomposed  state,  concluded 
that  if  combined  with  mercury  decomposition  would  occur,  and  that  the 
latter  would  be  reduced  and  deposited  in  the  tissues.  In  other  words, 
that  this  amide  Avould  serve  as  a  vehicle  for  the  diffusion  of  the  mercurial. 
Liebreich  is  said  to  have  demonstrated  this  fact  before  the  Medical  So- 
ciety of  Berlin.  He  employed  a  1  per  cent,  solution,  and  administered 
one  or  more  Pravaz  syringefuls  daily  into  the  subcutaneous  tissues. 
The  formamide  is  readily  soluble  in  water,  of  neutral  reaction,  and  does 
not  coagulate  albumin.  The  action  of  the  drug  is  rapid  and  effective. 
Injected  under  the  skin,  it  is  easily  borne,  attended  with  little  pain,  and 
not  liable  to  produce  salivation.  It  is  said  by  Liebreich  to  be  much  less 
irritating  and  painful  than  the  sublimate.  Relapses  after  this  treatment 
are  said  to  be  rare,  and  mild  in  character.  Kopp  ^  in  Neisser's  clinic 
treated  one  hundred  and  twenty-six  cases  by  Liebreich's  method,  which 
he  submitted  to  what  seems  to  have  been  a  careful  and  impartial  trial. 
He  used  from  twenty-five  to  forty  injections  into  the  buttocks  in  early 
and  late  syphilis.  He  observed  salivation  and  stomatitis  in  twelve  cases 
(four  men,  eight  women),  abscess-formation  in  one  woman,  pain  of  a  mild 
and  ephemeral  character  in  thirty-four  cases,  and  in  a  more  lasting  and 
pronounced  form  in  thirty-one  cases.  Subcutaneous  nodules  and  inflam- 
matory infiltration  occurred  forty-one  times.  Kopp  concludes  from  the 
treatment  of  mild  cases  that  relapses  are  frequent,  and  that  it  is  less 
energetic  than  inunctions.  The  formamide  solution  keeps  better  than 
that  of  mercurial  peptones,  but  not  as  well  as  a  solution  of  the  cyanide  of 
mercury.  Zeissl  ^  the  Younger  used  the  formamide  in  fifteen  cases.  He 
found  the  pain  less  than  that  of  sublimate,  and  that  no  inflammatory 
reaction  was  induced.  On  the  arm  or  forearm  he  saw  in  one  case  a  little 
redness  and  swelling,  which  disappeared  in  two  or  three  days.  The 
lesions  in  the  immediate  vicinity  of  the  injected  spots  did  not  disappear 
more  rapidly  than  those  more  remotely  situated.  In  several  cases  limited 
portions  of  the  skin  became  gangrenous.  Stomatitis  was  also  observed. 
In  rebellious  cases  Zeissl  used  a  greater  number  of  injections,  of  which 
twenty  was  the  average  for  a  cure.  Rona*  used  the  formamide  upon 
fourteen  cases,  of  which  only  five  kept  up  the  treatment  to  the  end,  three 
refusing  treatment  after  the  first  injection,  five  after  the  third,  and  one 
after  the  ninth,  on  account  of  the  severity  of  the  pain.  The  therapeutical 
effect  of  the  drug  was  highly  unsatisfactory,  and  in  one  of  the  five  cases 
mentioned  as  having  kept  up  the  treatment  a  relapse  occurred  very 
promptly.  The  most  recent  observer  who  has  experimented  with  Lieb- 
reich's compound  is  Vyshogrod,^  who  treated  with  it  two  hundred  and 

'  "  Ueber  die  Behandlung  der  Syphilis  mit  Quecksilberformamid,"  Wien.  med.  Presse, 
1883,  xxiv.  pp.  17-20. 

^  "  Ueber  die  Behandlung  der  Syphilis  mit  Subcutanen  Injectionen  von  Hydrargy- 
rum formamidatum  (Liebreich),"  Vierteljahr.filr  Derm,  und  Syphilis,  1885,  pp.  55  et  seq. 
and  pp.  184  et  seq. 

•^  "  Zur  Behandlung  der  Syphilis  mit  Quecksilberformamid,"  Wien.  med.  Presse,  Nos. 
5  and  6,  vol.  xxiv.,  1883. 

*  Syphilis  gyogyi-asa  formiamidum  hvdrargyratum  (higany-formiamid)  oldataval, 
Orvosi  hfitil,  Budapest,  1883,  xxvii.  pp.  294-298.  ' 

^  Proceedings  of  the  Caucasian  Medical  Society,  May  14,  1889  ;  and  British  Journal  of 
Dermatology,  vol.  i.  pp.  381  et  seq. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      903 

twelve  patients,  Russian  soldiers.  This  author  speaks  of  the  rapid 
disappearance  of  secondary  syphilitic  lesions,  of  the  rarity  of  abscess 
indurations,  and  of  relapses,  and  of  the  absence  of  mouth  affections. 
Added  to  its  activity,  its  painlessness,  and  freedom  from  disagreeable 
complications,  the  author  thinks  the  remedy  has  the  further  advantage  of 
being  cleanly  and  cheap.  In  remarks  upon  Vyshogrod's  paper  Liinke- 
vitch  of  Tiflis  spoke  of  the  formamide  as  one  of  his  favorite  remedies, 
and  Korona  of  the  same  place  endorsed  it  as  effective  and  comparatively 
painless,  and  without  abscesses  when  given  in  the  buttocks,  but  followed 
by  abscesses  if  given  in  the  back.  On  the  other  hand,  Gay  of  Kazan 
says  that  the  formamide  is  the  most  painful  of  all  mercurials,  while  the 
bicyanide  is  the  least  painful.  The  latter  thinks  that  all  mercurials  cause 
the  least  pain  when  they  are  injected  into  the  buttocks,  and  the  most 
intense  when  introduced  into  the  scapular  and  lumbar  regions. 

Some  years  ago  I  used  this  compound  hypodermically  in  several 
selected  cases,  and  by  reason  of  its  comparative  slowness  of  action  and 
of  the  severe  pains  induced  I  soon  abandoned  it. 

G-lycocoll  of  Mercury. — Wolff  of  Strasburg  claims  that  combinations 
of  (1)  glycocoll,  (2)  of  alanin,  and  (3)  of  asparagin  with  mercury  are 
much  to  be  preferred  to  the  formamide  of  Liebreich,  as  being  more 
prompt  in  their  action.  Given  in  large  doses,  these  salts  produced 
active  salivation  and  severe  effects  upon  the  gastro-intestinal  canal. 
They  cause  only  slight  local  reaction,  and  after  the  injection  of  0.01, 
mercury  is  found  in  from  six  to  twenty-four  hours  in  the  urine.  Wolff 
thinks  that  if  the  reaction  at  the  point  of  injection  is  slight,  the  mer- 
curial preparation  acts  more  quickly,  for  the  reason,  he  claims,  that 
albuminate  of  mercury  is  not  formed  and  absorption  of  such  a  deposit 
not  necessary ;  in  other  words,  that  the  remedy  is  taken  up  without 
having  undergone  chemical  metamorphosis. 

The  durability  of  the  three  preparations  of  Wolff  varies.  Asparagin- 
mercury  is  very  unstable ;  alanin-mercury  keeps  better ;  and  glycocoll- 
mercury  is  a  stable  product.     It  is  prepared  as  follows ; 

^.   Hydrarg.  oxid.,  0.1    gm. ; 

Glycocoll.,  0.25  " 

Dissolve  the  glycocoll  in  5  grammes  of  water,  then  add  the  mercury. 
When  mixed,  add  water  enough  to  make  10  grammes,  and  filter.  This 
is  the  solution  for  general  use.  Or  it  may  be  made  as  follows  by  keeping 
on  hand  these  solutions  :  ^ 

1.  A  solution  of  carbonate  of  sodium  1.50  to  water  100. 

2.  Sublimate  3.75  in  water  100. 

3.  Glycocoll  2.50  in  water  100. 

These  must  be  kept  in  stoppered  bottles.  A  mixture  of  equal  parts 
of  each  of  these  solutions  forms  the  injection  fluid.  The  dose  is  a 
Pravaz  syringeful,  which  contains  1  centigramme  of  oxide  of  mercury. 
The  needle  of  the  syringe  must  be  of  platinum.  The  injections,  accord- 
ing to  Wolff,  are  best  made  in  the  back,  after  the  method  of  Lewin  (see 

'  "Ueber  die  Subcutane  Anwendung  des  Glycocoll-asparagin  und  Alanin-qiieck- 
silbers  und  deren  Wirkung  auf  den  Syphilitische  Process,"  Monalshefle  fur  Prak.  DemialoL, 
vol.  iii.,  1884,  p.  152. 


904  SYPHILIS. 

Sublimate  Injections).  One  injection  should  be  made  every  day  or  every 
second  day.  Secondary  manifestations  are  promptly  effaced  by  this  treat- 
ment, but  it  is  evident,  from  Wolff's  remarks,  that  a  sharp  lookout  must 
be  kept,  lest  untoward  symptoms  supervene.  Wolff  thinks  that  the 
prompt  elimination  of  mercury  in  this  form  is  very  advantageous. 

Almimate  of  3Iercury. — This  preparation,  hydrargyrum  alaninicum, 
was  first  brought  forward  as  an  antisyphilitic  agent  by  De  Luca,^  who 
claims  that  it  is  exceptionally  well  tolerated  by  stomach  ingestion  and  by 
hypodermic  injection.  In  the  latter  form,  it  is,  he  claims,  preferable  to 
all  other  mercurial  preparations,  by  reason  of  the  smallness  of  the  dose 
required  and  the  mildness  of  the  local  reactions.  In  infantile  syphilis  it 
is  to  be  preferred  to  other  forms  of  mercury  when  given  by  the  mouth. 
In  whatever  manner,  given,  its  effects  are  gratifying  and  particularly 
lasting.  It  may  prove  of  benefit  in  cases  of  late  syphilitic  manifesta- 
tions. Selenew,^  to  test  De  Luca's  statement,  employed  this  treatment  in 
twenty-three  cases,  using  a  1  per  cent,  watery  solution,  and  injecting  ^ 
of  a  grain  of  the  salt  into  the  buttocks  once  daily.  The  number  of  in- 
jections required  varied  between  twenty-four  and  fifty -four,  and  the 
average  sojourn  in  the  hospital  was  fifty  days.  Selenew  concludes  as 
follows :  Alaninate  of  mercury  does  not  offer  any  advantages  over  other 
soluble  preparations  of  mercury  now  in  use,  either  as  regards  the  inten- 
sity of  its  general  action  or  its  local  effects  or  complications.  2.  In  the 
course  of  its  therapeutic  use  fresh  eruptions  appear  frequently ;  which 
fact,  therefore,  indicates  a  feeble  antisyphilitic  power  of  the  drug.  3. 
In  about  40  per  cent,  of  cases  the  injections  give  rise  to  local  pain  of 
mild  character  and  to  circumscribed  infiltration.  4.  In  about  50  per 
cent,  of  cases  the  remedy  induces  gingivitis  and  stomatitis,  and  in  some 
few  a  mild  and  ephemeral  diarrhoea.  5.  Elimination  of  mercury  in  the 
urine  begins  on  the  first  day  of  treatment,  and  increases  between  the 
twentieth  and  thirtieth  injections,  and  undergoes  oscillations  during  sub- 
sequent days ;  and  in  this  presents  nothing  unusual.  6.  The  prepara- 
tion is  very  stable,  and  in  a  dark  bottle  will  remain  unchanged  for  many 
days. 

Succinimide  of  mercury  was  discovered  by  Dessaignes  in  1852,  and 
was  introduced  as  an  antisyphilitic  remedy  by  Vollert^  in  1888,  under 
the  auspices  of  Professor  Wolff  of  Strasburg.  It  is  soluble  in  water, 
does  not  become  cloudy,  and  does  not  precipitate  albumin  in  hydrocele 
or  pleuritic  effusions.  It  causes  little  infiltration,  and  never  abscesses, 
if  carefully  used.  Wolff  introduces  the  syringe  obliquely,  and  endeavors 
in  this  Avay  to  distribute  the  liquid  in  the  cellular  tissue.  He  further 
aids  diffusion  by  gentle  massage.  The  dose  is  about  one-tenth  of  a  grain 
and  upward,  dissolved  in  water  and  injected  into  the  buttocks.  The 
usual  advantages  are  claimed  for  this  agent. 

Selenew  *  has  also  used  the  succinimide  in  the  form  of  a  1  per  cent. 

'  "  L'AIinina  Mercurica  (alaninato  di  Mercurio)  nella  terapia  della  sifilide,"  La 
Riforma  Medka,  March,  1888. 

2  "Das  Quecksilberalanilat  bei  Syphilis,"  Meditzin.  Obozren.,  No.  xvii.  pp.  445  et  seq. 

^  "  Ueber  Succinimid-quecksilber  ein  neues  niittel  zur  Subcutanen  Injectionen," 
Therapeut.  Monatshefte,  Sept.,  1888,  pp.  401  et  seq. 

*"Zur  Syphilis-behandlung  mit  Subcutanen  Injektionen  von  Hydrargyrum  Suc- 
cinimidicum,"  St.  Petersburgh  mcd.  Wochenschriff,  No.  36,  1890;  and  Monatsheftefur  Prak. 
DermaL,  vol.  ii.,  1890,  p.  406. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      905 

solution  upon  thirty-three  patients,  requiring  nine  hundred  and  thirty- 
three  injections.  His  conclusions  are  as  follows :  Syphilitic  manifesta- 
tions disappeared  after  twenty-four  to  forty  injections.  After  or  during 
the  first  five  injections  roseola  and  papules  often  increased  in  extent  and 
intensity.  The  initial  sclerosis  and  the  ganglia  Avere  but  little  afi'ected. 
Gingivitis  was  observed  in  six  cases.  Pain  and  infiltration  were  almost 
always  absent.  Relapses  observed  during  seven  months  occurred  in 
8|-  per  cent.,  against  yellow  oxide  8,  alanilate  20,  salicylate  37,  and 
gray  oil  30  per  cent.  Mercury  is  found  in  the  urine  within  the  first  few 
days.  It  is  therefore  a  mild  preparation,  suitable  for  mild  cases  in  women 
and  children.     In  general  its  action  is  not  very  energetic. 

Urea-Mercury. — Schiitz,^  in  Doutrelepont's  clinic,  has  used  a  com- 
bination of  urea  with  mercury  in  the  treatment  of  syphilis.  He  thinks 
that  mercurial  preparations  formed  with  the  amides  are  the  most  efficient, 
and  that  urea,  the  amide  of  carbonic  acid,  is  preferable  to  Liebreich's 
formamide  and  Wolff's  amide.     Schiitz  used  the  following  prescription  : 

^.  Hydrarg.  bichlor.,  1.00  gm. ; 

Aqua?  destillat.,  100.00 ; 

Urea,  .22-.50.— M. 

Of  this  solution  the  dose  is  a  Pravaz  syringeful  once  daily. 

This  preparation  is  readily  absorbed,  and  is  very  promptly  found  in 
the  urine.  It  is  said  to  cause  little  local  reaction  of  any  kind,  and  to 
produce  the  rapid  disappearance  of  syphilitic  lesions.  It  has  the  advan- 
tage also  of  being  cheap,  hence  it  can  be  used  in  charitable  practice. 
The  length  of  treatment  was  from  thirty -three  to  eighty-seven  days,  or  an 
average  of  seven  and  a  half  weeks. 

Iodoform. — This  agent  was  first  used  subcutaneously  in  syphilis  by 
Bozzi^  in  a  case  of  severe  nocturnal  osteocopic  pains,  together  with 
periodic  chills  and  fever,  for  all  of  which  quinine  in  large  doses  had  been 
given  without  benefit.  Two  injections  of  iodoform,  each  containing  If 
grains  suspended  in  glycerin,  were  given  at  an  interval  of  nine  days. 
There  was  marked  benefit  after  the  first  injection,  and  two  days  after  the 
second  there  was  entire  subsidence  of  the  pains.  Abscesses  followed  each 
injection.     This  treatment  was  then  forgotten  for  many  years. 

In  1882,  Thomann^  published  a  short  paper,  in  which  he  detailed 
good  results  from  the  injection  of  iodoform  in  early  syphilis  and  in  cases 
of  the  initial  sclerosis  and  of  ganglionic  enlargement.  He  began  with 
doses  of  0.30  (grs.  4|^),  and  increased  them  to  0.75  (grs.  lOf).  The  drug 
was  suspended  in  glycerin  and  almond  oil,  the  latter  combination  seeming 
to  cause  more  cutaneous  hyperaemia  than  the  glycerin  mixture.  The 
eifects  were  said  to  be  good,  the  pain  on  injection  slight,  and  the  after- 
effects very  mild. 

Neumann^  also  tried  this  agent  hypodermically,  and  found  that  while 

'  "  Ueber  Queeksilberchloridliarnstoff:  ein  neiies  Antisypliiliticura,"  Deutsche  med. 
Wochenschrift,  1885,  pp.  21  o  et  seq. 

^  "  Dolori  Osteocopici  Sifilitici  curati  colla  Injeztione  Sottocutanea  di  lodoformio," 
Giornale  Ital.  delle  Mahdlie  Vi'iier.  e  della  Pelle,  vol.  i.,  1871,  pp.  49  and  50. 

^  "Ueber  Subcutane  Iodoform  Einspritzungen  bei  Syphilis."  Cenlralblatl fur  die  Med. 
Wissensch.,  No.  44,  1881 ;  and  ibid.,  No.  85,  1882. 

*  "  Ueber  Hypodermatische  Behandlung  der  Syphilis  juit  Iodoform,"  Ameif/er  der 
Gessell.  d.  Aerzte,  No.  27,  Vienna,  1882. 


906  SYPHILIS. 

it  caused  the  disappearance  of  early  syphilitic  manifestations,  its  action 
was  very  slow,  and  that  inflammatory  reaction  was  produced. 

Mracek  ^  reported  a  case  of  early  syphilis  in  which  in  thirteen  days  6 
grammes  of  iodoform  suspended  in  glycerin  were  injected.  The  thera- 
peutic result  was  not  striking.  Iodine  was  promptly  found  in  the  urine, 
and  only  disappeared  therefrom  after  the  lapse  of  forty  days. 

In  a  later  communication  Thomann^  concludes  that  this  agent  is  use- 
ful in  the  second  stage  in  producing  resolution  of  swollen  ganglia,  par- 
ticularly when  the  injections  are  made  in  close  proximity  to  them.  It  is, 
however,  most  beneficial  in  tertiary  syphilis,  when  0.50  to  1.50  are  used 
at  a  dose.  Thomann  says  that  in  his  later  observations  he  used  as  much 
iodoform  in  thirteen  injections  as  he  had  at  an  earlier  date  in  sixty-five 
injections,  and  that  he  produced  no  bad  results.     He  concludes — 

1.  That  in  tertiary  syphilis  iodoform  exerts  a  favorable  influence  upon 
the  healing  process. 

2.  That  larcfe  doses  shorten  the  length  of  treatment. 

3.  That  a  long  time  after  the  discontinuance  of  the  iodoform  injections 
(as  long  as  forty-three  days)  iodine  is  found  in  the  urine.  It  also  appears 
that  the  remedy  has  a  lasting  eff'ect  upon  the  system. 

4.  That  no  bad  efi"ects  are  to  be  observed,  such  as  acne,  iodine-catarrh,  etc. 
It   must   always   be  remembered   that   iodoform,  whether   applied  to 

wounds  of  an}^  kind  or  administered  by  the  stomach  or  hypodermically, 
is  a  very  uncertain  remedy,  and  liable,  even  in  moderately  small  doses, 
to  produce  toxic  efi"ects  of  varying  gravity.  Consequentl}^,  if  the  phy- 
sician sees  fit  to  give  it  a  trial  he  should  watch  its  effects  very  carefully, 
particularly  as  to  the  cerebro-spinal  system.  In  this  connection  it  is 
interesting  to  note  that  Jennings  ^  observed  purpura  in  a  man  who  had 
been  takino-  the  druo;  bv  the  stomach  in  one-grain  doses  three  times  a 
day  for  six  weeks.  Upon  its  discontinuance  the  eruption  ceased.  The 
mental  symptoms  produced  by  the  drug  are  stupor  and  obtuseness, 
delirium,  and  even  mania. 

Iodide  of  Potassium. — This  agent  was  first  used  hypodermically  by 
Eulenberg  and  Thierfelder.  but  as  a  method  of  treatment  it  has  not  been 
largely  adopted.  In  1882,  Besnier*  reported  a  case  of  intolerance  of 
this  drug,  in  which  7 J  grains,  taken  by  the  mouth,  produced  extreme 
pruriginous  disturbance,  and  in  which  he  injected  the  same  dose  into  the 
centre  of  a  gummatous  syphilide  without  producing  the  same  phenomena. 
He  then  remarks  that  this  new  therapeutical  procedure  should  be  made 
the  subject  of  experiment,  in  order  to  determine  its  practical  worth.  In 
a  later  ^  communication  Besnier  states  that  he  has  further  used  this  treat- 
ment, and  still  thinks  well  of  it. 

Gilles  de  la  Tourette ^  in  five  cases  injected  1^  grains  of  the  iodide 

^  "  Ueber  Hypndermatische  Behandlung  der  Syphilis  mit  Iodoform,"  Anzeiger  der 
Gessell.  d.  Aerzte,  No.  27,  Vienna,  1882. 

^  "  Ueber  Behandlung  der  Tertiiiren  Syphilis  Mittels  Iodoform  Einspritzung,"  Cen- 
tralblatt  fur  die  Med.  Wissemchajten,  No.  20,  1«S2. 

^  Journal  of  Cutaneous  and  Genito-urinary  Diseases,  1888,  p.  175. 

*  "  Un  cas  d'Eruption  bulleuse  due  a  I'lodure  de  Potassium,"  Annales  de  Derm,  et  de 
Syphil.,  1882,  p.  169. 

*  "Sur  les  Injections  sous-cutanees  d'lodnre  de  Potassium,"  Progrh  medical.,  Jan.  13, 
1883. 

®  "  Note  sur  les  Injections  sous-cutanees  d'lodure  de  Potassium,  Society  de  Biologic, 
Jan.  3,  1883,"  Annales  de  Derm,  et  de  Syph.,  1883,  p.  610. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      907 

without  any  marked  local  complications.  He  advises  that  the  solution 
shall  be  neutral,  that  the  injections  should  be  made  deeply  into  parts  rich 
in  cellular  tissue,  and  that  the  punctures  should  be  made  quite  far  apart. 
Slight  massage  over  the  site  of  injections  is  beneficial  in  relieving  the 
disagreeable  itching  produced  by  the  injections.  Hypodermically  used, 
the  author  thinks  that  cases  of  iodide  idiosyncrasy  and  intolerance  may 
be  overcome.     The  drug  acts  very  rapidly  -when  used  in  this  manner. 

Jackubowitz^  recommends  parenchymatous  injections  for  syphilitic 
adenitis  and  inflamed  ganglia  due  to  any  cause.  He  uses  a  solution  of 
iodide  of  potassium  15  grains,  tincture  of  iodine  5  drops,  in  1  ounce  of 
water.  By  means  of  a  hypodermic  needle  this  is  thrown  into  the  sub- 
stance of  the  glands.  The  needle  is  thrust  obliquely  into  the  most  promi- 
nent part  of  the  swelling,  and  a  fourth  part  of  the  contents  of  the  syringe 
is  slowly  thrown  in.  In  four  such  manoeuvres  the  syringe  is  emptied. 
Several  such  operations  are  often  necessary  for  a  cure.  The  pain  is  stated 
to  be  mild,  though  slight  uneasiness  is  felt,  owing  to  the  distention  of  the 
tissues.  In  those  cases,  not  uncommon,  in  which  the  glands  are  very 
much  swollen,  as  well  as  in  some  cases  of  subacute  adenitis  of  simple 
origin,  this  method  may  be  employed. 

In  this  connection  it  may  be  well  to  mention  some  late  observations 
by  K5bner.-  though  the  injections  were  made  into  the  rectum  rather  than 
into  the  cellular  tissue.  Kobner  presented  to  the  Dermatological  Society 
of  Berlin,  two  years  after  cure,  the  case  of  a  woman  fifty-six  years  old 
who  had  had  syphilitic  myositis  of  the  whole  left  sterno-cleido-mastoid 
muscle,  of  eleven  years'  standing.  She  had  also  the  same  lesion  of  the 
lower  third  of  the  right  sterno-cleido-mastoid,  as  Avell  as  gummy  infiltra- 
tions into  other  muscles  and  into  various  bones.  The  iodide,  given  by 
the  stomach,  acted  badly,  and  the  woman  refused  to  take  it.  Inunctions 
of  mercurial  ointments  and  injections  of  about  12  grains  of  the  iodide 
into  the  rectum  produced  a  complete  cure  in  about  nine  weeks.  Kobner 
thus  uses  the  iodide  in  all  cases  of  old  syphilis  in  which  it  produces 
gastric  or  general  disturbance  when  given  by  the  stomach.  In  cases  of 
cerebral  syphilis  in  which  there  is  difficulty  of  deglutition,  and  in  syph- 
ilitic coma,  large  quantities  of  the  drug  may  be  thus  introduced  into  the 
system.  Professor  Rabow  in  the  treatment  of  mental  diseases  found 
Kobner's  method  of  using  the  iodide  and  bromide  of  potassium  more 
satisfactory  and  rapid  than  any  other.  Kobner  also  claims  that  he  has 
caused  more  or  less  absorption  of  hypertrophied  prostates  by  means  of 
the  rectal  injection  of  the  iodide  and  bromide  of  potassium  combined 
with  belladonna.  In  order  to  determine  the  fact  of  the  absorption  of  the 
iodide,  Kobner  advises  that  the  distal  half  of  the  tongue,  on  its  upper  or 
lower  surface,  or  the  inside  of  the  cheeks,  shall  be  lightly  painted  with  a 
solution  of  nitrate  of  silver.  The  solution  at  once  turns  yellow  if  the 
saliva  contains  iodine  from  the  formation  of  iodide  of  silver. 

^  "Zur  methode  bei  Parenchymatosen  Tnjectionen,  eine  neue  Behandlung  der  Syph- 
ilitisclien  Biibonen,"  Weiner  med.  Presiie,  Nos.  3  and  4,  1875. 

'^  "  Ueber  die  Anwendung  von  lod-  und  Brom-priiparaten  per  Rectnm  zu  localen 
(regioniiren)  und  Allgemeinen  Heilzwecken,"  Therapeutische  Monatshefle,  1889,  No.  10. 


908  SYPHILIS. 

Thermal    Baths  ;    Hot- water    and    Hot-air    Baths  ;    Sublimate 
Lotions  and  Baths,  and  Electro-mercurial  Baths. 

The  Hot  Sprmgs  of  Arkansas  and  the  Treatment  of  Syphilis. — From 
time  out  of  mind  the  waters  of  mineral  springs  have  been  regarded  by 
the  laity  as  curative,  and  even  specific,  in  the  treatment  of  syphilis  and 
skin  diseases  especially,  and  in  certain  visceral  and  arthritic  diseases. 
There  has  been,  and  perhaps  always  will  be,  a  deep-rooted  belief  that 
waters  made  in  the  laboratory  of  Nature  possess  an  occult  and  potent 
effect  far  in  advance  of  any  production  of  the  chemistry  of  man.  Among 
the  many  and  varied  mineral  and  thermal  springs  of  this  country,  those 
of  the  Hot  Springs  of  Arkansas  have  undoubtedly  taken  the  most  promi- 
nent rank,  and  among  the  laity,  and  even  among  the  profession,  there  is 
a  widespread  belief  in  their  efficacy  in  syphilitic  affections,  skin  diseases, 
and  those  of  a  rheumatic  nature.  For  many  years  I  have  had  exceptional 
opportunities  for  studying  the  effects  of  the  waters  of  the  Hot  Springs, 
and  the  treatment  pursued  there  upon  patients  who  have  been  under  my 
care  and  were  temporarily  sent  there  for  benefit,  upon  patients  who  had 
been  under  other  physicians  prior  to  their  sojourn  at  the  Hot  Springs, 
and  upon  others  whose  treatment  had  been  begun  there.  From  this 
large  number  of  cases  I  hope  to  be  able  to  present  a  fair  estimate  of  the 
value  of  these  springs  as  a  therapeutic  resource  in  the  treatment  of 
syphilis. 

An  analysis  of  the  water  of  the  most  prominent  springs  in  the 
Arkansas  Valley  shows  that  their  chief  ingredient  is  silicic  acid,  and 
that  it,  with  iron,  alumina,  lime,  magnesia,  potash,  soda,  and  traces  of 
iodides  and  bromides,  exists  in  the  proportion  of  8^  grains  to  the  gallon 
of  water.  It  is  very  evident  that  no  startling  effect  can  be  produced 
by  this  natural  solution,  yet  some  of  the  advocates  of  the  Springs  speak 
in  quite  positive  terms  of  the  specificity  of  the  waters,  whatever  that 
may  mean.  Others  claim  that  the  beneficial  effect  of  the  waters  is 
due  to  the  electricity,  produced  by  chemical  decomposition,  with  which 
they  are  said  to  be  charged,  while  others  think  that  they  are  imbued 
with  a  peculiar  heat  which  is  curative.  To  my  mind,  the  salutary  and 
hygienic  effects  of  these  waters  (as  far  as  they  are  productive  of  good) 
reside  in  their  heat  alone.  The  stimulation  of  the  capillaries  and  of 
the  circulation  generally,  including  the  lymphatic  system,  as  well  as  the 
stimulation  of  each  individual  cell  of  the  skin,  by  the  heated  water,  and 
the  brisk  frictions  subsequent  to  the  bath,  I  think  act  as  profound  vitaliz- 
ing agents  and  are  productive  of  great  benefit.  But  there  are  many  acces- 
sory conditions  appertaining  to  a  sojourn  at  these  thermal  springs  which 
play  a  very  important  part  in  the  hygienic  reconstruction  which  is  often 
gained.  Having  taken  the  long  journey,  after  much  anticipation, 
preparation,  and  often  at  great  sacrifice  in  the  matter  of  time  and 
money,  patients  arrive  at  the  Springs  with  an  earnestness  of  purpose 
and  with  a  fixed  resolve  that  they  will  make  an}'-  personal  sacrifice, 
particularly  in  the  matter  of  creature  comforts,  in  order  to  be  benefited 
or  cured.  They  for  a  time  undergo  personal  reformation,  and  usually 
sedulously  refrain  from  alcoholics,  from  tobacco,  from  the  card-table 
with  its  late  hours,  and  from  sexual  indulgence.  They,  as  far  as  they 
can,  leave  behind  them  all  business  and  social  cares ;  they  eat  regularly. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      909 

go  to  bed  early,  and  perhaps  sleep  late,  and,  in  short,  conform  as  far 
as  possible  to  the  most  rigid  hygienic  rules.  They  have  an  entire  change 
of  scenery  and  of  domestic  relations,  and,  in  fact,  of  the  whole  routine 
of  life.  They  breathe  a  pure  air,  have  abundant  opportunity  for  outdoor 
exercise,  and  generally  enjoy  rest  and  contentment.  Certainly,  no  one 
can  ask  for  more  auspicious  auxiliaries  to  medical  treatment. 

It  has  been  claimed  that  the  sedation  and  tendency  to  sleep  induced 
by  the  baths  at  the  Hot  Springs  are  peculiar  and  due  to  some  occult 
effect  of  the  waters.  It  is  true  that,  as  a  rule,  hot  baths  usually  have 
an  opposite  effect,  but  I  have  many  times  seen  the  same  soporific  result 
follow  hot  salt-water  baths  taken  at  our  seaside  resorts.  In  some  in- 
stances I  have  found  that  excitement  and  sleeplessness  followed  baths 
taken  at  the  Hot  Springs. 

Let  us  now  consider  the  conditions  in  which  benefit  may  accrue  to 
syphilitics  who  undergo  treatment  at  the  Springs.  While  I  am  dis- 
posed to  give  this  celebrated  resort  its  full  meed  of  praise  in  the  treat- 
ment of  syphilis,  I  must  here  state  my  emphatic  belief  that  in  the 
majority  of  cases  there  is  not  the  slightest  necessity  of  going  so  far  away 
to  attain  a  cure,  and  that  a  very  large  number  of  the  cases  which  go 
there  do  so  because  they  have  not  been  properly  handled  at  their  homes. 
In  other  words,  the  faultiness  in  the  physician's  methods  of  treatment 
and  his  shortcomings  in  the  management  of  his  patients  are,  in  many 
instances,  the  real  reasons  why  patients  have  to  betake  themselves  so  far 
away  for  relief.  Furthermore,  in  very  many  instances  the  apathy  of  the 
patient,  his  carelessness  and  irregularity  in  folloAving  treatment,  his  ab- 
sorption in  business  matters,  his  often  flagrant  want  of  attention  to  health 
and  hygiene,  so  thwart  his  physician's  efforts  that  he  perhaps  obtains  no 
good,  and  possibly  grows  steadily  worse. 

At  no  time  during  the  primary  stage  of  syphilis  does  treatment  at  the 
Hot  Springs  offer  any  advantage  whatever.  Treated  on  the  classical  lines, 
the  chancre  can  always  be  healed,  and  in  the  rare  event  of  phagedena  we 
are  certainly  as  well  equipped  at  home  as  our  colleagues  at  the  Springs.  In 
like  manner,  no  peculiar  benefit  can  be  derived  in  the  early  exanthematic 
stage.  At  this  time  the  general  health  and  nutrition  of  patients  are  usually 
good,  and  they,  as  a  rule,  respond  readily  to  the  action  of  mercurials. 

All  fair-minded  men,  however,  who  have  much  to  do  with  the  treat- 
ment of  syphilis  must  certainly  admit  that  in  certain  cases  and  in  certain 
conditions  a  sojourn,  under  proper  medical  care,  at  the  Arkansas  Hot 
Springs  is  very  often  followed  by  the  most  gratifying  results. 

I  myself  have  sent  many  cases  to  colleagues  at  the  Springs,  and 
have  never  had  occasion  to  regret  it ;  and  I  am  glad  that  as  a  thera- 
peutic resource  we  have  these  springs  at  our  command  in  cases  of 
urgency  and  need.  While  in  general  we  can  readily  manage  the  cases 
of  ulcerating  syphilides,  including  the  impetigo  form,  the  ecthyma  form, 
the  rupial,  and  the  serpiginous,  we  certainly  do  find  instances  wliich  are 
rebellious  and  which  improve  wonderfully  at  tlic  Springs.  In  these 
cases,  however,  Ave  have  usually,  as  complicating  conditions,  annemia, 
debility,  and  malassimilation,  in  which  event  specific  medication  is 
more  or  less  slow  or  impotent  in  its  Avorking.  Many  of  these 
cases  have  run  the  gamut  of  mercurial  and  iodide-of-potassium  treat- 
ment, and  these  remedies  then   act  as  depressants,  rather  than  as  anti- 


910  SYPHILIS. 

syphilitics.  In  such  cases  the  change  of  scene  and  air  and  the  baths  are 
of  inestimable  value. 

The  matter  may  be  summed  up  in  this  way :  In  many  cases  where 
cachexia,  due  to  any  cause,  and  intolerance  of  the  usual  specific  medica- 
tion are  found  to  exist  and  the  activity  of  the  syphilis  still  persists,  treat- 
ment at  thermal  springs  is  indicated. 

In  many  instances  of  gummata  in  broken-down  subjects  the  baths  are 
often  of  great  value,  and  I  have  seen  gummatous  infiltration  in  the  throat 
much  benefited  by  the  treatment  used  at  the  Hot  Springs. 

The  osseous  and  articular  lesions  of  syphilis  may  be  only  temporarily 
benefited  at  the  Springs,  but  late  syphilitic  rheumatism,  rheumatic  condi- 
tions complicated  with  visceral  disease,  combinations  of  gout  and  syphilis, 
late  syphilitic  cachexia  without  visible  lesions,  and  the  generally  broken- 
down  state  of  old  syphilitics  addicted  to  alcoholic  and  other  indulgences, 
are  all  frequently  much  benefited,  and  some  cases  thereafter  enjoy  fairly 
good  health. 

When,  owing  to  the  usual  causes  already  spoken  of,  syphilis  does  not 
go  on  auspiciously  to  its  extinction,  a  sojourn  at  the  Hot  Springs  is  often 
of  decided  value  for  its  moral  as  well  as  its  physical  effects.  Such  patients 
when  at  home  live  in  a  rut,  and,  while  they  perhaps  keep  at  their  daily 
affairs,  they  are  depressed  and  very  often  more  or  less  despondent.  Change 
of  scene,  of  air,  of  habits  and  customs  enlivens  them,  Avhile  previously 
the  treadmill  of  their  existence  had  made  life  burdensome. 

In  persistent  and  chronic  cerebral  and  spinal  affections  of  the  most 
varied  character  due  to  syphilis,  and  the  various  morbid  states  and  dys- 
crasise  which  so  commonly  complicate  it,  protracted  sojourns  at  the  Hot 
Springs  are  often  productive  of  marvellous  results.  In  these  cases  very 
often  the  tolerance  of  antisyphilitic  agents,  which  are  so  necessary  to  relief 
and  cure,  is  obtained,  and  patients  are  often  rescued  from  invalidism  and 
death. 

But  there  are  still  other  considerations  offered  by  the  treatment  pur- 
sued at  the  Hot  Springs.  Many  cures  are  there  made  for  the  reason  that 
mercury  is  not  withheld  from  the  sufferer,  as  it  had  been  at  home.  Many 
of  the  Hot  Springs  physicians  are  alive  to  the  fact  that  the  methods  of 
treatment  pursued  by  many  surgeons  in  the  large  cities  are  faulty.  These 
latter  often  fail  to  cure  their  cases  for  the  reason  that  they  use  mercury  in 
too  small  quantities.  They  do  harm  with  the  drug  rather  than  good. 
They  do  not  eradicate  the  disease,  but  by  their  timorousness  and  want  of 
vigorous  treatment  induce  a  condition  of  hydrargyrosis — a  mercurial 
cachexia.  I  have  seen  many  instances  of  this  complication.  At  the 
Springs,  after  proper  preparatory  treatment,  they  receive  mercury  liber- 
ally, and  it  acts  well  upon  them  physically  and  morally.  This  fact,  to 
my  knowledge,  will  account  for  many  seemingly  surprising  cures  made  at 
the  Hot  Springs. 

Then,  again,  there  are  teachers  who  inculcate  the  doctrine  that  mer- 
cury is  only  beneficial  in  the  early  part  of  syphilis — let  us  say  in  its  first 
year.  After  that  it  is  by  them  taught  that  its  function  is  ended  and  the 
era  of  iodide  of  potassium  begins.  This  fallacious  doctrine  often  works 
sad  havoc  on  patients,  and  they  hie  them  to  the  Springs  to  regain  their 
health  and  to  get  their  sovereign  panacea,  mercury.  If  this  remedy  had 
been  administered  at  the  patients'  homes,  they  Avould  not  have  had  the 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      911 

necessity  of  knocking  at  the  Hot  Springs  surgeon's  door  and  of  begging 
for  relief. 

In  like  manner,  in  many  instances  the  administration  at  the  Springs 
of  iodide  of  potassium  in  large  and  increasing  doses  has  cured  cases  which 
languished  in  suffering  and  disease  at  home  because  only  small  doses  were 
given.  But  I  think  the  tendency  to  minimize  the  dose  of  the  iodide  of 
potassium  is  not  as  widespread  among  the  profession  as  it  is  in  the  case  of 
the  mercurial  preparations. 

In  the  foregoing  paragraphs  I  think  I  have  shown  that  the  successful 
treatment  of  syphilis  at  the  Hot  Springs  is  in  many  instances  due  to  the 
derelictions  and  shortcomings  of  the  home  physicians,  who  were  imbued 
with  faulty  ideas  as  to  the  dose  of  mercury  necessary  for  cure,  and  often 
to  the  method  of  use. 

I  think  that  in  a  large  number  of  cases  (and  I  have  seen  scores  of 
instances)  patients  have  resorted  to  the  Hot  Springs  for  treatment  of 
syphilis  because  their  cases  were  not  actively  handled,  were  not  thoroughly 
medicated,  or  were  treated  in  a  free-and-easy,  happy-go-lucky  manner,  or 
were  treated  in  a  too  stereotyped,  narrow-gauge  way  at  their  homes.  But 
here  it  is  Avell  to  remember  that  many  cases  of  syphilis  do  badly  or  go 
wrong  in  consequence  of  the  apathy  and  want  of  care  and  of  the  indul- 
gences on  the  part  of  the  patient. 

Furthermore,  there  is  another  very  important  consideration  regarding 
syphilitics  at  the  date  of  the  onset  of  their  malady.  Though  they  may 
have  been  deeply  impressed  with  the  gravity  of  their  condition,  they  often 
become  lulled  into  a  feeling  of  false  security  after  a  sojourn  at  the 
Springs.  I  have  seen  many  patients  who  in  later  years  have  suffered 
severely  from  syphilis,  and  who  on  the  breaking  out  of  their  disease  had 
hastened  to  the  Hot  Springs.  They  there  underwent  a  course  of  treat- 
ment, and  the  evidence  of  their  disease  vanished.  Thinking  that  besides 
the  skill  of  man  they  had,  as  we  may  say,  supernatural  aid  from  the  wells 
of  Nature,  many  have  gone  away  with  a  sense  of  happy  security,  imagin- 
ing themselves  cured;  others  have  thought  that  a  similar  sojourn  a  few 
months  or  a  year  later  was  all  that  was  necessary ;  while  others,  again, 
have  decided  to  apply  for  medical  aid  only  if  they  should  notice  later 
manifestations  of  their  disease.  This  glamour  of  security  and  health 
conferred  by  the  mystery  of  the  waters  has  brought  many  a  man  to  inval- 
idism and  death  through  some  late-appearing  cerebral  or  visceral  lesion 
of  syphilis. 

There  is,  however,  no  necessity  for  taking  such  a  long  journey,  for 
other  springs  will  do  equally  as  well.  In  Virginia,  and  elsewhere  in 
America,  there  are  hot  springs  which  will  act  as  valuable  adjuvants  in  the 
treatment  of  syphilis,  and  this  is  the  sole  action  of  the  Arkansas  springs. 
Take  away  the  mercurial  ointment  and  iodide  of  potassium  from  any 
thermal  spring,  and  its  business  will  soon  close  up  for  want  of  patronage. 

During  the  summer  months  syphilitic  patients  can  enjoy  pure  air, 
beautiful  scenery,  and  repose  and  quiet  at  Richfield  Springs,  where  also 
they  may  have  any  form  of  bath,  and  may  under  medical  advice  partake 
of  natural  sulphur  waters.  There  is  nothing  to  be  obtained  at  the  Arkan- 
sas Hot  Springs  which  cannot  be  had  at  Richfield. 

The  internal  use  of  the  waters  of  the  Hot  Springs  of  Arkansas  has 
been  claimed  to  be  very  beneficial  in  the  treatment  of  syphilis,  and  the 


912  SYPHILIS. 

idea  is  fostered  in  that  happy  valley  that  these  waters  are  in  a  measure 
specific.  Such,  however,  is  not  the  case.  They  simply  act  as  diaphoretics 
and  diuretics,  and  can  at  any  health  resort  he  replaced  by  a  draught  of 
hot  milk,  hot  tea,  a  little  gin  and  hot  water,  a  little  essence  of  ginger  and 
water,  or  any  other  pleasing  and  innocuous  hot  drink. 

In  the  section  on  Mercurial  Inunctions  the  question  of  the  value  of 
sulphur  water  has  been  considered.  I  may  here  repeat  that  the  experience 
of  physicians  at  Aix-la-Chapelle  and  at  other  springs  which  give  forth 
sulphur  waters  goes  to  show  that  in  certain  cases,  particularly  chronic  ones, 
these  waters,  in  combination  Avith  proper  mercurial  treatment,  act  very 
beneficially  as  diaphoretics  and  eliminants.  My  reading  and  experience 
teach  me  that  there  are  no  criteria  in  any  case  by  which  it  may  be  stated 
that  sulphur  waters  are  indicated,  or  that  they  will  probably  produce 
benefit.  The  only  course  to  pursue  is  to  try  them,  and  be  guided  by  the 
results  observed.  It  has  been  claimed  that  these  waters  tend  to  advance 
the  elimination  of  mercury  from  the  system  of  those  who  have  been  long 
and  injudiciously  dosed  with  that  drug.  In  support  of  the  statement, 
chemical  analyses  of  the  urine  in  such  cases  have  been  made  and  published 
to  show  that  mercury  has  thus  been  ferreted  out  and  thrown  off,  but  in 
many  of  them  it  is  very  probable  that  the  synchronous  employment  of  hot 
sulphur-water  baths  has  had  much  to  do  with  the  eliminative  process. 

Still  further,  it  is  claimed  that  the  internal  use  of  sulphur  waters  has  a 
direct  action  in  preparing  the  system  to  receive  mercury  and  throw"  off  the 
syphilitic  poison.  This  assertion  may  be  partly  true,  but  we  should  always 
remember  that  change  of  air  and  scene,  rest,  and  improvement  of  the 
patient's  habits  and  regimen  also  have  much  influence  in  preparing  him  to 
receive  treatment  and  in  making  his  tissues  less  vulnerable  to  the  syphi- 
litic poison. 

Liebreich  has  stated  that  when  mercury  acts  slowly  or  ceases  to  act  the 
original  susceptibility  of  the  system  to  it  may  be  restored  by  a  generous 
diet  and  an  abundance  of  salt.  I  have  many  times  witnessed  marked 
improvement  in  old  cases  of  syphilis,  which  had  hitched  and  halted  in  a 
mercurial  course,  from  daily  hot  sea-baths.  In  these  cases,  however,  a 
change  of  air  and  scene  were  also  essential  factors  of  benefit. 

The  subject  of  the  influence  of  hot  baths  in  the  treatment  of  syphilis 
has  of  late  years  attracted  much  attention,  and  one  of  the  most  valuable 
papers  upon  it  is  by  Dr.  Vasily  K.  Borovsky,^  who  investigated  the  sub- 
ject at  the  suggestion  of  Professor  Tarnowski.  This  observer  carried  out 
his  clinical  observations  on  28  syphilitic  patients.  Heat  was  employed  in 
the  form  of  (a)  ordinary  hot-water  baths  at  98°  to  104°  Fahr.  of  thirty 
minutes'  duration  ;  (b)  artificial  sulphur-baths  (prepared  by  adding  1  pound 
of  sulphur  to  each  bath  at  from  100°  to  104°  Fahr.  of  from  twenty  to 
thirty  minutes'  duration  ;  and  (c)  hot-air  baths  at  from  180°  to  200°  Fahr. 
of  from  fifteen  to  thirty  minutes'  duration.  Dr.  Borovsky's  results  may 
be  summarized  as  follows:  1.  Both  tepid  and  hot-Avater  baths,  as  well  as 
those  of  sulphur  and  hot-air,  invariably  increase  the  elimination  of  mei'- 
cury  in  the  urine.  2.  The  elimination  proceeds  more  energetically  the 
higher  the  temperature  to  which  the  patient  is  exposed.  3.  The  cause 
of  such  intensified  excretion  of  mercury  should  be  sought  in  an  increase 

1  "On  the  Influence  of  Hot  Baths  on  the  Elimination  of  Mercury  in  the  Urine,"  St. 
Petersburg  Inaugural  Dissertation,  1889  ;  and  British  Journal  of  Dermatol.,  1889,  vol.  ii.  p.  22. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      913 

of  the  systemic  metabolism,  accompanied  by  the  disintegration  of  mer- 
curial albuminates.  4.  A  mercurialized  patient's  organism  actually  can 
be  completely  freed  from  mercury  by  means  of  a  systematic  employment 
-of  heat  in  one  form  or  another.  5.  In  such  cases,  when  the  elimination 
of  mercury  ceases  spontaneously,  it  can  be  made  to  reappear  by  the  use 
of  hot  baths.  6.  Mercurial  stomatitis  can  be  cured  by  heat  more  quickly 
than  by  any  other  means.  7.  Hot-air  baths,  Avhile  inducing  an  enormous 
perspiration,  promote  the  elimination  of  mercury  also  through  the  sweat- 
glands.  The  total  quantity  of  sweat  excreted  during  a  bath  amounts  to 
400  c.  cm.  and  more;  that  of  mercury  in  the  sweat  to  1.8  milligrams  and 
more  per  400  c.  cm.  Hence,  as  a  means  for  freeing  the  patient's  system 
from  mercury  they  should  be  preferred  to  all  other  baths.  8.  The  appear- 
ance of  mercury  in  the  sweat  naturally  suggests  that  diaphoretics  generally 
are  useful  adjuvants  in  the  treatment  of  mercurialism.  9.  Tepid  baths 
(88°  Fahr.)  should  only  be  resorted  to  in  cases  of  hydrargyrosis  in  which 
higher  temperatures  are  contraindicated  on  some  grounds.  10.  Hot-air 
baths  are  borne  by  patients  better  than  hot-water  ones  (98°  Fahr.),  which 
sometimes  give  rise  to  fainting.  11.  Hot-air  baths  at  170°  or  180°  Fahr. 
of  twenty  minutes'  duration  were  borne  better  than  those  at  from  140°  to 
160°  Fahr.  of  thirty  minutes'  duration,  while  the  physiological  and  thera- 
peutical effects  of  the  former  are  practically  identical  with  those  of  the 
latter.  12.  In  persons  having  an  idiosyncrasy  against  mercury  the  em- 
ployment of  heat  sometimes  affords  the  possibility  of  safely  continuing 
mercurial  treatment.  13.  Hot-air  baths,  while  inducing  intense  thirst, 
involve  an  increased  ingestion  of  fluids,  which  in  its  turn  leads  to  an 
increase  in  the  bodily  metabolism.  14.  As  regards  the  elimination  of 
mercury  from  the  organism,  artificial  sulphur-baths  do  not  offer  any  advan- 
tages whatever  over  other  baths.  15.  The  time  required  for  the  complete 
excretion  of  the  metal  from  the  patient's  system  varies  according  to  the 
total  amount  ingested,  individual  peculiarities  of  the  patient,  temperature 
of  the  baths,  etc.  16.  A  simultaneous  treatment  of  syphilis  by  mercury 
and  heat  may  sometimes  effect  a  cure  more  quickly  than  a  mercurial  treat- 
ment alone.  17.  The  heat-treatment  alone  (one  or  two  baths  daily  for  a 
fortnight),  however,  usually  proves  powerless  to  bring  about  a  cure.  18. 
In  patients  with  diseased  vascular  system  the  use  of  hot  water  requires 
great  caution. 

The  practical  deductions  to  be  made  from  this  study  are  that  as  an 
adjuvant  to  a  mercurial  or  a  mixed  treatment  heat,  dry  or  moist,  may 
be  employed  in  certain  conditions  and  with  certain  restrictions,  with 
much  benefit.  Thus  it  is  well  to  order  patients  taking  mercury  to  take 
one  or  two  hot  baths  each  week  on  going  to  bed.  They  undoubtedly 
increase  the  potentiality  of  the  drug  and  benefit  the  patient  by  increased 
elimination  and  metabolism.  They  may  also  take  Turkish  or  Russian 
baths.  Baths  of  moist  heat  with  mercurial  fumes  have  already  been 
treated  of  in  this  article. 

The  subject  of  the  local  treatment  of  syphilis  by  heat  has  been  thor- 
oughly prosecuted  by  Dr.  Kalashnikoff '  of  St.  Petersburg  upon  thirty-two 
hospital  patients.  In  cases  of  generalized  syphilides  one  of  the  patient's 
upper  or  lower  extremities  (the  most  affected  one)  was  placed  in  a  hot 

'  "  On  the  Local  Treatment  of  Syphilis  by  Heat,"  Si.  Petersburg  Inaucjural  Dissertu- 
iion,  1889. 

68 


914  SYPHILIS. 

bath,  117°  or  118°  Fahr.,  for  half  an  hour  tAvice  a  day  (morning  and 
evening).  During  the  intervals  the  limb  Avas  constantly  kept  wrapped 
in  a  warming  compress.  In  cases  of  syphilides  situated  on  the  hands, 
buttocks,  neck,  face,  genitals,  and  such  regions  of  the  body  generally, 
where  local  baths  were  impracticable,  either  hot  fomentations  or  an 
India-rubber  bag  containing  hot  water,  115°  or  120°  Fahr.,  were  applied 
to  the  part  for  an  hour  twice  daily,  and  in  the  intervals  constant  warm- 
ing compresses  were  adjusted.  Kalashnikoff  found  that  local  heat  affords 
a  powerful  means  for  promoting  the  absorption  of  syphilitic  products  in 
the  region  treated.  Primary,  secondary,  and  tertiary  lesions  subjected 
to  the  influence  of  heat,  117°  or  118°  Fahr.,  were  made  to  disappear 
more  quickly  than  by  mercurial  treatment.  Under  a  simultaneous  treat- 
ment by  heat  and  mercury  the  resolution  of  syphilides  was  even  more 
rapidly  accomplished.  Kalashnikoff  found  that  in  cases  of  relapse  such 
regions  as  have  been  treated  by  heat  either  remain  free  from  any  rash 
or  are  affected  in  a  strikingly  slighter  degree  in  comparison  with  other 
regions  of  the  body.  The  beneficial  effects  of  heat  are  attributed  to  its 
inducing  cutaneous  hyperaemia,  accelerating  the  local  circulation,  raising 
the  temperature  of  the  blood,  and  modifying  the  condition  of  metabol- 
ism. According  to  Kalashnikoff,  it  is  probable  that,  while  promoting 
the  absorption  of  syphilitic  infiltrations,  heat  at  the  same  time  destroys 
the  syphilitic  virus  itself.  Care  as  to  the  fitness  of  the  patient  to  this 
treatment  and  to  the  details  of  the  latter  should  be  exercised. 

The  efficient  and  energetic  action  of  local  heat  in  syphilis  has  been 
attested  by  Domashneff,  Stepanoff,  Fischer,  Kadestock,  and  others,  and 
it  should  be  borne  in  mind  as  an  adjuvant  method  of  reserve.  But  in 
its  employment  watchfulness  and  care  are  very  necessary.  I  am  fully 
in  accord  with  Professor  Tarnowski,^  who  while  admitting  that  heat 
applied  externally  can  lead  to  a  rapid  absorption  of  cutaneous  syphilides, 
emphatically  objects  to  regarding  their  disappearance  as  being  identical 
with  cure  of  the  disease.  The  truth  is,  probably,  that  external  lesions 
are  only  displaced  and  driven  to  other  parts  of  the  economy,  such  as 
viscera,  heart,  arteries,  brain,  etc.  Thus  it  should  never  be  adopted  as 
a  method  of  cure,  for  it  may  be  injurious  or  even  dangerous.  It  may, 
however,  in  proper  cases,  be  employed  moderately  and  carefully  as  an 
adjuvant  to  general  methodical  and  local  treatment. 

Sublimate  baths  are  very  often  of  much  benefit  in  extensive  rashes 
of  the  skin.  In  cases  of  papular,  scaly,  tubercular,  or  ulcerative  syph- 
ilides these  baths,  at  a  temperature  of  100°  Fahr.,  are  frequently  the 
means  of  causing  a  prompt  disappearance  of  the  lesions.  From  4  to  8 
drachms  of  the  sublimate  may  be  used  in  the  bath,  to  which  also  may 
be  added  double  the  quantity  of  chloride  of  ammonium  or  common  salt. 
The  baths  should  be  taken  at  night,  and  the  patient  should  remain  in 
them  from  fifteen  minutes  to  half  an  hour,  the  time  being  gauged  accord- 
ing to  the  sensations  produced  by  them.  When  strong  sublimate  baths 
are  taken  rather  frequently,  it  is  necessary  to  diminish  or  suspend  the 
mercury  taken  by  the  mouth. 

A  watery  solution  of  corrosive  sublimate  (1  to  3  grains  to  the  ounce) 
is  often  of  much  benefit  when  applied  locally  on  lint  or  cotton  as  a  com- 

1  Vrach,  1889,  No.  5,  p.  156,  and  No.  9,  p.. 238. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      915 

press  for  dermal  lesions,  periosteal  swellings,  onychia,  etc.  Detmold  ^ 
recommends  for  external  use  a  watery  solution  of  corrosive  sublimate  (2 
grains  to  the  ounce)  which  he  instructs  patients  to  rub  well  upon  each 
extremity,  using  half  an  ounce  at  an  application  night  and  morning. 
The  results  of  this  treatment  were  most  gratifying,  and  Detmold  resorts 
to  it  to  the  exclusion  of  afl  others.  The  application  does  not  irritate 
the  skin  nor  produce  salivation,  though  it  was  thought  that  griping 
pains  in  the  stomach  were  observed  after  its  continued  use.  This  treat- 
ment is  by  no  means  new,  but  it  has  been  brought  into  prominence  by 
Detmold. 

Gargles  of  corrosive  sublimate,  varying  in  strength  from  2  to  8 
grains  to  8  ounces  of  water,  are  often  very  beneficial  in  buccal  and 
pharyngeal  ulcerative  lesions. 

It  is  well  to  remember  Van  Swieten's  liquid,  since  it  is  useful  as  a 
local  application  in  many  conditions.     Its  formula  is  as  follows : 

^.  Hydrargyri  chloridi  corrosiv.,  gr.  ij  ; 

Alcoholis,  fsiij ; 

Aquae  dest.,  q.  s.  f^iv. — M. 

One  teaspoonful  contains  ^^  of  a  grain  of  corrosive  sublimate. 

This  preparation  is  particularly  adapted  for  local  treatment  of  sec- 
ondary and  tertiary  lesions  about  the  head,  face,  and  neck. 

Among  the  curiosities  of  syphilitic  therapeutics  may  be  mentioned 
the  electric-sublimate  baths  exploited  by  Ehrmann  and  Gaertner.^  These 
baths  contain  three  drachms  of  sublimate,  which  salt,  it  is  thought, 
enters  the  system  by  means  of  an  electric  current  of  an  intensity  of  200 
milliamperes.  The  baths  are  given  every  day  or  every  second  day,  and 
should  be  of  half  an  hour's  duration,  though  the  current  is  only  to  be 
kept  on  for  fifteen  minutes.  The  authors  of  this  method  of  treatment 
claim — 1st,  that  the  introduction  of  mercury  takes  place  in  the  same 
way  as  when  inunctions  are  used,  and  that  the  stomach  and  liver  are 
spared ;  2d,  that  absorption  takes  place  by  almost  the  whole  surface  of 
the  skin,  upon  which  the  mercurial  also  exerts  a  local  action  ;  3d,  that 
the  quantity  of  mercury  absorbed  is  proportionate  to  the  intensity  and 
duration  of  the  current,  and  that  exactitude  of  dose  is  thus  made  pos- 
sible ;  4th,  that  it  is  painless  and  without  danger.  Under  this  treatment 
the  urine  shows  the  presence  of  mercury  after  sixteen  to  thirty  baths  ; 
hence  absorption  is  not  rapid.  After  a  time  it  was  found  that  the  system 
did  not  take  up  any  more  mercury.  Toxic  effects,  such  as  diarrhoea, 
salivation,  and  scaling  eczema,  were  noted  in  a  few  cases. 

Another  method  of  treatment  of  syphilis  has  been  proposed  by 
Brdmond^  which  is  claimed  to  be  successful  when  other  methods  fail. 
The  patient  is  placed  in  a  box  with  his  head  out,  and  a  sprayer  projects 

^  "  Diagnosis  and  Treatment  of  Syphilis,"  Med.  News,  March  8,  1884. 

'^  "  Le  Bain  electrique  au  Sublim^,  experience  suriin  nouveau  Traitenient  mercurial," 
La  Seniaine  medicale,  1889,  p.  438;  and  "  Du  Traitement  de  la  Syphilis  par  les  Bains 
electriqiies  au  Subiim^,"  ibid.,  1890,  p.  357. 

^"Traitement  de  la  Syphilis  par  1' Absorption  cutande  des  Medicaments,"  La  Se- 
maine  medicale,  1889,  p.  284;  and  "Traitement  de  la  Syphilis  aux  Di verses  periodes  de 
la  Maladie,  par  1' Absorption  des  Medicaments  par  la  Peau,"  Journal  des  Mai.  cutan.  et 
Syph.,  vol.  i.,  1890,  p.  297. 


916  SYPHILIS. 

at  him,  all  over  his  body,  numerous  jets  of  steam  containing  particles  of 
sublimate  or  iodide  of  potassium. 

Treatment  of  the  Syphilides. — Erythematous  Syphilide. — As  a 
rule,  internal  medication  causes  this  syphilide  to  disappear  promptly,  but 
it  is  always  well  to  hasten  its  involution  by  sublimate  baths,  mercurial 
vapor  baths,  or  by  inunction.  Upon  the  face,  neck,  hands,  and  wrists 
this  syphilide  may  be  persistent,  and  its  disappearance  may  be  hastened 
by  using  the  following  ointments : 

^.  Hydrargyri    ammonati   vel   hydrargyri 

oxidi  rubri,  gr.  xx  ; 

Unguent,  aquae  rosse,  §j. — M. 

!^;.  Hydrargyri  subsulph.  flav.,  3ss  ; 

Vaselini,  ^j. — M. 

The  latter  is  much  thought  of  by  Mauriac.     In  some  cases  of  persistent 
eruption  about  the  face  the  following  lotion  may  be  used : 

I^.  Hydrargyri  chloridi  corros.,  gr.  iv ; 

Aquae  coloniensis,  3ij  ; 

Aquse,  ad  Biv. — M. 
Apply  three  or  four  times  a  day. 

The  erythematous  syphilide  is  not  uncommonly  complicated  by  a 
seborrhoeic  process,  as  shown  by  the  development  of  orange-red  patches 
of  scaly  skin  upon  those  parts  of  the  forehead,  glabella,  alae  nasi,  and 
around  the  mouth,  on  which  the  sebaceous  and  sudoriferous  glands  are 
most  abundant.  This  condition  is  also  found  on  the  scalp  and  upon  the 
sternal  region.  For  these  cases  resorcin  in  liquid  or  ointment  form  is 
very  efficient.  The  following  ointment  may  be  used,  after  well  wash- 
ing the  parts"  with  the  simple  tincture  of  green  soap  (tinctura  saponis 
viridis)  : 

^.  Resorcin.,  3ss-3j ; 

Acidi  carbolici,  gtt.  xx  ; 

Unguent,  aquse  rosse,  Ij. — M. 

The  Papular  Syphilides. — These  eruptions  are  usually  amenable 
to  internal  medication  if  they  are  attacked  early.  But  even  if  internal 
treatment  is  ordered,  one  or  other  of  the  external  methods  should  be 
used  occasionally,  in  order  to  expedite  their  involution.  The  small 
and  large  miliary  papular  syphilides  are  the  ones  which  are  most  resistant 
to  remedies  general  and  local.  They,  like  all  stubborn  papular  syph- 
ilides, should  be  treated  by  hot  baths,  either  alkaline  or  sulphur,  and  by 
frictions  of  mercurial  ointment.  Massage  has  recently  been  recommended 
by  Balzer^  as  an  adjunct  in  the  treatment  of  these  syphilides.  Mercu- 
rial ointment  is  to  be  rubbed  into  the  surfaces  firmly  and  deeply,  each 
seance  occupying  from  twenty  minutes  to  half  an  hour.     I  have  used  this 

1  "  Contribution  a  r Etude  du  Traitement local  des  Syphilides;  Utility  de  Massage," 
La  France  medicate,  Jan.  9,   1891,  pp.  18  et  seq. 


THE  GENERAL  3IETH0DICAL   TREATMENT  OF  SYPHILIS.      917 

method  of  treatment  for  many  years,  and  have  long  since  become  con- 
vinced of  its  efficacy  and  necessity  in  many  cases.  In  some  cases  of  ex- 
tensive pigmentation  following  syphilitic  eruptions  baths  and  massage 
treatment  have  been  followed  by  striking  results.  Scaling  eruptions  of 
the  palms  and  soles,  the  sequelae  of  the  erythematous  and  papular  syph- 
ilides,  are  peculiarly  obstinate  and  prone  to  relapse.  They  may  be 
benefited  by  local  sublimate  baths,  as  recommended  by  Sigmund,  and, 
more  recently,  by  Gilles  de  Latourette.^  Hot  alkaline  baths  with  the 
addition  of  bran  are  also  very  efficient.  After  immersion  of  the  parts 
they  should  be  enveloped  in  a  mild  form  of  mercurial  ointment,  as 
follows : 

!l^.  Unguent,  hydrargyri  nitratis,  Sij  ; 

Olei  rusci,  Sj  ; 

Unguenti,  §j . — M. 

"Sf.  Unguent,  hydrargyri  nitratis,  3ij  ; 

Olei  cadini,  3j  ; 

Vaselini,  ^j.-^M. 

^.  Hydrargyri  ammoniati  vel  hydrargyri 

oxidi  rubri,  gr.  x-xxx  ; 

Olei  rusci,  3J  ; 

Yaselini,  §j. — M. 

Such  is  the  inflammatory  condition  present  in  some  cases  that  a 
soothing  ointment  is  required,  as  follows : 

^.  Unguent,  diachyli  (fresh),  5ij  ; 

Unguent,  hydrarg.  nitratis,  ^j  ; 

Olei  rusci,  •  3ss. — M. 

In  some  cases  of  localized  eruption  a  mild  solution  (from  1  to  4  grains 
to  the  ounce,  of  bichloride  of  mercury  in  flexible  collodion  or  traumaticin 
may  prove  very  efficient.  Sometimes,  when  the  tendency  to  scaling  is 
very  great  and  persistent,  chrysarobin  may  produce  happy  results. 

Pustular,  Encrusted,  and  Serpiginous  Syphilides. — The  early 
and  intermediate  pustular  syphilides  require  sublimate,  mercurial  vapor, 
and  sulphur  and  alkaline  baths.  Then  the  patient's  body  should  be 
rubbed  with  mercurial  ointment  or  a  strong  white  precipitate  ointment. 
About  the  face  it  is  imperative  that  these  lesions  should  be  efficiently 
acted  upon,  in  order  to  cause  their  prompt  disappearance  and  to  prevent 
cicatrices.     For  this  purpose  the  following  ointments  may  be  used : 

^.   Zinci  oxidi, 

Pulv.  amyli,  cm.  3ij  ; 

Unguent,  hydrargyri  (freshly  prepared), 

Vaselini,  da.  3ss. — M. 

^  Progrls  medical,  June  10,   1886. 


918  SYPHILIS. 

^.  Hydrargyri  ammoniati,  gr.  xxx  ; 

Zinci  oxidi, 

Pulv.  amyli,  da.  3;ij  ; 
Vaselini,  §ss. — M. 

Resorcin,  1  drachm,  may  be  substituted  for  the  white  precipitate  in  cases 
in  which  there  is  a  seborrhoeic  complication. 

The  encrusted  syphilides  require  the  use  of  baths  and  fomentations  for 
the  removal  of  crusts,  and  then  calomel  or  iodoform  may  be  dusted  upon 
the  raw  surfaces,  Avhich  should  be  covered  with  absorbent  gauze.  When 
these  surfaces  are  extensive  iodoform  should  be  used  sparingly,  lest  it 
produce  a  toxic  effect,  or  it  may  be  mixed  with  an  equal  quantity  of  sub- 
nitrate  of  bismuth  and  then  applied  more  freely. 

The  serpiginous  syphilide  is  sometimes  very  obstinate  in  its  course, 
ordinary  treatment  failing  to  prevent  its  extension.  Under  these  circum- 
stances free  but  careful  curetting,  after  removal  of  crusts  and  disinfection, 
as  found  beneficial  by  Spillmann  ^  in  five  cases,  may  prove  remarkably 
efficient.  I  have  seen  one  such  application  promptly  cause  the  healing 
of  a  case  which  had  been  rebellious  for  many  months.  A  similar  proce- 
dure may  be  beneficial  in  some  cases  of  extensive  rupia  after  the  removal 
of  the  crusts  and  the  laying  bare  of  a  well-marked  fungating  surface. 
Some  raw  surfaces  left  by  ulcerating  syphilides  show  a  tendency  to  exu- 
berant fungating  growths.  When  not  sufficiently  well  marked  to  require 
curetting,  they  may  be  carefully  touched  with  carbolic  or  nitric  acid, 
after  the  manner  laid  down  for  the  treatment  of  chancre. 

Gummatous  Syphilides. — The  early  or  precocious  gummata  indicate 
the  necessity  for  the  use  of  the  mixed  treatment,  or  of  iodide  of  potassium 
in  combination  with  mercury  applied  locally.  Daily  inunctions  should  be 
made,  and  mercurial  ointment  spread  on  lint  should  be  bound  upon  the 
parts.  If  much  pain  is  present  belladonna  ointment  may  be  mixed  with 
the  mercurial  ointment. 

In  their  non-ulcerated  state  late  gummata  may  be  treated  in  the  man- 
ner just  now  described.  When  ulceration  is  active  it  may  be  necessary 
in  some  cases  to  scrape  away  the  base  and  the  margin.  The  necrotic 
membrane  which  is  so  commonly  seen  in  these  ulcers  should  be  treated 
with  compresses  of  sublimate  solution  (1  to  500,  1000,  or  2000),  or  with 
compresses  of  carbolic-acid  water  (5  per  cent.).  The  application  of  car- 
bolic acid  or  nitric  acid  may  be  necessary.  When  the  slough  or  mem- 
brane on  the  surface  of  the  sore  is  not  very  dense  or  adherent,  iodoform 
may  be  dusted  upon  it.  When  a  raw  surface  has  been  exposed  the  appli- 
cation of  a  mild  mercurial  ointment  with  the  addition  of  some  balsam  of 
Peru  (1  drachm  to  the  ounce)  will  usually  cause  prompt  healing.  In 
very  large  and  deep  gummatous  ulcers,  after  dusting  with  iodoform,  ster- 
ilized sand  may  be  freely  packed  in  and  retained  by  absorbent  gauze  and 
bandage. 

Tubercular  Syphilides. — These  when  of  the  non-ulcerative  variety, 
should  be  treated  in  the  manner  indicated  for  papular  syphilides.  Being 
late  and  deep  lesions,  they  require  the  administration  of  both  mercury 
and  iodide  of  potassium.  To  cause  their  involution  mercurial  baths  and 
sublimate  baths  may  be  employed.  Each  tubercle  should  receive  very 
^  Progres  medical,  Sept.  5,  1885. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.      919 

vigorous  friction  with  mercurial  ointment,  "which  when  practicable  should 
be  kept  in  constant  contact  with  the  lesion.  In  some  cases  mercurial 
plasters  may  be  very  efficacious.  Scaling  conditions  of  the  skin  left  by 
this  syphilide  require  a  similar  treatment  to  that  of  the  scaling  sequelae 
of  the  papular  syphilides. 

Treatment  of  Affections  of  the  Nervous  System. — The  early  superven- 
tion of  symptoms  referable  to  the  cerebro-spinal  system  in  many  instances 
necessitates  the  precocious  use  of  the  iodide  of  potassium.  Syphilitic 
headaches  will  frequently  be  found  to  be  very  persistent  and  rebellious  to 
treatment  when  mercury  is  given  by  the  mouth.  I  have  seen  in  consul- 
tation many  such  instances,  where  the  use  of  pills  has  been  pushed  to  the 
extreme  of  intense  salivation,  and  yet  the  nocturnal  headaches  persisted. 
In  some  few  cases  calomel,  in  doses  of  |-  or  \  grain  every  three  or  four 
hours,  may  prove  beneficial,  but  the  danger  of  salivation  is  always  to  be 
feared  if  its  use  is  at  all  prolonged.  Mercurial  inunctions  into  the  neck 
and  temples  will  usually  prove  very  beneficial,  and  synchronously  iodide 
of  potassium  in  increasing  doses  should  be  given. 

Any  affection  of  the  cerebro-spinal  system  occurring  in  the  early 
years  of  syphilis  should  be  treated  by  mercury,  either  administered  by 
inunctions,  made  as  near  the  head  as  possible,  or  by  hypodermic  injec- 
tions, two  or  three  of  which  may  be  given  in  the  neck.  At  the  same 
time  iodide  of  potassium  should  be  given  internally.  This  remedy  may 
be  taken  in  milk,  in  Vichy  water,  and  in  cases  of  weak  stomach  may  be 
combined  with  Fairchilds  essence  of  pepsin,  and  also  with  bitter  tonics. 
In  some  cases  a  dose  of  30  grains  three  or  four  times  a  day  will  have  the 
desired  effect.  In  obstinate  cases,  however,  the  remedy  must  be  pushed 
with  a  free  hand  until  amelioration  in  the  condition  is  produced  or  the 
obstinacy  of  the  case  shows  that  such  disorganization  has  been  produced 
by  the  syphilitic  process  that  further  impi^ovement  is  hopeless.  As  much 
as  1  ounce  or  1^  ounces  have  been  required  in  many  cases  to  produce  a 
cure.  I  am,  however,  firmly  of  the  conviction  that  when  mercury  is 
synchronously  administered,  as  it  certainly  should  be  even  in  advanced 
cases,  it  will  seldom  be  necessary  to  push  the  iodide  as  heroically  as  has 
been  done  in  the  past. 

Besides  the  essential  treatment  here  succinctly  outlined,  much  treat- 
ment directed  to  concomitant  and  consecutive  symptoms  and  conditions 
will  be  required,  and  should  be  instituted  according  to  the  indications 
presented. 

Treatment  of  Gingivitis,  Stomatitis,  and  Salivation. — A  patient  under 
mercurial  treatment  should  be,  as  before  stated,  carefully  watched  as  to 
the  condition  of  his  mouth,  throat,  and  nose.  When  there  is  any  tend- 
ency to  hyperemia  of  the  mouth  and  throat,  free  gargling  three  or  four 
times  a  day  with  solutions  of  chlorate  of  potassium  and  alum,  of  common 
salt,  or  of  borax  should  be  used.  When  patients  are  undergoing  an  in- 
unction cure,  particularly,  it  is  well  to  Avash  the  mouth  three  or  four 
times  a  day  with  strong  alum-water  or  Avith  a  solution  of  alum  and  ace- 
tate of  lead,  as  follows  : 

!^j.  Pulv.  aluminis,  .5iij  ; 

Plumbi  acetatis,  3ss  ; 

Aquae,  ^viiss. — M. 


920  "  SYPHILIS. 

The  first  signs  of  irritation  of  the  gums  should  cause  a  diminution  of 
the  dose  or  a  suspension  of  treatment  and  the  adoption  of  local  therapeu- 
tics. In  any  and  all  cases  of  mercurial  action  upon  the  mouth  the  phy- 
sician should  be  very  conservative  in  the  use  of  caustic  applications. 
For  mild  cases  of  gingivitis  the  application  by  a  brush  of  equal  parts  of 
tincture  of  myrrh  and  tincture  of  iodine  once  a  day,  followed  by  some 
mild  mouth-wash,  will  usually  be  all-sufiicient.  When  the  case  is  severe, 
and  the  tissues  of  the  mouth  and  throat  are  very  much  inflamed  and 
swollen,  frequent  rinsings  with  very  warm  solutions  of  borax  and  alum 
to  which  listerine  and  glycerin  are  added  are  very  soothing.  Once  or 
twice  a  day  it  may  be  necessary  to  use  as  a  mouth-wash  and  gargle  a 
solution  of  the  nitrate  of  silver  (4  to  8  grains  to  the  ounce).  Much 
benefit  often  follows  rinsing  the  mouth  with  a  solution  of  bichloride  of 
mercury.  For  this  purpose  Von  Swieten's  solution,  either  in  its  purity 
or  diluted,  will  prove  very  efficacious.  It  is  thought  by  Galippe,  Renzie, 
and  others  that  much  of  the  intensity  of  the  mouth-inflammation  in  mer- 
curial poisoning  is  due  to  the  activity  of  microbes,  which  are  so  numerous 
in  the  mouth,  and  that  by  its  antiseptic  action  the  bichloride  is  very  effi- 
cient in  these  conditions.  Patients  thus  sufiering  should  be  well  nour- 
ished by  means  of  nutritious  broths  and  sarco-peptones,  and  should  take 
quinine  freely.  They  should  be  kept  in  the  fresh  air  as  much  as  possible. 
Much  benefit  and  comfort  may  be  derived  from  the  application  of  a  solu- 
tion of  cocaine  to  ulcerated  surfaces.  The  judicious  use  of  hot  baths 
"will  aid  in  the  elimination  of   the  mercury  from  the  system. 


CHAPTEE    LXXXyi. 

HEREDITAEY  SYPHILIS. 

The  words  "  congenital  "  and  "  infantile  "  are  used  to  designate  this 
variety  of  syphilis;  the  former  lacks  precision,  and  the  latter  may  be 
applied  with  equal  propriety  to  the  hereditary  and  the  acquired  forms. 
The  term  hereditary  syphilis,  therefore,  seems  preferable.  According  to 
Kassowitz,^  one-third  of  all  children  procreated  of  syphilitic  parents  are 
dead  born,  and  of  those  born  living  24  per  cent,  die  within  the  first  six 
months  of  life.  In  his  personal  experience  Fournier^  found  that  in 
private  practice  more  than  2  out  of  3  hereditarily  syphilitic  children  died, 
either  before,  at,  or  soon  after  birth.  In  hospital  practice  Fournier  found 
that  out  of  167  children  born  of  syphilitic  mothers,  145  died;  which 
means  that  1  child  out  of  7  or  8  survived.  It  having  been  claimed  that 
Fournier's  personal  statistics  made  an  exceptionally  bad  showing,  and 
that  they  were  exaggerated,  he  collected  those  from  the  whole  world,  his 

^  Die  Vererbung  der  Syphilis,  Yienna,  1876. 

^  La  SypJdlk  bereditaire  tardive,  Paris,  1886,  pp.  160  et  seq. 


HEREDITARY  SYPHILIS.  921 

own  excepted.  He  gathered  the  histories  of  447  cases  of  children  whose 
fathers  or  mothers  were  syphilitic,  and  found  that  out  of  this  number 
there  Avere  343  deaths,  there  being  only  104  Avho  survived.  Of  the  343 
children  who  died,  only  6  lived  beyond  the  first  year.  The  proportion 
of  living  children,  according  to  these  statistics,  is  1  to  4.3.  We  may 
understand  why  the  lesions  of  hereditary  syphilis  are  so  severe  and  exten- 
sive, and  why  its  fatality  is  so  great,  when  we  consider  how  early  in 
foetal  life  the  specific  virus  exerts  its  influence,  and  how  thoroughly  it 
must  be  diffused  through  the  organism  of  the  embryo. 

In  the  majority  of  cases  of  hereditary  syphilis  symptoms  appear 
about  the  third  week  of  life.  Some  authors  have  observed  a  postpone- 
ment of  symptoms  until  the  end  of  the  first  year  or  even  later,  but  in  my 
experience  the  twelfth  week  has  been  the  utmost  limit. 

In  case  of  the  infection  of  both  parents  the  disease  is  likely  to  be 
transmitted  in  an  intense  form,  resulting  in  the  death  of  the  foetus  or  in 
the  early  manifestation  of  symptoms. 

There  are  few  exceptions  to  the  rule  that  the  severity  of  the  disease 
decreases  with  each  succeeding  child.  The  danger  of  the  death  of  an 
infected  child  diminishes  as  it  grows  older,  and  freedom  from  symp- 
toms until  after  the  sixth  month  justifies  a  favorable  prognosis.  Death 
results  most  frequently  in  cachectic  children  and  from  gastro-intes- 
tinal  affections,  which  are  to  a  great  extent  dependent  on  visceral 
lesions. 

Syphilis  is  generally  transmitted  only  to  the  second  generation ; 
exceptionally,  in  case  of  excessive  activity  of  the  disease  in  the  first 
inheritor,  it  may  perhaps  appear  even  in  the  third  generation.^  The 
course  of  hereditary  syphilis  differs  in  many  respects  from  that  of  the 
acquired  disease.  The  latter  always  begins,  as  we  have  seen,  by  the 
development  of  a  local  lesion,  which  is  followed  by  a  definite  secondary 
period  of  incubation,  at  the  expiration  of  which  constitutional  manifesta- 
tions appear,  while  the  hereditary  disease  presents  no  initial  lesion  and 
cannot  be  divided  into  stages.  Moreover,  while  many  of  the  lesions  of 
each  are  similar,  being  undoubtedly  caused  by  the  syphilitic  poison,  on 
the  other  hand,  a  large  number  of  those  in  the  hereditary  form  are  merely 
the  result  of  perverted  nutrition,  and  may  occur  in  any  adynamic  disease. 
Among  such  lesions  may  be  classed  certain  affections  of  the  eyes,  peculiar 
osseous  malformations,  hydrocephalus,  impaired  growth  of  the  hair,  as 
well  as  deafness  and  deaf-mutism,  the  ultimate  cause  of  Avhich  is  un- 
known. 

The  lesions  of  hereditary  syphilis  are  more  hypememic  and  active 
than  those  of  the  acquired  form,  and  tend  to  involve  larger  surfaces. 
As  a  rule,  the  early  lesions  are  more  generally  distributed  and  are  more 
symmetrical  than  those  which  are  developed  later. 

Vesicular  and  bullous  syphilides,  so  rare  in  acquired  syphilis,  are 
quite  common  in  hereditary,  while  rupia  is  almost  unknown  in  the  latter. 
Affections  of  the  nasal  mucous  membrane,  which  are  infrequent  and 
appear  late  in  the  former,  are  among  the  earliest  and  most  reliable  diag- 
nostic symptoms  of  the  hereditary  disease.  Visceral  affections  are  much 
more  common  in  the  latter  than  in  the  former,  frequently  being  multiple, 
and  coexisting  with  lesions  similar  to  those  of  the  secondary  stage  of  the 

'  Vide  infra. 


922  SYPHILIS. 

acquired  disease.  Gummatous  and  connective-tissue  infiltrations  are 
often  developed  before  birth,  and  are  more  diffuse  and  symmetrical  "when 
they  appear  before  the  end  of  the  first  year  of  life ;  when  seen  after  that 
period  they  may  present  the  characteristics  of  the  acquired  forms.  A 
peculiar  and  constant  lesion  of  the  ossifjang  ends  of  the  long  bones  has 
been  observed  during  the  early  months  of  hereditary  syphilis.  Certain 
bone-lesions  may  be  developed  at  a  later  period  which  resemble  those  of 
the  acquired  disease.  Affections  of  the  nervous  system,  although  more 
common  than  has  been  supposed,  are  comparatively  rare  in  hereditary 
syphilis. 

Evidences  of  hereditary  taint  usually  disappear  before  puberty, 
although  syphilitic  lesions  undoubtedly  hereditary  have  been  observed 
at  later  periods,  and  in  some  instances  after  years  of  apparent  latency. 
The  extent  to  which  inherited  syphilis  furnishes  immunity  to  the  acquired 
form  is  still  undetermined. 

The  opinion,  which  has  been  sustained  chiefly  by  E-icord,  Maison- 
neuve,  and  Montanier,  that  syphilis,  especially  in  its  tertiary  form,  may 
be  transmitted  to  offspring  as  scrofula,  phthisis,  or  rickets,  is  utterly 
untenable. 

Syphilis  is  always  transmitted  as  syphilis,  although  the  cachexia 
induced  by  it  undoubtedly  predisposes  the  infant  to  affections  of  this 
kind,  just  as  any  adynamic  disease  may  do.  The  prevalence  of  this 
tendency,  which  is  quite  rare  in  America,  seems  to  be  very  marked  in 
Germany,  where  Kassowitz  and  Alois  Monti  found  that  nearly  every 
syphilitic  child  became  rachitic. 

In  hereditary  syphilis  as  in  the  acquired  disease  the  same  tendency 
exists  to  the  development  of  tuberculosis,  and  this  dangerous  symbiosis 
is    always   to  be  feared  in  infected  children,  old  and  young. 

The  Duration  and  Progress  of  Hereditary  Syphilis. — The  duration  of 
hereditary  syphilis  depends  altogether  upon  two  conditions — the  intensity 
of  the  diathesis  and  the  treatment.  It  is  not  uncommon  for  children  to 
present  mild  and  superficial  symptoms  for  a  few  months  or  a  year,  and 
then  become  blooming  and  healthy,  never  again  to  be  affected  with  syph- 
ilitic lesions.  Again,  severe  and  extensive  lesions  may  be  exhibited 
during  the  early  months,  which  relapse  at  irregular  intervals  in  an  equally 
intense  but  more  limited  form  for  a  few  years;  or  syphilitic  lesions  maybe 
developed  from  time  to  time  until  the  tenth  or  twelfth  year,  perfect  health 
being  established  after  that  time.  In  very  chronic  cases  symptoms  may 
recur  more  or  less  frequently  until  puberty.  My  observations  lead  me  to 
the  conclusion  that  they  do  not  appear  after  that  date.  In  general,  the 
severity  of  hereditary  syphilis  is  expended  within  the  first  few  years,  and 
subsequent  lesions,  although  possibly  extensive  and  deep,  do  not  show 
the  malignancy  of  early  ones. 

The  course  of  hereditary  syphilis  is  equally  chronic  as  that  of  the 
acquired  disease,  and  is  even  more  irregular  and  uncertain.  For  this 
reason  the  lesions  cannot  be  arranged  in  chronological  order,  and  a 
precise  division  of  the  disease  into  stages  is  likewise  impracticable. 
Visceral  and  superficial  lesions  frequently  coexist ;  the  interval  between 
early  and  late  lesions  may  be  but  a  few  months  or  even  many  years. 

As  in  the  acquired  form,  so  in  hereditary  syphilis,  the  extensive  super- 
ficial exanthems  are  peculiar  to  the  first  months  of  the  disease.     With 


HEREDITARY  SYPHILIS.  923 

these  may  coexist  lesions  of  the  mucous  membranes,  of  the  bones,  or  of 
the  viscera.  Relapsing  syphilides  are  usually  less  extensive  than  the  first 
eruption,  and  their  lesions  are  less  numerous.  They  may  be  composed  of 
either  papules,  pustules,  or  vesicles,  the  eruption  being  polymorphous  or 
made  up  of  one  variety  of  lesion.  The  course  of  these  relapsing  syph- 
ilides may  be  even  more  chronic  than  that  of  the  first  eruption,  and  the 
interval  between  the  two  may  be  a  few  weeks  or  several  months.  Some- 
times the  second  rash  appears  before  the  complete  disappearance  of  the 
first.  It  may  be  said  that  these  relapses  of  general  eruptions  are,  as  a 
rule,  peculiar  to  the  first  two  or  three  years  of  the  disease.  Subsequent 
eruptions  are  of  another  order,  more  profound,  more  localized,  and  less 
likely  to  relapse.  These  later  orders  of  dermal  lesions  may  be  papulo- 
tubercular  or  perhaps  pustular,  but  in  general  they  are  tubercular,  tuber- 
culo-ulcerous,  and  gummatous. 

These  cases  of  late  development  are  rather  rare,  although  I  have  seen 
fully  six  dozen  in  Avhich  such  lesions  have  appeared  at  the  third,  sixth, 
eighth,  twelfth,  fifteenth,  and  twentieth  years.  In  fully  one-half  they 
occurred  between  the  fourth  and  twelfth  years,  in  three-eighths  between 
the  third  and  fifth,  and  in  the  remainder  between  the  twelfth  and  twentieth 
years.  It  is  very  rare  to  see  dermal  lesions  extensive  and  superficial  after 
the  second  or  third  year,  they  being  usually  profound  and  limited,  and  in 
this  respect  differing  from  those  of  the  acquired  disease.  Under  the  head- 
ing of  syphilis  hereditaria  tarda  many  interesting  cases  of  dermal,  osseous, 
visceral,  and  cerebro-spinal  lesions,  have  been  reported  during  the  last 
decade.     In  many  cases,  however,  the  history  of  syphilis  is  very  vague. 

In  the  majority  of  cases  the  development  of  visceral  lesions  takes  place 
in  intra-uterine  life,  and  their  course  after  birth  is  retrogressive.  The 
principal  organs  attacked  are  the  liver,  the  lungs,  the  brain,  and  the 
kidneys.  Our  knowledge  of  the  frequency  and  extent  of  their  devel- 
opment after  birth  is  incomplete.  Besides  the  cutaneous  and  visceral 
lesions  of  the  first  year  or  two,  other  syphilitic  affections  are  frequently 
observed.  In  many  cases  the  diaphyso-epiphyseal  lesions  of  the  bones 
appear  during  intra-uterine  life  and  run  their  course  in  the  early  months 
of  the  disease,  possibly  relapsing  at  a  later  period  ;  or  they  may  appear 
for  the  first  time  during  the  first  year  of  life.  From  the  fourth  up  to 
the  twentieth  year  the  shafts  of  the  bones  may  be  afi"ected  by  periostitis, 
and  joint  aff"ections  often  occur. 

The  lesions  of  the  mucous  membrane  are,  like  those  of  the  skin, 
superficial  and  often  extensive  in  the  first  years  of  life ;  at  later  periods 
they  are  circumscribed,  profound,  and  destructive.  Occasionally  iritis, 
choroiditis,  or  retinitis  occurs,  generally  between  the  third  and  sixth 
years,  while  we  observe  that  keratitis  may  appear  at  any  time  up  to  the 
fifteenth  or  even  twentieth  year. 

In  the  somewhat  rare  cases  of  hereditary  syphilis  presenting  cerebral 
and  nervous  symptoms,  it  has  been  noted  that  such  sjnnptoms  and  nutri- 
tional affections  of  the  cranium,  teeth,  etc.,  begin  in  the  early  years  of 
life  and  leave  more  or  less  marked  traces. 

The  severity  of  hereditary  syphilis  exhausts  itself  within  the  first 
three  years  of  life ;  whatever  symptoms  are  manifested  after  that  time 
are  developed  in  the  most  chronic  and  irregular  manner.  Therefore,  if 
any  division  of  the  disease  into  stages  were  to  be  made,  the  first  four 


924  SYPHILIS. 

years  might  be  considered  the  first  stage,  or  the  period  of  the  disease 
proper,  the  second  stage  extending  from  that  time  indefinitely,  but  not 
beyond  the  twentieth  year. 

The  Process  of  Procreation. — The  study  of  hereditary  syphilis  is  much 
simplified  by  a  clear  understanding  of  the  process  of  procreation,  which 
is  described  by  Haeckel  ^  as  follows  :  "  The  nature  of  fructification  rests 
essentially  upon  the  truth  that  the  male  procreative  cell  becomes  inti- 
mately blended  w^ith  the  female  amoeba-like  ovule.  By  this  means,  in 
the  first  place,  the  ovule  is  incited  to  further  development,  and,  sec- 
ondly, the  transmission  to  the  child  of  the  hereditary  qualities  of  both 
parents  is  efi"ected.  The  male  procreative  cell  entails  upon  the  child 
the  individual  character  of  the  father,  and  the  female  ovum  transmits 
hereditarily  to  the  new  being  the  characteristics  of  the  mother." 

The  embryo  resulting  from  the  union  of  these  two  germinating  cells  is 
nourished  and  matured  in  the  womb  of  the  mother  through  the  utero- 
placental circulation.  The  influence  of  the  father  upon  the  foetus  is  lim- 
ited to  the  supply  of  organic  cells  at  the  time  of  fecundation  ;  that  of  the 
mother  continues  in  a  modified  form  through  the  period  of  gestation. 
Since  numerous  facts  support  the  idea  of  the  transmission  to  offspring  of 
mental  and  physical  qualities,  we  are  warranted  in  assuming  that  diseases, 
among  them  syphilis,  may  be  likewise  inherited,  the  sperm-cells  of  the 
male  and  the  ovule  of  the  female  being  the  conveying  media.  Hereditary 
syphilis  may  therefore  be  derived  from  one  or  both  parents,  since  it 
originates  in  the  procreative  cells  of  either  male  or  female. 

Ifijluence  of  the  Father. — So  many  undoubted  instances  of  the  trans- 
mission of  syphilis  from  father  to  child  have  been  reported  that  further 
evidence  is  scarcely  needed.  The  risk  of  contagion  from  the  father  is 
great  in  proportion  to  the  activity  of  his  symptoms.  If  procreation  takes 
place  while  he  is  in  the  first  period  of  incubation,  the  child  will  escape, 
and  may  do  so  even  during  the  secondary  period  of  incubation,  but  infec- 
tion is  more  probable  as  the  latter  stage  advances.  Probably,  his  malign 
influence  begins  with  the  evolution  of  constitutional  manifestations. 

There  is  abundant  evidence  that  if  the  disease  is  not  treated  the  sperm- 
cells  will  retain  the  syphilitic  virus  through  the  first  year,  since  temporary 
and  spontaneous  latency  of  the  disease  is  observed  only  at  a  later  period. 
On  the  other  hand,  mercurial  treatment  may  so  modify  the  disease  that 
the  child  Avill  escape  even  within  the  first  year.  We  see  frequent  exam- 
ples of  this  when  men  recently  syphilitic  and  compelled  to  marry  are  put 
under  an  active  mercurial  course,  and  within  a  year  become  fathers  of 
children  Avho  never  show  the  slightest  evidence  of  syphilis.  Rare  in- 
stances occur  in  which  the  di.sease,  although  unmodified  by  treatment, 
infects  the  system  of  the  father  so  slightly  that  the  foetus  escapes  even 
during  the  first  year. 

Mercurial  treatment,  however,  is  the  most  potent  means  at  our  com- 
mand of  finally  eradicating  the  disease.  Without  it,  the  danger  of  trans- 
mitting the  disease  to  offspring  usually  persists  up  to  the  fourth  year  of 
syphilitic  infection.  By  faithful  pursuance  of  a  mercurial  course  the 
probability  of  the  procreation  of  healthy  children  is  increased  from  year 
to  year. 

'■  Anlhropologie  oder  Entwickelungsgeschichte  des  Menschen,  Leipzig,  1875,  p.  138,  quoted 
by  Kassowitz. 


HEREDITARY  SYPHILIS.  925 

The  effect  of  mercury  is  not  always  permanent,  especially  if  it  is  em- 
ployed in  only  a  single  brief  course  during  the  first  year.  The  sperm- 
cells  of  the  father  having  as  a  result  of  treatment  ceased  to  procreate 
syphilitic  children,  the  disease  may,  on  the  cessation  of  treatment,  again 
hecome  active,  and  the  next  child  or  children  may  in  consequence  be 
syphilitic.  This  fact  has  been  conclusively  proved  by  a  number  of  cases 
reported  by  Kassowitz,^  and  also  in  two  cases  under  my  own  observation,^ 
in  both  of  which  the  father  was  syphilitic  and  the  mother  healthy.  Seven 
children  were  born,  of  whom  the  first  five  were  syphilitic,  the  sixth  per- 
fectly healthy,  and  the  seventh  markedly  diseased.  In  this  case  the 
mother  was  healthy,  and  the  disease  of  the  father  was  uninfluenced  by 
treatment  until  after  the  birth  of  the  fifth  child,  when  he  was  under 
active  treatment,  which  was  abandoned  after  the  birth  of  the  sixth. 

Our  chief  points  of  guidance  in  estimating  the  probable  influence  of  a 
syphilitic  father  upon  his  offspring  are  the  degree  to  which  the  disease  has 
a,ff"ected  his  system  and  its  amenability  to  treatment.  It  is  well  to  add 
that  the  earlier  a  mercurial  course  is  begun,  the  greater  will  be  its  effect 
upon  the  disease  and  the  more  complete  the  future  immunity  of  the 
patient.  When  the  symptoms  are  trifling  we  should  not  assume  that  the 
sperm-cells  are  healthy ;  on  the  contrary,  we  should  insist  upon  an  active 
and  prolonged  course  of  treatment. 

Those  rare  cases  in  which  distinct  evidences  of  syphilis  are  shown, 
such  as  gummata,  nodes,  palmar  psoriasis,  etc.,  without  any  indication  of 
transmission  of  disease  to  offspring,  have  merely  the  local  relics  of  an 
exhausted  syphilis. 

This  paternal  transmission  is  called  germinative  or  spermatic  infection, 
and  if  syphilis  is  really  a  disease  due  to  a  bacterium,  we,  guided  by  ana- 
logical evidence,  can  readily  understand  the  nature  of  the  process.  As 
pointed  out  by  Von  Diiring,^  Pasteur's  discovery  that  "  the  germs  of  the 
disease  of  silk-worms,  called  pebrin,  pass  into  the  ovulum  and  into  the 
spermatic-  cells  of  the  infected  worm,  which  retains  its  power  of  fecunda- 
tion and  germination,  and  transmits  the  infection  to  its  offspring,  throws 
a  flood  of  light  upon  the  pathology  of  the  transmission  of  syphilis  by 
heredity.  When  to  this  evidence  we  add  the  results  of  the  experiments 
of  Maffuci  and  Baumgarten,  who  succeeded  in  infecting  eggs  with  tuber- 
culosis and  in  detecting  that  disease  in  the  resulting  chicken,  it  almost 
seems  that  the  question  is  settled." 

Although  the  paternal  influence  in  transmission  is  now  generally 
acknowledged,  there  are  authorities  who  still  claim  that  the  disease  is 
derived  exclusively  from  the  mother.  This  theory,  now  known  as  that  of 
Cullerier,  who  was  one  of  its  prominent  advocates,  is  based  upon  observa- 
tions which  were  rendered  imperfect  by  failure  to  appreciate  the  facts  that 
syphilis  may  be  influenced  by  treatment  and  that  the  disease  has  periods 
of  true  latency. 

In  support  of  this  view  Cullerier  cites  the  cases  of  two  men  who,  in 
the  early  stages  of  syphilis,  underwent  treatment,  one  even  to  salivation, 

^  Op.  cit.,  and  "  Ueber  Vererbung  und  Uebertragung  der  Syphilis,"  Archiv  fur  Derm, 
und  Syph.,  1884,  pp.  198  et  seq. 

■■'  "  A  Contribution  to  tlie  Study  of  the  Transnaission  of  Syphilis,"  Arch.  Clin.  Surg,, 
N.  Y.,  Sept.,  1877. 

^  Monatshfifte  fiir  Prak.  Dermal.,  vol.  xx.,  No.  5,  1895. 


926  SYPHILIS. 

and  of  many  healthy  women  who  bore  within  a  year  of  marriage  perfectly 
healthy  children.  In  the  light  of  our  previous  studies  the  explanation  is 
very  simple.  Moreover,  Cullerier's  articles  show  that  he  has  seen  syph- 
ilitic mothers  produce  diseased  children,  and  has  failed  to  learn  the  condi- 
tion of  the  father,  whose  influence  on  the  offspring  is  almost  as  powerful 
as  that  of  the  mother,  and  he  has,  therefore,  reached  a  dangerous  and 
false  conclusion.  It  is  useless  to  consider  in  detail  the  arguments  and 
cases  of  those  who  follow  in  the  same  line,  chief  of  whom  are  Follin, 
Notta,  Charrier,  and  Oewre.  I  would  advise  a  perusal  of  the  criticism 
upon  this  theory,  and  upon  the  cases  offered  by  its  advocates,  in  the 
admirable  works  of  Kagsowitz. 

I  think  we  are  fully  warranted  in  adopting  the  conclusion  that  the 
father  may  transmit  syphilis  to  his  offspring. 

The  Influence  of  the  Mother. — In  order  that  syphilis  may  be  con- 
veyed by  the  mother  her  disease  must  be  constitutional.  It  is  very  prob- 
able that  the  ovule  of  the  female  is  infected  in  the  same  way  as  are  the 
spermatozoa  of  the  male. 

When  impregnation  occurs  later  than  within  two  weeks  of  the  evolu- 
tion of  general  manifestations,  the  foetus  is  almost  inevitably  affected,  and 
the  activity  of  the  disease  in  the  child  will  be  in  proportion  to  that  of  its 
early  stage  in  the  mother,  unless  the  disease  has  already  been  modified  by 
active  mercurial  treatment. 

Statistics  show  that  such  embryos  rarely  reach  maturity,  abortion  oc- 
curring usually  from  the  fifth  to  the  seventh  month,  sometimes  as  early  as 
the  third. 

In  such  cases,  in  addition  to  the  disease  of  the  ovule  itself  the  nutri- 
tion and  growth  of  the  foetus,  which  depend  upon  the  richness  and  purity 
of  the  mother's  blood,  are  impaired  in  proportion  to  the  severity  of  the 
disease  in  the  mother,  although  her  specific  syphilitic  influence  ceases 
after  conception. 

The  claim,  which  my  own  experience  tends  to  confirm,  is  made  by 
Fournier  and  others  that  syphilis  affects  women  more  profoundly  than 
men,  and  that  it  induces  in  them,  more  frequently  and  more  severely,  a 
condition  of  chloro-ansemia.  Women  in  this  condition  becoming  preg- 
nant are,  doubtless,  very  likely  to  abort,  while,  on  the  contrary,  an  em- 
bryo profoundly  syphilitic  may  reach  maturity.  Under  these  circum- 
stances treatment  probably  does  not  cure  the  disease  of  the  foetus,  but 
may  act  upon  it  indirectly  by  improving  the  condition  of  the  mother. 

In  many  women,  however,  as  in  some  men,  the  course  of  syphilis  is 
very  mild,  and  during  the  whole  secondary  period  an  appearance  of  per- 
fect health  is  retained. 

The  blood  of  such  women  is,  of  course,  not  profoundly  altered,  hence 
the  nutrition  of  the  child  is  relatively  good.  This  point  Avill  be  more 
fully  considered. 

Since  arbitrary  rules  regarding  the  parental  influence  in  the  transmis- 
sion of  syphilis  cannot  be  laid  down,  I  shall  give  merely  the  general 
results  reached  in  the  experience  of  reliable  observers,  supplemented  by 
my  own. 

The  frequent  observation  that  the  product  of  conception,  occurring 
while  either  parent  is  in  the  early  and  active  stage  of  the  disease,  is 
intensely  syphilitic  or  fails  to  reach  maturity,  and  that  healthier  children 


HEREDITARY  SYPHILIS.  927 

are  produced  as  the  disease  of  the  parent  becomes  less  severe,  is  ground 
for  the  assertion  that  the  severity  of  the  syphilis  in  offspring  is  in  propor- 
tion to  its  activity  in  either  or  each  parent  at  the  time  of  conception. 
Thus,  if  a  syphilitic  woman  becomes  pregnant,  or  if  the  disease  is  derived 
from  a  man  in  whom  it  is  active,  the  first  foetus  may  live  only  to  the 
third  month.  Without  treatment  the  next  pregnancy  may  have  a  similar 
result,  gestation  possibly  being  a  little  longer.  As  the  disease  becomes 
modified  by  time  or  treatment  a  living  but  syphilitic  child  may  be  born ; 
in  succeeding  pregnancies  the  traces  of  the  disease  fade,  until  finally 
healthy  children  may  be  produced. 

The  power  of  hereditary  transmission  peculiar  to  the  mother  depends, 
as  in  the  case  of  the  father,  upon  the  state  of  the  syphilis  in  her  organism, 
similar  periods  of  latency,  both  spontaneous  and  due  to  mercurials, 
being  met  with  in  the  female.  If  her  system  at  the  time  of  conception  is 
temporarily  free  from  syphilitic  influence,  her  ovules  are  capable  of  pro- 
ducing healthy  children. 

The  number  of  syphilitic  children  which  a  woman  may  produce  varies. 
In  some  cases  of  a  mild  character  healthy  children  may  follow  the  birth 
of  one  or  two  infected  ones.  In  other  cases,  particularly  in  those  partially 
or  entirely  untreated,  there  may  be  six  or  more. 

As  a  rule,  after  the  lapse  of  six  years  the  influence  of  the  disease  has 
become  so  feeble  that  the  risk  of  transmission  is  extremely  slight. 

Mercurial  treatment  seems  to  have  quite  as  marked  an  effect  in  eradi- 
cating the  disease  and  in  diminishing  its  transmissibility  with  women  as 
with  men. 

We  have  seen  in  the  case  of  the  father  that  the  disease  may  be  tem- 
porarily so  modified  by  treatment  that  healthy  children  will  alternate 
with  those  diseased.      The  same  is  true  of  the  mother. 

The  rare  occurrence  of  a  syphilitic  woman  giving  birth  to  twins,  one 
diseased  and  the  other  healthy,  seems  difficult  of  explanation,  but  is  doubt- 
less due  to  the  infection  of  one  ovule  alone.  Much  light  is  thrown  upon 
this  apparent  anomaly  by  the  fact  that  certain  syphilitic  cells  or  molecules 
may  be  temporarily  confined  to  parenchymatous  organs,  while  the  system 
at  large  remains  exempt. 

We  come  now  to  an  interesting  question :  Can  syphilis  he  conveyed 
through  the  utero-placental  circulation  ? 

This  mode  of  transmission  is  now  pretty  generally  admitted,  but  many 
discrepancies  are  found  in  the  statements  of  its  advocates.  It  is  claimed 
by  some  that  the  transmission  of  syphilis  to  the  child  depends  upon  the 
occurrence  of  the  mother's  infection  during  the  first  half  of  pregnancy, 
while  others  regard  the  latter  half  as  the  dangerous  period.  It  seems 
singular  that  this  theory  has  been  accepted  at  all,  in  view  of  the  preva- 
lence of  so  much  uncertainty  and  lack  of  precision. 

The  question,  however,  is  a  very  simple  one — namely.  Can  the  syphi- 
litic infection  of  the  mother  be  conveyed  through  her  blood  to  the  child? 

The  experiments  of  Pellizzari  have  conclusively  proved  that  the  blood 
cells  are  the  active  agents  of  syphilitic  infection.  After  fecundation  the 
embryo  is  not  supplied  with  cells  of  any  kind,  but  simply  with  serum. 
There  is,  therefore,  after  the  occurrence  of  conception  no  possibility  of  the 
transmission  of  syphilis,  provided  the  structure  of  the  placenta  is  not 
impaired. 


928  SYPHILIS. 

The  literature  of  the  subject  furnishes  not  a  single  reliable  case  in 
proof  of  the  theory.  Many  cases,  apparently  convincing,  are  reported 
which  on  careful  scrutiny  show  some  vital  defect.  The  following  is  an 
illustration  of  this  point :  A  pregnant  woman,  healthy  at  conception,  be- 
comes syphilitic  during  gestation,  and  brings  forth  a  premature  macerated 
child,  or  a  syphilitic  child  may  be  born  at  full  time.  Of  such  cases  cer- 
tain authors  say  that  the  former  was  a  syphilitic  embryo,  and  that  the 
latter  derived  its  syphilis  from  the  mother.  Such  errors  as  these  are  the 
chief  cause  of  the  doubt  now  resting  on  this  question. 

A  syphilitic  woman  may  bring  forth  a  macerated  child,  but  undeniable 
lesions  of  syphilis  must  be  found  on  the  child  itself  to  prove  its  infection. 
The  anaemic  condition  of  the  mother,  and  not  the  specific  poison  in  her 
blood,  may  have  caused  the  premature  expulsion  of  the  child. 

Statistics  show'  that  syphilis  contracted  by  the  mother  during  preg- 
nancy is  a  very  prolific  cause  of  premature  birth.  The  aborted  products, 
however,  may  differ  in  no  respect  from  those  met  with  in  the  case  of 
mothers  who  have  passed  through  some  severe  adynamic  disease,  having 
no  specific  nature  whatever,  and  cannot  be  called  syphilitic  in  the  absence 
of  undoubted  lesions. 

A  syphilitic  child  may  be  born  at  full  term  of  a  mother  infected  at 
some  time  during  gestation.  It  has  often  been  assumed  that  in  such  case 
the  disease  is  derived  from  the  mother;  on  the  contrary,  it  always  is 
derived  from  the  father.  It  is  possible  for  a  healthy  woman  carrying  a 
syphilitic  foetus  to  become  infected  herself,  since  the  disease  of  her  embryo 
imparts  to  her  no  immunity.  This  fact  has  been  cited  as  evidence  of 
syphilis  acquired  by  the  mother  through  conception,  the  truth  being  that 
it  was  subsequently  acquired  directly  from  the  father. 

The  importance  of  learning  all  the  facts  relating  to  father,  mother,  and 
child  before  drawing  conclusions  seems  to  have  been  often  disregarded. 
As  an  illustration  I  may  mention  the  article  of  Hutchinson  ^  of  London, 
in  which,  of  six  cases  reported,  not  one  bears  out  the  theory  advocated, 
some  lacking  most  important  details,  while  others  are  clearly  instances  of 
syphilis  derived  from  the  father. 

The  cases  cited  by  Oewre,  who  also  supports  this  theory,  are  equally 
unreliable  for  similar  reasons.^ 

The  hypothesis  of  Finger  ^  as  to  the  question  of  placental  infection  of 
the  mother  appeals  to  our  reason,  though  we  may  have  mild  misgiving, 
since  it  is  not  proved  that  syphilis  is  really  a  bacterial  disease.  It  is  the 
rule  that  the  placenta  acts  as  a  very  perfect  filter,  and  wholly  prevents 
the  passage  of  solid  particles  of  matter.  Now,  following  Finger,  if  we 
assume  that  the  products  of  syphilitic  infection  are  ptomaines  or  toxines 
which  are  soluble,  and  of  tissue-elements  which  are  solid  particles,  the 
deduction   may  be   made  that  in  the  pregnant  woman   there   is    always 

^  "A  Clinical  Lecture  on  the  Communication  of  Syphilis  from  a  Mother  to  her  Foetus," 
MecL  Times  and  Gaz.,  Lond.,  Mar.  30,  1877. 

^  Among  those  who  deny  the  theory  in  the  most  positive  manner,  and  who  furnish 
large  numbers  of  trustworthy  cases,  may  be  mentioned  Pick,  Hennig,  Kobner,  Spiith, 
Schaunstein,  Bidenkap,  Biirensprung,  and  Kassowitz.  Barensprung  details  fourteen 
cases,  and  says  emphatically  that  he  has  never  seen  a  syphilitic  child  born  of  a  mother 
infected  during  pregnancy.  The  cases  of  Pick  and  Kassowitz  are  also  especially  valu- 
able. 

^  "  Die  Syphilis  als  Infectionskrankheit  vom  Stand-Punkte  der  modernen  Bacteri- 
ologie,"  Archivfur  Derm,  und  Syphilis,  1890,  pp.  340  et  seq. 


HEREDITARY  SYPHILIS.  929 

going  on  an  interchange  of  serum  between  her  and  her  offspring.  Now, 
if  this  serum  contains  syphilitic  toxines,  it  is  fair  to  conclude  that  the 
mother  receives  a  modified  syphilitic  infection  or  intoxication;  she  is, 
as  we  may  say,  vaccinated.  This  condition,  while  in  all  probability  not 
rendering  her  syphilitic,  confers  upon  her  an  immunity  to  the  infection. 
On  this  subject  Von  Diiring  states  that  it  is  possible  for  micro-organisms 
to  so  damage  the  placenta  by  causing  emboli,  hemorrhages,  and  endo- 
thelial necroses  that  its  filtering  power  is  in  a  measure  lost,  and  that 
through  it  solid  particles  may  permeate.  If  all  these  hypotheses  are 
true  in  essence,  the  conclusion  is  warranted  that  in  some  exceptional 
cases  the  healthy  mother  may  be  infected  by  her  syphilitic  foetus. 

Assuming  that  the  toxine  theory  is  scientifically  true,  we  may  infer 
that  the  pregnant  woman  who  is  infected  with  syphilis  after  conception 
nourishes  her  infant  with  a  serum  more  or  less  rich  in  toxines,  and  that 
in  proportion  to  the  quantity  and  malignancy  of  the  circulating  poison 
the  child  is  affected,  and  that  when  it  is  very  intense  death  is  produced. 

The  answer  to  the  question  above  propounded  is  :  TJiat  in  all  proba- 
bility/ the  toxic  principles  of  syphilis  may  be  conveyed  through  the  utero- 
placental circulation  from  mother  to  foetus,  and  vice  versa,  and  that 
full  infection  may,  in  rare  cases,  occur  when  the  filtrative  power  of  the 
placenta  has  been  impaired  by  morbid  changes. 

The  mothers  who  bear  syphilitic  children  and  present  no  evidence 
of  infection  may  be  thin  and  pallid  or  healthy  and  robust.  Some  au- 
thors think  that  they  are  the  bearers  of  a  modified  syphilis,  while  still 
others  claim  that  they  later  on  may,  and  often  do,  present  tertiary  mani- 
festations. In  all  probability  those  authors  who  claim  that  a  modified 
syphilis  has  been  produced  are  correct.  Though  Von  During  emphati- 
cally says  that  these  women  are  in  a  latent  tertiary  condition  and  that 
they  do  later  on  present  undoubted  evidence  of  tertiary  syphilis,  and 
reports  three  cases,  I  think  that  we  have  not  as  yet  a  sufficiency  of  uncon- 
trovertible facts  to  allow  us  to  make  magisterial  statements.  We  want 
more  well-  and  long-observed  cases. 

It  is  very  certain,  however,  that  these  women  acquire  an  immunity  to 
syphilitic  infection  from  others.  On  this  subject  Colles^  says  :  "  I  have 
never  witnessed  nor  heard  of  an  instance  in  which  a  child  deriving  the 
infection  of  syphilis  from  its  parents  has  caused  an  ulceration  on  the  breast 
of  its  mother."  In  like  manner,  Baumfes,^  in  speaking  of  a  case,  says  : 
"  This  is  in  accord  with  the  observed  fact  that  a  mother  who  has  borne 
syphilitic  children  which  derive  the  infection  from  the  semen  of  the 
father  does  not  contract  syphilis  in  nursing  her  own  offspring,  while 
a  strange  Avoman  may  do  so."  Colles's  statement  of  what  he  observed 
has  passed  current  as  Colles's  law.  Von  During  very  happily  formulates 
it  as  follows :  "  A  healthy  woman  who,  impregnated  by  a  syphilitic  man,  has 
borne  a  syphilitic  child,  may  be  free  of  all  symptoms  of  syphilitic  infection, 
and  may  at  the  same  time  be  refractory  against  any  syphilitic  infection." 

This  clinical  fact  has  been  verified  by  the  results  of  experimental 
inoculation.      Thus  Caspary  ^  reports  the  case  of  a  woman  who  bore  her 

^  Practical  Obaervations  on  the  Venereal  Disease,  London,  1837,  p.  285. 
^  Precis  theorique  et  pratique  des  maladies  veneriennes,  vol.  i.  1840,  pp.  ISO  et  seq. 
^  "Ueber  Gesunde  Mutter  hered.  Syph.  Kinder.,"  Vicrtcljahr.  fur  Derm,  und  Syph., 
1875,  p.  437. 

59 


930  SYPHILIS. 

husband  when  he  was  free  from  syphilis  several  healthy  children.  He 
then  contracted  the  infection,  and  afterward  she  became  pregnant  and 
aborted,  and  gummatous  changes  were  found  in  the  placenta.  Caspary 
inoculated  this  woman  with  the  secretion  of  mucous  patches,  without 
any  result.  Finger  ^  inoculated  with  syphilitic  material  three  women  in 
this  condition,  and  failed  to  produce  any  effects.  We  are  unable  to  say 
whether  the  immunity  gained  by  these  women  is  limited  in  duration  or 
whether  it  exists  during  lifetime. 

Immu7iity  due  to  Hereditary  Syphilis. — As  a  general  rule,  persons 
who  have  suffered  from  hereditary  syphilis  in  early  life  possess  an  im- 
munity against  acquired  infection.  This  rule  has  very  rare  exceptions. 
I  published  ^  the  case  of  a  woman  who  a\  as  infected  at  puberty,  and  who 
carried  with  her  the  disfigurements  of  early  hereditary  syphilis.  Taver- 
nier^  has  also  reported  two  cases  in  which  the  probability  exists  that 
hereditary  disease  was  followed  later  on  by  acquired  infection. 

W.  Boeck  *  mentions  the  case  of  a  child,  the  victim  of  hereditary 
syphilis,  whom  he  treated  in  its  first  year  by  means  of  syphilization, 
and  who  returned  when  he  was  eighteen  years  old  with  the  acquired 
disease. 

Hutchinson  ^  reports  two  cases  in  which  young  men  of  well-character- 
ized heredito-syphilitic  physiognomy  had  chancres  which  became  inflamed 
and  were  followed  by  a  "  rupia  rash."  I  am  unable  to  convince  myself 
that  either  of  these  two  unfortunates  presented  satisfactory  evidence  of 
a  late  acquired  infection. 

Lang  ^  mentions  the  case  of  a  man  twenty-five  years  old  who  had  suf- 
fered until  his  eighteenth  or  twentieth  year  with  a  severe  form  of  hered- 
itary syphilis,  who  came  to  him  with  a  typical  hard  chancre  and  swelling 
of  the  inguinal  ganglia.     The  further  history  is' not  given. 

Dowse ''  reports  the  case  of  a  girl  nine  years  old  whose  mother  had 
had  eight  miscarriages,  and  whose  upper  central  incisors  were  notched 
and  irregular,  but  yet  who  gave  no  history  of  congenital  syphilis.  This 
girl  was  infected  with  syphilis  from  the  condylomata  lata  of  a  neighbor's 
child,  and  had  generalized  syphilides  and  lesions  of  the  alse  nasi,  pharynx, 
larynx,  trachea,  and  bronchi.     She  died  of  the  disease. 

Transmission  of  Syphilis  to  the  Third  Generation. 

Transmission  of  syphilis  through  two  generations  to  the  third  has 
been  claimed,  and  it  may  perhaps  occur,  but  there  is  as  yet  no  satisfac- 
tory evidence  to  prove  it. 

The  proof  would  consist  of  the  following  facts. 

1.  The  existence  of  syphilis  in  one  or  both  grandparents. 

2.  A  clear  history  of  hereditary  syphilis  in  the  child. 

1  "Ueber  Immunitat  gegen  Syphilis,"  Allcj.  Wien.  med.  Zeitg.,  1885,  No.  50. 
'^  Journ.  of  Cutan.  and  Gcn.-urin.  Diseases,  Dec,  1890. 
^  Annales  de  Derm,  etde  SypL,  1887,  pp.  513  et  seq. 
*  Under soqelser  angaaende  Si/phllis,  C'hristiania,  1875,  p.  270. 

^  "  New  Facts  and  Opinions  as  to  Inherited  Syphilis,"  London  Hospital  Reports,  1865, 
pp.  169  and  170. 

«  Op.  clt.,  Wiesbaden,  1884  and  1886,  p.  458. 

'  Medical  Times  and  Gazette,  June  9,  1877,  p.  630. 


HEREDITARY  SYPHILIS.  931 

3.  Proof  (absolute)  that  the  father  of  the  child  or  the  person  of  the 
woman  spoken  of  in  the  second  particular  was  free  from  syphilis. 

4.  That  the  child  when  fully  grown  had  not  been,  and  was  not  then, 
infected  with  acquired  syphilis.  * 

5.  That  her  offspring  undoubtedly  had  hereditary  syphilis.  Vague 
lesions  should  not  be  considered  at  all. 

A  number  of  cases  have  been  published  on  this  subject,  but  they  are 
lacking  in  some  essential  fact. 

In  King's  case^  the  mother  was  undoubtedly  affected  with  syphilis 
prior  to  birth  of  the  child  or  the  father  was  syphilitic. 

In  Hutchinson's  ^  case  the  only  evidence  pointing  to  syphilis  in  the 
child  was  chronic  synovitis  of  the  left  knee. 

In  the  case  of  Devasse  ^  there  is  a  history  of  syphilis  in  the  grand- 
mother, and  in  all  probability  hereditary  syphilis  in  the  grandchild,  but 
there  is  no  history  of  the  mother  at  all,  and  that  of  the  father  is  very 
unsatisfactory. 

Atkinson  *  reported  a  case,  the  weak  point  of  which  is  that  the  mother's 
eruption  at  puberty  gives  evidence  of  activity  of  infection.  It  was  gen- 
eralized and  superficially  papular,  and  indicated  recent  infection. 

Dezanneau  ^  also  reports  a  case  in  which  everything  is  assumed. 

C.  Boeck "  reports  a  case  in  which  the  weak  point  is  that  the  child 
was  born  with  active  syphilis  of  a  mother  twenty-nine  years  old  who 
had  previously  had  two  healthy  children. 

Invasion  and  Evolution  of  Hereditary  Syphilis. 

Before  considering  in  detail  the  lesions  of  syphilis,  its  evolution  and 
mode  of  invasion  should  be  described. 

The  mortality  of  syphilitic  children  is  very  great,  fully  one-third  dying 
before  maturity.  Abortion  resulting  from  the  death  of  the  foetus  usually 
occurs  about  the  sixth  month,  while  that  caused  by  infection  of  the  mother 
during  pregnancy  takes  place  somewhat  later.  An  aborted  foetus  is  usually 
in  a  macerated  condition,  the  skin  being  easily  detached  and  the  surface 
having  a  livid  purple  color,  and  various  lesions  will  be  found  in  some  of 
the  viscera.  The  integument  may  show  nothing  characteristic  or  large 
bullie  may  be  found  on  the  soles  and  palms. 

In  syphilitic  children  stillborn  at  term  or  dying  soon  after  birth  fre- 
quently no  lesion  of  the  skin  is  found.  The  greater  number  of  syphilitic 
children  born  living  appear  well  nourished  and  perfectly  healthy,  but, 
generally  at  the  end  of  three  weeks,  evidences  of  disease  show  themselves. 
The  date  of  evolution  of  syphilis  has  been  noted  by  Kassowitz  in  124 
cases,  in  11  of  which  it  was  the  first  week  ;  in  21,  the  second ;  in  34,  the 
third  or  fourth  ;  in  40,  it  was  the  second  month  ;  and  in  18,  the  third 
month.  The  time  seems  to  depend  upon  the  varying  intensity  of  foetal 
infection,  the  early  appearance  of  symptoms  indicating  a  virulent  type  of 
disease. 

*  Journal  of  Cutan.  and  Gen.-vrm.  Diseases,  vol.  vii.,  1889,  pp.  328  et  seq. 

*  London  Hospital  Reports,  1865,  pp.  153  et  seq. 

*  Syphilis  ses  formes  son  unite,  Paris,  1865,  p.  366. 

*  Archives  of  Dermatology,  vol.  iii  ,  pp.  106  et  seq. 

^  Annales  de  Derm,  et  de  Syph.,  1888,  pp.  162  et  seq. 
6  Ibid.,  1889,  pp.  782  et  seq. 


932  SYPHILIS. 

The  prognosis  in  the  case  of  syphilitic  children  is  always  unfavorable, 
death  from  marasmus  often  ensuing  within  a  month,  but  it  becomes  less 
serious  the  later  the  appearance  of  active  symptoms. 

The  first  indication  of  disease  in  a  child  apparently  healthy  at  birth  is 
the  characteristic  snuffling,  which  is  the  cause  of  great  discomfort,  and  in 
some  cases  death  ensues  from  the  obstruction  to  breathing.  Emaciation 
may  progress  to  such  an  extent  as  to  leave  the  skin  of  the  body  loose  and 
wrinkled.  The  integument  of  the  face  seems  to  be  drawn  tight  over  the 
bones  and  assumes  an  eai'thy  sallowness.  The  eyes  become  prominent,  and 
the  juvenile  expression  is  lost  until  these  children  come  to  look  like  little 
old  men  and  women.  In  some  cases,  however,  even  of  children  intensely 
diseased,  excessive  emaciation  is  not  observed,  so  that  there  seems  to  be 
no  special  relation  between  this  condition  and  the  activity  of  the  disease. 
Simultaneous  with  these  changes  the  child's  nutrition  suffers,  gastro-intes- 
tinal  and  pulmonary  lesions  may  be  developed,  and  various  skin  eruptions 
make  their  appearance. 

Eruptions  of  Hereditary  Syphilis. 

The  principal  eruptions  are — the  erythematous  syphilide,  or  roseola ; 
the  papular  syphilide ;  the  vesicular,  the  pustular,  the  bullous,  and  the 
tubercular  syphilides ;  and  a  form  of  furuncle. 

With  certain  modifications  the  features  of  syphilitic  eruptions  in  infants 
are  similar  to  those  in  adults.  In  both  cases  they  appear  in  crops,  but  in 
the  hereditary  disease  the  later  rashes  are  less  symmetrical,  and  are  likely 
to  be  limited  to  particular  regions,  and  the  fever  accompanying  an  erup- 
tion in  the  acquired  disease  is  frequently  absent.  Although  their  general 
course  is  subacute,  yet  on  account  of  the  activity  of  cell-growth  and  cir- 
culation in  the  integument  of  infants  the  eruptions  are  developed  rapidly 
and  tend  to  involve  extensive  surfaces.  It  may  also  be  noticed  that  such 
lesions  as  papules  and  condylomata  are  less  firm  and  solid  than  similar 
ones  in  adults. 

The  erythematous,  papular,  tubercular,  and  gummatous  eruptions  are 
essentially  the  result  of  syphilitic  processes,  while  all  the  ulcerative  rashes 
are  the  outcome  of  a  symbiosis  of  syphilis  and  pyogenic  bacteria. 

The  Erythematous  Syphilide,  or  Roseola. — This  is  the  most  frequent 
and  earliest  hereditary  ei'uption,  appearing  about  the  third  week,  and 
often  preceded  or  accompanied  by  coryza.  It  begins  on  the  lower  part 
of  the  abdomen  as  minute  round  or  oval  pink  spots,  which  at  first  disap- 
pear on  pressure.  It  rapidly  invades  the  trunk,  face,  and  extremities, 
and  is  generally  fully  developed  within  a  week.  The  spots  then  vary 
from  a  third  to  half  an  inch  in  diameter,  assume  a  dull-red  coppery  hue, 
and  no  longer  disappear  on  pressure,  owing  to  pigmentation  of  the  skin. 
In  some  cases,  as  in  adults,  punctse  of  a  deeper  color  are  seen  on  the  sur- 
face of  the  roseolous  patches,  denoting  the  situation  of  follicles  around 
which  the  hypersemia  is  more  intense. 

The  patches  are  not  usually  elevated,  and  desquamation  is  generally 
absent,  except  in  severe  cases  about  the  hands,  feet,  and  nates,  where  it 
may  be  limited  to  the  margins  of  the  patches,  or  it  may  be  so  extensive 
as  to  resemble  psoriasis.  Sometimes  the  spots  run  together  and  fissures 
form,  either  superficial  or  of  sufiicient  depth  to  cause  much  pain. 


HEREDITARY  SYPHILIS.  933 

The  early  change  of  color  to  a  coppery  hue,  seen  in  irregular  patches 
upon  the  chin,  in  the  folds  of  the  neck,  and  on  the  nates,  where  other 
lesions  frequently  coexist,  is  an  important  diagnostic  feature. 

The  tendency  to  a  circular  form,  so  common  in  acquired  syphilis,  is 
observed  in  later  hereditary  eruptions  more  frequently  than  in  roseola. 

The  eruption  is  sometimes  so  evanescent  and  its  color  so  faint  that  it 
passes  unobserved.  By  attention  to  the  characteristics  mentioned  and  to 
the  history  of  the  patient  the  diagnosis  will  generally  be  sufficiently 
easy. 

The  Papular  Syphilide  and  Condylomata  Lata. — These  lesions  will 
be  described  together  on  account  of  their  pathological  similarity. 

The  papular  syphilide  may  be  the  first  eruption,  and  not  unfrequently 
it  is  intermingled  with  a  roseola,  or  three  or  four  different  syphilides  may 
be  seen  at  the  same  time  on  one  child.  The  small  acuminated  papule  of 
acquired  syphilis  is  scarcely  ever  seen,  except  in  a  relapse  or  late  in  the 
course  of  the  disease.  Flat  papules,  small  and  large,  scattered  symmet- 
rically over  the  body  are  the  common  forms.  Crescentic  grouping  is 
seldom  seen  except  at  a  late  period,  and  then  only  about  the  joints  and 
on  the  extremities.  The  papules,  at  first  dull  red,  and  then  coppery, 
may  have  a  smooth  surface,  or  the  epidermis  may  exfoliate,  especially  on 
the  soles  and  palms. 

In  this  connection  may  be  mentioned  certain  diffuse  infiltrations  some- 
times observed  which  have  not  yet  been  carefully  described.  When 
papules  are  copiously  distributed  upon  the  palms  and  soles,  it  may  be 
noted  that  they  increase  rapidly  in  size  and  number  and  fuse  together. 
The  skin  is  of  a  dull-red  color,  much  thickened  and  scaly.  An  entire 
foot  or  hand,  or  the  gluteal  region  from  the  thighs  to  the  top  of  the 
sacrum,  may  be  thus  involved. 

Irritation  from  active  movements  or  from  pressure  often  excites  fis- 
sures and  ulceration,  which  are  the  cause  of  much  suffering.  This  condi- 
tion may  accompany  any  lesion  of  hereditary  syphilis;  its  course  is 
chronic,  and  it  is  not,  as  a  rule,  affected  by  internal  medication.  The 
duration  of  the  hereditary  papular  syphilide  depends  upon  treatment,  to 
which  it  promptly  yields. 

Condylomata  lata  are  simply  modifications  of  the  papular  syphilides, 
due  to  their  situation  between  the  folds  of  skin  or  at  its  junction  with 
mucous  membranes  or  wherever  there  is  moisture.  The  change  in  the 
papule  is  chiefly  hypertrophic,  there  being  no  decided  histological  differ- 
ence between  the  two  forms  of  eruption.  In  size  condylomata  vary ; 
their  shape  is  governed  by  the  conformation  of  the  parts  upon  which 
they  grow  ;  and  in  color  they  are  usually  grayish-pink  to  dark  brown. 
Their  surface  is  generally  flat,  sometimes  fissured  and  ulcerated,  when  a 
scanty  offensive  secretion  exudes,  which  may  form  a  thin  dirty-colored 
crust.  Particularly  in  cachectic  infants  a  false  membrane  may  form, 
Avhich  is  slightly  adherent,  and  leaves  a  raw,  bleeding  surface  on  re- 
moval. 

When  condylomata  reach  a  diameter  of  more  than  an  inch — an  un- 
usual size — the  margins  become  elevated  and  rounded  and  end  abruptly 
in  the  surrounding  skin.  The  latter  may  be  of  its  natural  tint  or 
hyper?emic,  or  it  may  be  the  seat  of  the  diffuse  infiltration  already 
spoken  of. 


934  SYPHILIS. 

Condylomata  are  among  the  early  and  most  obstinate  of  hereditary 
lesions,  local  measures  appearing  to  have  more  eflFect  upon  them  than 
internal  medication.  They  vary  greatly  in  number,  and  in  infants  are 
most  frequently  seen  about  the  anus.  A  characteristic  symptom  is  ex- 
hibited when  they  exist  at  each  angle  of  the  mouth,  associated  with 
mucous  patches  in  the  buccal  cavity.  They  are  much  aggravated  by 
neglect  and  want  of  cleanliness,  but  with  proper  care  and  treatment  they 
shrink  and  disappear,  leaving  a  temporary  copper-colored  stain. 

The  Vesicular  Syphilide. — This  rare  form  of  eruption  occurs  among 
the  early  symptoms  in  severe  cases  of  hereditary  syphilis.  It  is  never 
general,  but  is  usually  associated  with  a  pustular  or  bullous  eruption,  and 
appears  in  groups  of  vesicles,  closely  and  irregularly  packed  together, 
upon  the  chin  and  about  the  mouth,  upon  the  forearms,  the  nates,  the 
hypogastrium,   or   the  thighs.     It  rarely  shows  a  tendency  to  relapse. 

The  size  of  the  individual  vesicles  varies.  The  smallest  are  about 
two  lines  in  diameter,  and  elevated  about  one-quarter  of  a  line  above  the 
general  surface,  or  conical,  contain  transparent  serum,  and  are  situated 
upon  a  firm  infiltrated  base  which  has  a  brownish-red  color.  Larger 
vesicles  seem  to  be  situated  upon  papules,  and  their  contents  are  sero- 
purulent.  Unlike  eczema,  the  distinct  vesicles  show  a  tendency  to  remain 
isolated  and  to  involve  deeper  portions  of  the  skin,  and  rarely  coalesce  to 
form  superficial  weeping  patches.  Though  chronic  in  its  course,  this 
eruption  generally  yields  to  internal  or  topical  treatment. 

Tlie  Pustular  Syphilide. — This  eruption  usually  appears  before  the 
eighth  week  in  children  profoundly  syphilitic,  but  is  not  infrequently 
seen  in  those  whose  nutrition  is  fair.  The  later  it  appears,  the  more 
likely  are  the  pustules  to  be  small,  few,  and  superficial.  It  may  invade 
the  entire  body,  but  is  usually  more  abundant  on  the  thighs,  buttocks, 
and  face,  while  elsewhere  the  pustules  are  thinly  scattered  and  irregular. 

The  pustules  vary  from  a  third  of  a  line  to  a  line  in  diameter  at  their 
bases,  and  from  a  third  to  half  of  a  line  in  elevation.  The  deep-red  color 
of  their  thickened  bases  ends  abruptly  at  their  margins.  They  may  re- 
main intact  for  many  days,  and  after  rupture  the  ulcerated  surface  may 
or  may  not  become  incrusted.  Especially  about  the  mouth  there  is  a 
tendency  to  grouping  and  the  formation  of  quite  extensive  patches,  or  the 
whole  head  and  face  may  be  thus  involved.  The  crusts  are  generally 
darker  than  those  of  eczema  and  contagious  impetigo,  and  the  ulceration 
beneath  is  deeper.  Itching  and  burning  are  usually  slight,  but  much 
uneasiness  and  even  suffering  may  be  caused  in  certain  locations,  as  when 
pustules  form  on  the  scrotum,  the  buttocks,  or  the  face.  Groups  of  pus- 
tules, attended  by  much  redness  and  thickening  of  the  surrounding  skin, 
may  form  on  the  palms  and  soles,  and  the  nails  may  be  destroyed  by 
pustules  developed  around  them  or  beneath  their  free  extremities. 

This  eruption  usually  leaves  no  permanent  trace,  but  in  some  cases 
marked  loss  of  tissue  and  scarring  result,  which  become  less  noticeable  as 
the  child  grows  older.  Sometimes  alopecia  results  from  cicatrices  on  the 
scalp ;  the  free  border  of  the  lips  or  the  angles  of  the  mouth  may  be 
partially  destroyed. 

The  pustular  eruption  may  or  may  not  be  associated  with  some  other 
form,  the  vesicular  being  seen  with  it  most  frequently.  When  a  second 
pustular  eruption  is  developed  within  the  first  three  or  four  years  of  the 


HEREDITARY  SYPHILIS.  935 

disease,  it  is  apt  to  be  much  more  limited  in  extent  than  the  first,  but  in 
other  respects  is  precisely  similar. 

Furuncular  Eruptioyis. — As  early  as  the  sixth  month  or  as  late  as  the 
third  year  crops  of  furuncles  may  appear,  constituting  the  sole  symptom 
of  hereditary  syphilis  or  associated  with  other  lesions.  If  symmetrically 
arranged,  as  they  usually  are,  they  are  quite  numerous  ;  if  irregularly 
distributed,  they  are  few.  They  differ  in  some  respects  from  ordinary 
furuncles. 

Their  bases  are  usually  compact,  well  defined,  and  of  a  dull  coppery- 
red  color.  Their  formation  is  slow  and  without  signs  of  active  inflamma- 
tion. They  begin  as  a  small  nodule  in  the  corium,  and  gradually  increase 
to  the  size  of  half  a  nutmeg.  A  superficial  ulcer  forms  at  the  summit  of 
the  nodule,  and  a  mass  of  slough  comes  away,  leaving  a  deep  cavity  with 
irregular,  unhealthy  walls  and  everted  discolored  margins,  which  may 
remain  in  a  sluggish  condition  for  many  weeks  or  may  increase  in  dimen- 
sions. The  discharge  is  scanty  and  offensive.  The  duration  of  these 
lesions  is  from  one  to  several  months,  and  repair  is  often  followed  by 
permanent  cicatrices. 

Several  older  writers  have  referred  to  certain  ulcers  about  the  heel 
and  ankles  as  being  diagnostic  of  hereditary  syphilis.  These  ulcers  are 
simply  the  results  of  pustules  or  bullae,  which  are  often  developed  in  those 
situations,  and  are  liable  to  irritation,  which  renders  them  very  persistent. 

The  Bullous  Syphilide — Pemphigus. — This  eruption,  sometimes  seen 
at  birth  and  sometimes  a  month  or  six  weeks  after  birth,  is  always  indic- 
ative of  a  severe  form  of  hereditary  syphilis,  and  is  frequently  a  pre- 
cursor of  death.  As  regards  its  situation,  it  resembles  the  pustular 
syphilide,  but  the  palms  of  the  hands  and  the  soles  of  the  feet  are  most 
frequently  attacked,  the  lower  extremities  being  most  extensively  in- 
volved, while  upon  the  trunk  the  bullae  are  sparsely  scattered. 

Diffuse  infiltration,  ulceration,  and  the  formation  of  fissures  may 
attend  the  development  of  this  eruption  upon  the  thighs  and  buttocks 
and  upon  the  extremities.  It  may  accompany  pustules  and,  less  fre- 
quently, one  or  more  of  the  other  syphilides,  is  generally  copious,  and  is 
always  symmetrical.  The  bullae  are  developed  rapidly,  and  their  seror 
purulent  contents  soon  become  purulent.  They  are  surrounded  by  a  rim 
of  thickened  integument  of  a  coppery  color,  and,  unlike  other  forms  of 
pemphigus  in  children,  lack  uniformity  of  shape,  some  being  conical, 
others  rounded,  and  still  others  flattened. 

Although  they  are  developed  rapidly,  the  subsequent  course  of  bullae 
is  chronic.  After  having  been  ruptured  their  progress  is  similar  to  that 
of  pustules.  This  syphilide  differs  from  every  other  form  of  eruption  in 
being  limited  to  a  single  outburst,  rarely  or  never  relapsing. 

Tlie  Tubercular  Syphilide. — This  lesion,  much  rarer  in  hereditary 
than  in  acquired  syphilis,  may  occur  as  early  as  the  sixth  month,  or,  as  a 
second  attack,  may  be  met  with  several  years  after  birth.  The  tubercles 
begin  as  deeply-seated  papules  or  as  small  movable  nodules,  in  the  latter 
case  greater  depth  of  tissue  being  involved.  The  skin  soon  becomes 
implicated,  and  a  sharply-defined  tumor,  from  a  quarter  of  an  inch  to  an 
inch  or  more  in  diameter,  results,  which  may  disappear  leaving  no  trace, 
or  it  may  break  down  into  an  ulcer  wliich  is  very  persistent  and  demands 
local  as  well  as  constitutional  treatment. 


936  SYPHILIS. 

Regions  where  the  connective  tissue  is  loose  and  abundant  are  the 
favorite  seat  of  tubercles  of  the  largest  size.  Their  surface  sometimes 
becomes  scaly,  and  the  eruption  then  resembles  psoriasis.  Similar  erup- 
tions are  also  seen  in  scrofulous  children,  but  the  greater  surrounding 
hypersemia,  Avhich  is  of  a  bluish  rather  than  a  coppery  color  in  the 
scrofulous  affection,  and  the  points  already  given  in  the  description  of 
ulcerations  of  acquired  syphilis,  may  aid  in  the  diagnosis. 

Crummata  and  Gummatous  Ulcers. — These  lesions  sometimes  appear 
as  early  as  the  third  year,  but  generally  later,  even  as  late  as  the  twen- 
tieth year.  After  this  period  it  is  not  usual  for  ulcerations  to  have  the 
features  of  hereditary  syphilis,  typical  gummata  having  been  observed  by 
me  in  only  one  instance. 

The  course  of  these  lesions  in  hereditary  syphilis  is  similar  to  that  in 
acquired,  and  therefore  needs  no  additional  description. 

Affections  of  the  Mucous  Membranes. 

One  of  the  earliest  and  most  constant  symptoms  of  hereditary  syphilis 
is  coryza,  which  is  due  to  structural  changes  in  the  mucous  membrane  of 
the  nasal  passages.  A  few  days  before  the  appearance  of  general  mani- 
festations there  may  appear  a  serous  discharge  from  the  nostrils,  some- 
times trifling,  sometimes  so  excessive  as  to  impede  respiration,  especially 
during  sleep  and  in  the  act  of  nursing.  This  discharge  is  accompanied 
by  the  characteristic  "snuffling." 

The  nasal  secretion  soon  becomes  purulent,  bloody,  and  very  offen- 
sive, and  causes  swelling  and  excoriation  of  the  alge  nasi  and  upper  lip. 
Tenacious  crusts  composed  of  the  dried  secretions  form  on  the  inflamed 
surfaces,  causing  much  discomfort.  In  its  mildest  and  rarest  form  this 
affection  is  a  simple  erythema.  Generally,  ulceration  of  the  mucous 
membrane  ensues,  and  not  infrequently  the  disease  progresses  to  the 
bony  structures,  producing  necrosis,  with  perforation  or  even  entire  de- 
struction of  the  septum,  followed  by  striking  deformity. 

The  intensity  and  chronicity  of  specific  coryza,  the  limitation  of  the 
disease  to  the  nasal  passages,  and  the  coexistence  of  other  syphilitic 
manifestations  are  sufiicient  to  establish  the  difi'erential  diagnosis. 

Mucous  Patches  of  the  Mouth. — In  the  infant  these  lesions  often  lose 
their  characteristic  appearance  quite  early.  At  first  they  consist  of 
slightly  elevated  portions  of  mucous  membrane  with  whitish  surfaces  and 
surrounded  by  erythematous  areolae.  The  pearly  epithelial  covering 
may  be  soon  cast  off,  leaving  a  smooth  red  surface,  slightly  depressed, 
which  may  ulcerate.  The  regular  outline  of  the  round  or  oval  patches 
may  be  lost  and  a  number  coalesce,  thus  involving  a  considerable  extent 
of  surface,  which  may  be  superficially  ulcerated^  and  in  cachectic  subjects 
is  often  partially  covered  by  an  extremely  adherent  false  membrane  of  a 
pale  brown  color.  The  patches  frequently  become  hypertrophied  and 
resemble  condylomata  lata. 

In  the  early  course  of  hereditary  syphilis  very  many  distinct  mucous 
patches  may  be  counted ;  at  a  later  period  they  are  less  numerous,  but 
they  show  a  decided  tendency  to  relapse,  having  been  seen  by  me  as  late 
as  the  sixth  year. 

The  most  common  situations  of  this  lesion  are  the  angles  of  the  mouth, 


HEREDITARY  SYPHILIS.  937 

the  mucous  membrane  lining  the  cheeks,  the  pillars  of  the  fauces  and  the 
tonsils,  the  sides  and  frequently  the  dorsum  of  the  tongue,  and  also  very 
often  the  portions  of  the  gums  adjacent  to  the  teeth.  On  account  of  the 
difficulty  of  pharyngeal  examination  in  young  infants  we  cannot  state 
positively  the  frequency  of  the  invasion  of  this  region.  There  is  cer- 
tainly less  tendency  to  extensive  ulceration  of  the  pharynx  and  tonsils  in 
infants  than  in  adults.  At  the  angles  of  the  mouth  the  ulceration  is  often 
extensive  and  painful. 

The  serous  secretion  of  mucous  patches  is  rather  free,  and  quite  as 
infectious  as  that  of  the  initial  lesion.  Hence  the  necessity  of  their  early 
recognition,  and  of  measures  to  prevent  contagion.  Nursing  at  the  breast 
of  any  one  but  the  mother,  kissing  and  fondling,  must  be  prohibited,  and 
great  care  and  cleanliness  must  be  observed  in  the  use  of  bottles,  cups, 
etc.  The  infection  of  the  nurse  by  a  child  having  mucous  patches  of  the 
mouth  is  particularly  liable  to  occur  in  hospitals  and  in  lying-in  asylums. 
An  instance  of  this  mode  of  contagion  has  been  reported  by  me  in  a  paper 
in  which  this  question  is  fully  considered. 

Only  when  ulceration  exists,  or  Avhen  the  mucous  patches  are  compli- 
cated with  diphtheritic  membrane,  is  their  diagnosis  from  stomatitis, 
simple  or  parasitic,  attended  by  difficulty.  In  the  absence  of  distinctive 
features  in  the  history  and  on  the  body  of  the  child  our  decision  must  be 
based  on  the  local  appearances.  In  simple  stomatitis  the  inflammation  is 
generally  more  diffuse,  the  whole  tongue  in  particular  being  intensely 
affected,  and  often  covered  with  vesicles  which  are  not  seen  in  the  specific 
disease.  The  tendency  of  mucous  patches  to  development  at  the  angles 
of  the  mouth  is  a  valuable  point  in  diagnosis.  In  parasitic  stomatitis  the 
inflammation  is  less  localized  than  in  the  specific,  the  general  hypersemia 
is  greater,  and  the  false  membrane  has  a  whiter  color  and  a  more  patchy 
appearance.  In  both  forms  of  non-specific  stomatitis  the  sulci  between 
the  gums  and  cheeks  and  the  gums  themselves  are  often  involved,  rarely 
in  the  specific. 

The  history  of  the  case,  therefore,  and  the  comparatively  circum- 
scribed character  and  limited  distribution  of  mucous  patches,  will  enable 
us  to  make  a  diagnosis. 

Grummatous  Infiltrations. — These  lesions,  consisting  of  cellular  infil- 
tration of  the  mucous  membrane,  are  usually  developed  upon  the  hard 
palate  or  upon  the  posterior  pharyngeal  wall,  when  they  may  be  mistaken 
for  retro-pharyngeal  abscess.  They  are  rarely  seen  before  the  third  year 
of  life,  and  generally  occur  from  the  sixth  to  the  twelfth.  The  first  indi- 
cation of  their  formation  is  a  reddish  elevation  of  the  mucous  membrane, 
forming  a  round  or  oval  patch  from  half  an  inch  to  an  inch  and  a  half  in 
diameter,  which  increases  in  size  and  in  prominence  until  a  well-defined 
tumor  results.  Necrotic  changes  almost  invariably  occur  in  the  tumor, 
leaving  an  ulcer  with  sharply-cut,  undermined  edges  and  tenacious  green- 
ish secretion,  involving  the  mucous  membrane  even  to  the  subjacent  bone. 

Their  course  is  chronic,  with  slight  tendency  to  invade  surrounding 
parts.  Upon  the  hard  palate  they  give  little  trouble,  but  upon  the  wall 
of  the  pharynx  they  are  the  source  of  much  suffering  and  inconvenience 
in  swallowing.  The  health  may  be  further  impaired  by  the  copious  secre- 
tions and  the  noxious  gases  developed.  Repair  of  the  ulceration  is  fol- 
lowed by  cicatricial  contractions,  which  on  the  hard  palate  may  affect 


938  SYPHILIS. 

phonation,  and  on  the  wall  of  the  pharynx  may  interfere  with  deglutition. 
The  diagnosis  is  generally  easy. 

In  tuberculous  ulceration  of  the  hard  palate  the  process  is  more  active 
and  less  sharply  limited,  while  other  evidences  of  phthisis  exist.  Retro- 
pharyngeal abscess  is  much  more  acute  in  its  invasion  and  progress  than 
a  gummy  tumor,  and  in  the  latter  case  signs  of  pre-existing  syphilitic 
lesions  may  be  found.  In  all  cases  the  previous  history  of  the  patient 
must  be  learned. 

Affections  of  the  Larynx. 

In  the  early  periods  of  hereditary  syphilis  the  larynx  and  upper  air- 
passages  may  be  the  seat  of  simple  hypersemia,  of  mucous  patches,  or  of 
ulceration  involving  the  mucous  membrane,  or  even  the  cartilages,  to 
such  an  extent  as  to  result  in  stenosis. 

Coincident  with,  or  following,  gummatous  infiltrations  into  the  pharynx 
similar  lesions  may  attack  the  larynx.  In  6  cases  observed  by  Dr. 
George  M.  Lefferts  destruction  of  this  organ  in  varying  extent  was  found. 
In  3  cases  the  disease  was  limited  to  the  epiglottis,  which  in  2  was  totally 
destroyed,  and  in  1  there  was  loss  of  half  of  its  free  border.  In  1  of  the 
2  cases  of  total  destruction  the  ulceration  had  extended  to  the  right 
arytenoid  epiglottic  fold.  In  the  remaining  3  cases  there  was  general 
destruction  of  the  superior  laryngeal  tissues  with  resulting  stenosis.  In 
all  of  these  cases  there  was  greater  or  less  destruction  of  the  pharynx, 
and  the  laryngeal  afiection  was  probably  an  extension  of  the  morbid  pro- 
cess from  that  region.  Our  knowledge  being  as  yet  so  limited,  we  can- 
not, of  course,  state  that  the  laryngeal  affections  are  always  secondary  to 
those  of  the  pharynx,  though  the  histories  of  these  cases  warrant  that 
view.  It  remains  for  future  observation  to  determine  whether,  in  the 
course  of  hereditary  syphilis,  the  larynx  is  primarily  attacked,  with  or 
without  attendant  lesions  of  the  pharynx.  The  ages  of  the  affected 
children  varied  between  ten  and  eighteen  years,  and  the  histories  of  all 
of  them  gave  evidence  of  inherited  syphilis. 

Like  gummatous  affections  of  the  pharynx,  those  of  the  larynx  belong 
to  the  late  manifestations  of  the  disease.  Like  them,  also,  their  course 
is  quite  rapid,  and  unless  promptly  checked  they  produce  great  deformity. 
Their  symptoms  are  a  varying  degree  of  hoarseness  and  even  total  loss  of 
voice,  with  difficulty  of  respiration  in  the  more  severe  cases.  Iodide  of 
potassium  in  full  doses  should  be  given.  These  affections  are  quite  rare, 
and  their  existence  is  not  even  mentioned  in  most  text-books. 

Dr.  J.  H.  Mackenzie,^  from  a  personal  study  of  one  hundred  and  fifty 
cases,  and  from  those  in  literature,  states  that  these  lesions  are  not  rare, 
and  may  be  observed  at  any  period  of  the .  disease,  but  that  the  most 
common  period  of  invasion  is  in  the  first  six  months  after  birth.  In  the 
throat  the  most  frequent  seat  of  invasion  is  the  palate,  more  especially 
the  hard  palate.  Then,  in  order  of  frequency,  are  the  fauces,  naso- 
pharynx, the  posterior  pharyngeal  wall,  the  nasal  fossae,  the  septum 
narium,  the  tongue,  and,  last,  the  gums.  These  ulcers  show  a  tendency 
to  centrality  of  position,  and  are  prone  to  be  followed  by  caries  and 
necrosis.  The  prognosis,  according  to  Mackenzie,  is  largely  dependent 
^  "  Congenital  Syphilis  of  the  Throat,"  Am.  Journal  Med.  Sciences,  Oct.,  1880. 


HEREDITARY  SYPHILIS.  939 

upon  the  age  of  the  chHd,  being  most  grave  in  the  very  young.  While 
deep  ulceration  of  the  larynx  is  at  all  periods  serious,  those  of  the 
pharyngo-laryngeal  region  are  especially  so,  and  are  usually  followed  by 
death  when  they  appear  within  the  first  year  of  life.  Later  in  life  these 
lesions  are  much  more  amenable.  Mackenzie  recommends  for  acute 
laryngeal  syphilis  mercurial  inunctions  over  the  thyroid  body,  the  in- 
halation of  calomel  and  iodate  of  zinc  in  the  form  of  vapor,  and  the 
heroic  use  of  iodide  of  potassium.  In  very  urgent  cases  tracheotomy 
must  be  resorted  to.  In  chronic  cases  the  mixed  treatment  may  be  used 
with  benefit.  This  author  speaks  highly  of  the  beneficial  results  ob- 
tained in  the  use  of  iodoform  locally,  and  of  the  iodate  of  zinc  in  vapor 
form. 

Affections  of  the  Lungs. 

Interstitial  cell-proliferation,  complicated  in  some  instances  with  gum- 
matous infiltration,  are  the  lesions  usually  found  in  hereditary  syphilitic 
infants. 

When  the  lesions  are  extensive  and  fully  developed  the  lung  is  re- 
duced in  size,  increased  in  consistency,  and  when  cut  is  found  to  be  firmer 
and  less  vascular  than  normal.  Scattered  upon  the  surface  of  the  lung 
and  through  its  substance,  on  the  smaller  vessels  and  bronchi,  which  are 
much  thickened  and  look  like  yellow  cords,  are  numerous  nodules  of 
various  sizes.  The  more  recent  are  small  and  of  a  grayish-pink  color ; 
the  older  ones  may  be  the  size  of  a  filbert,  are  light  yellow,  and  when 
excised  exude  a  thin  milky  fluid,  while  serum  escapes  from  the  lung-sub- 
stance. The  former  appear  to  be  homogeneous,  while  the  latter  are 
granular  and  may  contain  pus.  The  pulmonary  pleura,  especially  in  the 
vicinity  of  the  nodules,  is  thickened  and  opaque. 

The  entire  lung  is  usually  more  or  less  involved  in  the  morbid  pro- 
cesses, though  in  some  cases  the  nodules  may  be  few  and  confined  to  a 
portion  of  a  single  lobe. 

The  first  step  in  the  process  is  evidently  active  congestion,  followed 
by  cell-proliferation  around  the  bronchioles,  and  in  a  less  degree  in  the 
walls  of  the  capillaries,  resulting  in  partial  or  complete  obstruction  of 
their  lumen  and  consequent  destruction  of  the  function  of  the  lung  tissue. 

The  nodules,  which  represent  one  or  more  plugged  and  distended 
alveoli,  consist  of  a  mass  of  connective-tissue  cells,  fibrous  tissue,  granu- 
lar debris,  and  perhaps  some  gummatous  tissue.  Like  all  new  growths, 
they  are  liable  to  degeneration,  fatty  or  caseous,  and  may  contain  pus  in 
their  centres.  The  pleural  changes  are  due  to  hypertemia  and  increase 
of  fibrous  tissue.  True  gummatous  nodules  have  been  found  by  some 
observers.  While  two  forms  of  nodules,  the  gummatous  and  the  connec- 
tive tissue,  may  exist,  their  gross  and  microscopical  appearances  are  in 
some  cases  so  very  similar  that  it  is  impossible  to  distinguish  them.  The 
gray  hepatization  of  pneumonia  resembles  syphilitic  induration,  but  may 
be  recognized  by  the  greater  succulence  and  less  resistance  of  the  lining 
tissue  and  by  the  escape  of  true  pus  on  pressure.  Owing  to  the  nature 
and  extent  of  these  pulmonary  lesions  life  is,  in  most  cases,  destroyed. 
They  may,  however,  exist  in  a  moderate  and  localized  form  without  such 
a  result. 

A  child  five  months  old  who  had  passed  through  the  earlier  period  of 


940  SYPHILIS. 

its  disease,  having  had  a  papular  and  pustular  eruption,  developed  bron- 
cho-pneumonia, with  dulness  on  percussion,  imperfect  expansion,  and 
harsh  respiratory  sounds,  with  slight  crepitation  at  the  right  apex  and 
over  lower  lobe  of  the  left  lung.  Although  there  was  excessive  cough,  the 
increase  in  pulse-rate  and  in  temperature  Avas  very  slight,  and  no  acute 
symptoms  of  any  kind  were  exhibited.  This  condition  lasted  fully  six 
Aveeks,  and  finally  yielded  to  the  mixed  treatment  in  gradually  increasing 
doses.  I  examined  this  infant  six  months  later,  and  there  Avere  no  per- 
ceptible traces  of  the  lesion  in  either  lung.  I  have  seen  tAvo  cases,  essen- 
tially similar  both  in  course  and  method  of  cure,  in  which  lesions  of  the 
bones,  joints,  eyes,  and  integument  Avere  also  present. 

While  these  changes  usually  take  place  in  intra-uterine  life,  Ave  may 
find  them  at  any  time  when  the  syphilitic  diathesis  is  active,  but  most 
frequently  Avithin  the  first  eighteen  months  of  life.  They  are  not  attended 
by  much  systemic  reaction,  and  may  be  developed  in  any  portion  of  the 
lungs  either  symmetrically  or  unilaterally. 

Deformities  of  the  Teeth. 

The  teeth  sometimes  are  much  changed  in  hereditary  syphilis. 

Mr.  Hutchinson,  who  first  described  this  affection,  says:  "As  diagnos- 
tic of  hereditary  syphilis  various  peculiarities  are  often  presented  by  the 
other  teeth,  especially  the  canines,  but  the  upper  central  incisors  are  the  test 
teeth.  When  first  cut  these  teeth  are  usually  short,  narrow  from  side  to 
side  at  their  edges,  and  very  thin.     After  a  while  a  crescentic  portion 

Fig.  229. 


^^^^ 

''"^"^'-^^.,. ,.«««« 

Mi 

'^-^^^^ 

^ 

:^...I.4^^^^^^^-„  :   ■-       r 

Hutchinson's  teeth. 

from  their  edges  breaks  aAvay,  leaving  a  broad,  shalloAV,  vertical  notch 
Avhich  is  permanent  for  some  years,  but  betAveen  twenty  and  thirty  usually 
becomes  obliterated  by  the  premature  Avearing  doAvn  of  the  tooth.  The 
tAvo  teeth  often  converge,  and  sometimes  they  stand  widely  apart.  (See 
Pig.  229.)  In  certain  instances  in  Avhich  the  notching  is  either  Avholly 
absent  or  but   slightly  marked   there  is   still  a  peculiar  color  ('  a  dirty 


HEREDITARY  SYPHILIS.  941 

brownish  hue  resembling  that  of  bad  size  '  ^),  and  a  narrow  squareness  of 
form,  which  are  easily  recognized  by  the  practised  eye."  The  first  set  of 
teeth  do  not  exhibit  this  malformation. 

Affections  of  the  Peritoneum. 

Primary  morbid  changes  are  rarely,  if  ever,  seen  in  the  peritoneum. 
Thirty-one  cases  in  which  general  or  partial  uncomplicated  inflammation 
of  this  membrane  was  distinguished  have,  indeed,  been  reported  by  Simp- 
son, who  claims  the  existence  of  true  peritonitis. 

The  syphilitic  origin  of  many  of  these  cases  was,  however,  doubtful, 
and  in  some  the  exact  condition  of  the  viscera  was  not  observed.  Chronic 
adhesive  peritonitis,  more  or  less  localized  and  unattended  by  marked 
symptoms,  often  occurs,  originating  in  some  syphilitic  visceral  change, 
particularly  of  the  liver. 

Affections  of  the  Intestines. 

The  intestines  are  frequently  the  seat  of  microbic  invasion  early  in 
hereditary  syphilis,  and  from  this  cause  gastric  and  bowel  troubles  are 
developed.     The  intestines  may  be  the  seat  of  structural  change. 

Forster^  has  described  a  fibroid  degeneration  of  Peyer's  patches  in  a 
syphilitic  infant  who  died  six  days  after  birth  with  lobular  pneumonia 
and  purulent  bronchitis.  The  glandular  structure  of  the  patches  had 
been  replaced  by  elevated  grayish-red  masses,  with  smooth  surface  and 
yellowish  centre,  composed  of  nuclei,  cells,  and  fibres  of  connective  tissue. 
Similar  observations  have  been  made  by  Eberth,^  Roth,*  and  Oser,^  who 
have  described  an  afi'ection  consisting  of  multiple  circumscribed  indura- 
tions, varying  in  size  and  generally  circular,  situated  on  a  level  with 
Peyer's  patches  and  the  solitary  glands,  the  surrounding  mucous  mem- 
brane being:  smooth  and  slate-colored  or  more  or  less  ulcerated.  The 
latter  condition  resembles  that  of  a  dry  eschar,  but  leaves  an  ulcer  with 
a  bright  lardaceous  base.  This  lesion,  consisting  of  an  infiltration  of  cells 
similar  to  those  of  lymphatic  glands  and  of  connective  tissue,  is  usually 
limited  to  the  submucous  stratum. 

•  Affections  of  the  Liver. 

The  functional  activity  of  the  liver  in  infancy  renders  it  subject  to 
profound  structural  changes,  which  consist  chiefly  of  connective-tissue 
infiltration.  The  credit  of  first  calling  attention  to  this  important  lesion 
belongs  to  Gubler,^  from  whose  writings  the  following  clear  and  complete 
description  is  obtained : 

"  When  the  lesion  has  reached  its  maximum  the  liver  is  sensibly  hyper- 
trophied,  globular,  and  hard.     It  is  resistant  to  pressure,  and  even  when 

'  "  On  the  Means  of  Recognizing  the  Subjects  of  Inherited  Syphilis  in  Adult  Life," 
Medical  Times  and  Gaz.,  Lond.,  Sept.  11,  1858,  p.  265. 

'^  Wilrzb.  med.  Zlschr.,  Band  iv.  part  1,  18G3. 

^  "Ueber  syph.  Enteritis,"  Arch.  f.  path.  Anal.,  etc.,  xl.  p.  326,  1867. 

*  "Enteritis  syphilitica,"  ihid.,  xliii.  p.  298. 

^  "  Fiille  von  Enteritis  syphilitica,"  Arch.  f.  Dcrmnt.  u.  Syph.,  in.,  1870,  pp.  27  et  seq. 

^  "  M^moire  sur  une  nouvelle  Affection  du  Foie,  liee  a  la  Syphilis  h^r^ditaire  chez 
les  Enfants  du  premier  age/'  Gaz.  med.  de  Paris,  1852. 


942  SYPHILIS. 

torn  by  the  fingers  its  surface  receives  no  indentation  from  them.  The 
elasticity  of  the  organ  is  such  that  if  a  wedge-shaped  piece  taken  from  its 
thin  edge  be  pressed  it  escapes  like  a  cherry-stone  and  rebounds  from  the 
ground.  When  cut  into  it  creaks  slightly  under  the  scalpel.  The  distinct 
nature  of  its  two  substances  has  completely  vanished.  On  a  uniform 
yellowish  ground  a  more  or  less  close  layer  of  small,  white,  opaque  grains 
is  seen,  having  the  appearance  of  grains  of  semola,  with  delicate  arbores- 
cences  formed  of  empty  blood-vessels.  On  pressure  no  blood  is  forced 
out,  but  only  a  slightly  yellow  serum,  which  is  derived  from  the  albumin. 
Gubler  has  only  three  times  seen  the  change  carried  to  this  extent.  It  is 
most  frequently  much  less  marked.  Thus,  the  tissue  of  the  organ  is  firm, 
without  having  that  extreme  hardness  and  yellow  color,  which  might 
admit  of  comparison  to  some  kinds  of  flint.  The  interior  of  the  organ 
presents  rather  an  indefinite  color,  shaded  with  yellow  or  brownish-red, 
more  or  less  diluted ;  but  in  no  part  is  the  parenchyma  quite  healthy  in 
appearance. 

"  Again,  the  change  may  be  found  in  circumscribed  parts  only.  Gubler 
has  seen  it  confined  to  the  left  lobe,  to  the  thin  edge  of  the  right  lobe, 
and  to  the  lobulus  Sjngeln.  He  ascertained  by  injections  that  in  the 
indurated  tissue  the  vascular  network  is  almost  impermeable,  that  the 
capillary  vessels  are  obliterated,  and  that  even  the  calibre  of  the  larger 
vessels  is  considerably  diminished.  Microscopical  examination  enabled 
him  to  discover  the  cause  of  this  disposition  by  revealing  in  the  altered 
tissue  of  the  organ,  in  every  degree  of  change,  the  presence  of  fibro-plastic 
matter,  sometimes  in  considerable,  sometimes  in  enormous,  quantity.  In 
the  portions  intervening  between  the  diseased  parts  the  cells  of  the  hepatic 
parenchyma  maintain  all  the  characteristics  of  their  normal  condition. 
The  physical  consequences  of  the  deposit  of  these' elements  are  an  increase 
in  the  volume  of  the  liver,  the  compression  of  the  cells  of  the  acini,  the 
obliteration  of  the  vessels,  and  the  consequent  cessation  of  the  secretion 
of  bile.  In  all  the  subjects  examined  after  death  by  Gubler  he  always 
found  the  bile  in  the  gall-bladder  of  a  pale  yellow  color  and  very  sticky ; 
that  is  to  say,  very  rich  in  mucus  and  very  poor  in  coloring  matter." 

Later  observations  confirm  the  results  obtained  by  Gubler,  and  add 
much  to  our  knowledge  of  the  microscopic  changes  found  in  the  liver. 
The  primary  changes  are  vascular.  The  walls  of  the  vessels  are  much 
thickened,  and  around  the  tunica  adventitia  numerous  nuclei  and  cells, 
with  an  abundance  of  fine  fibrillar  connective  tissue,  are  found.  The 
calibre  of  some  of  the  vessels  is  diminished,  and  that  of  others  is  entirely 
obliterated.  Moreover,  various  stages  of  fatty  degeneration  of  the  hepatic 
cells  are  found.  Increase  of  connective  tissue  is  observed  in  the  parenchy- 
matous network  of  the  organ  and  in  the  capsule,  which  may  be  thickened 
either  in  its  entire  extent  or  especially  on  its  upper  surface.  Adhesions 
may  form  between  the  convex  surface  and  the  diaphragm  or  the  perito- 
neum of  the  anterior  abdominal  wall.  Certain  changes  in  the  veins  have 
been  described  by  Schiippel,^  under  the  title  "  peripylephlebitis  syph- 
ilitica," which  are  undoubtedly  a  part  of  the  morbid  process. 

Gummous  hepatitis  in  hereditary  syphilis  is  admitted  by  several  au- 
thors. There  are  two  forms,  one  consisting  of  numerous  minute  tumors 
scattered  through  the  liver,  called  by  Wagner  miliary  syphilome ;  and  the 

^  Archiv  der  Ileilkunde,  xi.,  1870,  pp.  74  et  seq. 


HEREDITARY  SYPHILIS.  943 

other  consisting  of  one  or  more  large  circumscribed  tumors,  such  as  are 
found  in  the  adult.  Either  of  these  lesions  may  be  accompanied  by  the 
fibro-plastic  infiltration  of  Gubler. 

The  clinical  history  and  microscopic  anatomy  of  this  affection  have 
been  carefully  studied  by  Rochebrune/  a  former  student  of  Gubler.  This 
observer  thinks  that  a  diagnosis  may  be  made  from  the  following  symp- 
toms :  A  deep  wine-colored  venous  stasis  and  oedema  of  the  lower  ex- 
tremities, often  accompanied  by  pemphigus ;  ascites,  due  to  mechanical 
obstruction  of  the  circulation,  as  in  cirrhosis ;  a  more  or  less  pronounced 
chloro-an^mic  appearance  of  the  face  ;  and  the  presence  in  the  urine  of 
albumin  and  h8emato-globulin.  Vomiting  may  occur,  and  constipation, 
alternating  with  diarrhoea,  has  been  observed.  Icterus,  symptomatic  of 
this  affection,  has  not  been  noticed.  A  fatal  result  commonly  ensues  in 
the  early  weeks  of  the  child's  existence. 

A  case  of  fatal  icterus  is  reported  by  Bar  and  Renon^  in  a  new-born 
child  whose  mother  was  syphilitic.  At  the  autopsy  the  liver  was  found 
to  be  hypertrophied  and  the  seat  of  gummata.  Portions  of  tissue  taken 
from  the  liver,  spleen,  and  some  blood  when  cultivated,  showed  very 
clearly  the  proteus  vulgaris.  This  organism  had  infiltrated  the  intra- 
cellular space  of  the  liver. 

Affections  of  the  Spleen. 

In  cachectic  children  and  in  those  in  whom  the  disease  assumes  a 
severe  form  more  or  less  hypertrophy  of  the  spleen  is  sometimes  observed, 
usually  during  the  early  stages  of  syphilis.  The  enlargement  is  rapid, 
the  size  of  the  organ  often  being  quadrupled  in  two  or  three  weeks. 
This  condition  may  persist,  according  to  Barlow,  even  for  a  year,  while, 
on  the  other  hand,  mercurial  treatment  induces  its  rapid  subsidence. 

Although  we  are  ignorant  of  the  pathology  of  this  affection,  the  acute- 
ness  of  its  invasion  and  its  rapid  involution  suggest  hypersemia  rather 
than  permanent  cell-growth.  Still,  it  is  quite  possible  that  cellular  hy- 
perplasia may  take  place  in  the  spleen,  as  it  does  in  the  liver.  Lance- 
reaux  says  that  the  hypertrophied  spleen  is  firm  and  smooth,  that  it  some- 
times becomes  adherent  to  other  organs,  that  the  condition  is  often  a 
simple  multiplication  of  cell-elements,  and  that  affections  of  the  liver,  and 
perhaps  of  the  lymphatic  glands,  generally  coexist. 

Gee,  who  first  described  the  affection  in  1867,  stated  that  it  occurs  in 
at  least  one-half  the  cases  of  hereditary  syphilis,  and  in  one-fourth  hyper- 
trophy is  excessive  and  accompanied  by  a  similar  condition  of  the  liver 
and  the  lymphatics.  In  two  post-mortem  examinations  he  found  enlarge- 
ment and  induration,  without  evidence  of  gummatous  infiltration  or  of 
amyloid  degeneration. 

In  view  of  its  gradual  diminution  as  the  general  condition  of  the  child 
improves,  splenic  hypertrophy  is  regarded  by  Gee  and  Barlow  as  an 
evidence  of  the  severity  of  the  syphilitic  cachexia. 

According  to  Parrot,^  there  are  two  forms  of  splenic  lesion  caused  by 
hereditary  syphilis.     The  first  is  an  hypertrophy,  in  which  the  organ  may 

1  Thhe  de  Paris,  1874. 

^  Comptes  Rendns  de  la  Societc  de  Biologie,  May  24,  1895. 

3  Mouvement  Med.,  Paris,  23  Nov.,  1872. 


944  SYPHILIS. 

become  three  times  its  natural  size,  which,  he  thinks,  is  a  secondary  re- 
sult of  portal  obstruction  caused  by  diffuse  infiltration  of  the  liver,  the 
spleen  then  being  compelled  to  serve  as  a  reservoir  of  the  blood.  The 
second  form  is  an  inflammation  resulting  in  the  formation  of  false  mem- 
branes around  the  capsule  of  the  organ.  Parrot  is  not  positive  regarding 
the  future  course  of  these  lesions,  but  is  inclined  to  attribute  to  them 
certain  lardaceous  degenerations  found  later  in  the  life  of  children  who 
suffered  from  hereditary  syphilis  at  their  birth.  He  thinks  that  these 
lesions  were  the  cause  of  rupture  of  the  spleen  in  the  case  of  a  new-born 
child  with  hereditary  syphilis,  the  details  of  which  were  reported  by 
Charcot  in  1865. 

Affections  of  the  spleen  have  been  studied  also  by  Birch-Hirschfeld  ^ 
in  thirty-two  cases  of  hereditary  syphilis.  He  found  the  organ  much  en- 
larged, but  was  unable  Avith  the  microscope  to  discover  any  abnormality. 
The  spleen  of  a  foetus  born  in  a  macerated  condition  was  soft  and  of  a 
dirty-violet  color.  In  case  of  still-birth  or  of  death  soon  after  birth  the 
density  of  the  organ  was  increased  and  its  color  was  dark  brown.  Two 
forms  of  lesion  of  the  spleen  are  therefore  recognized  by  Hirschfeld :  in 
one  the  organ  is  indurated  and  of  a  dark-brown  color ;  in  the  other  it  is 
soft  and  pale. 

Lesions  of  the  Pancreas. 

The  changes  in  the  pancreas  caused  by  hereditary  syphilis  have  been 
carefully  studied  by  Osterloh,  Oedmansson,  Wegner,  and  most  exten- 
sively by  Birch-Hirschfeld.^  The  last  mentioned  observer  found  in 
thirteen  syphilitic  children  who  died  during  or  soon  after  birth  varying 
degrees  of  morbid  change.  In  the  most  marked  cases  the  organ  was 
much  enlarged,  its  weight  was  doubled,  its  tissue  firm,  and  on  section  it 
presented  a  glistening  Avhite  appearance,  somewhat  like  that  of  scirrhus, 
the  granular  substance  being  very  indistinct.  Under  the  microscope  the 
interstitial  connective  tissue,  especially  between  the  larger  lobules,  was 
found  greatly  increased.  Portions  of  lobules  were  compressed,  and  their 
epithelium  was  atrophied  and  in  a  state  of  fatty  degeneration.  The 
vessels  of  the  interstitial  tissues  Avere  foAV  and  their  Avails  were  thick- 
ened. This  extreme  degree  of  the  process  Avas  observed  in  seven  cases ; 
in  six  the  changes  were  less  perceptible,  and  the  lobules  could  be  dis- 
tinctly seen,  although  the  organ  was  enlarged  and  rather  denser  than 
normal.     The  head  of  the  organ  Avas  more  altered  than  the  tail. 

Hirschfeld  thinks  that  this  marked  change  begins  late  in  intra-uterine 
life,  since  it  is  rarely  found  in  macerated  foetuses  prematurely  born. 
The  most  marked  case  Avas  that  of  a  child  Avho  died  five  months  after 
birth. 

It  is  probable  that  this  degeneration  of  the  pancreas  is  one  of  the 
causes  of  gastro-intestinal  disturbances  in  hereditary  syphilis. 

Affections  of  the  Kidney. 

Our  knoAvledge  of  the  condition  of  the  kidney  in  hereditary  syphilis 
is  verv  limited.     Lancereaux  states  that  he  has  found  connective-tissue 

1  "Zur  pathologischen  Anatomie  der  hered.  Syphilis,"  Arch.  d.  Heil/c.,  Leipz.,  Feb., 
1875. 

*  "Beitr.  zur  path.  Anat.  der  hered.  Svfh.  Neugebornen,"  Arch,  d  HedL,  Leipz.,  Feb. 
6,  1870. 


HEREDITARY  SYPHILIS.  945 

proliferation  with  fatty  degeneration  of  the  epithelium  lining  the  tubuli 
uriniferi.  The  organs  were  firm  and  of  a  yellow  color.  Bradley 
reports  the  case  of  a  syphilitic  child  four  months  old,  with  dropsy  and 
albuminuria,  who  was  cured  by  mercurial  treatment. 

The  studies  on  the  pathological  anatomy  of  the  kidney  by  Parrot 
show  that  these  organs  are  studded  with  numerous  small  tumors,  varying 
in  size  from  a  pin's  head  to  a  cherry-stone.  The  smallest  Avere  white, 
and  the  larger  were  yellow  at  their  periphery  and  reddish  in  their  centre. 
In  some  spots  there  was  partial  destruction  of  the  renal  tissue,  and  there 
were  also  infarctions.  The  lesion  consists  of  a  circumscribed  or  diffuse 
infiltration  of  round  embryonic  cells,  with  others  of  fusiform  shape,  into 
the  connective-tissue  framework,  followed  by  compression  or  destruction 
of  the  tubules  and  colloid  degeneration  of  their  epithelium.  In  the 
early  stages  of  this  affection  the  organs  become  much  enlarged,  and 
Molliere  reports  a  case  in  which  they  were  found  to  be  twice  their  nor- 
mal size.  Gradual  atrophy  follows  degeneration  of  the  new  cells,  and 
the  organs  may  finally  become  much  reduced  in  size. 

Affections  of  the  Suprarenal  Capsules. 

Lancereaux  has  noted  enlargement  of  these  organs  in  a  large  number 
of  cases.  Virchow  has  also  observed  it,  and  speaks  of  a  case  in  which 
complete  fatty  degeneration  was  found — a  condition  met  with  also  by 
Hulke.  According  to  Lancereaux,  proliferation  of  young  connective- 
tissue  cells  in  the  cortical  substance  has  been  found  by  Barensprung. 
In  a  case  in  which  the  left  suprarenal  capsule  was  enlarged  and  adhe- 
rent to  the  diaphragm  Hennig  found  its  contents  gelatinous. 

Affections  of  the  Testicles  and  their  Appendages. 

Though  it  was  formerly  stated  that  the  testicles  are  not  affected  in 
hereditary  syphilis,  there  is  to-day  so  much  evidence  from  many  careful 
observers  that  syphilis  does  attack  these  organs  in  hereditarily  infected 
children  that  it  is  almost  unnecessary  to  mention  this  old-time  contention. 
My  own  experience  is  sufficient  to  warrant  me  in  offering  a  succinct  ac- 
count of  these  affections,  but  I  have  availed  myself  of  a  rich  literature  in 
order  to  more  thoroughly  elaborate  this  subject. 

The  most  common  aflFection  is  orchitis,  and,  while  inflammation  of  the 
epididymis  is  sometimes  observed,  it  is  almost  always  as  a  complication  of 
orchitis.  Involvement  of  the  vas  deferens  is  quite  uncommon,  but  occurs 
as  a  complication  of  the  epididymo-orchitis.  Neither  of  these  affections  is 
really  of  frequent  occurrence,  as  shown  by  the  fact  that  in  literature 
something  like  fifty  cases  are  more  or  less  fully  described  or  alluded  to. 
Testicular  affections  are  among  the  rarer  manifestations  of  hereditary 
syphilis.  Pathologically,  the  testicular  lesion  has  been  recognized  by 
HutineP  as  early  as  the  ninth  and  twenty-third  days  of  birth.  Clin- 
ically, however,  it  is  seen  generally  in  children  from  three  to  six  and 
twelve  months  old,  and  in  diminishing  frequency  in  the  second  or  third 
years.     Somewhat  exceptionally  it  is  seen  in  later  years,  as  in  my  sixth 

'  "  Etude  sur  les  Lesions  syphilitiques  du  Testicule  chez  les  Jeunes  Enfants,"  Rev. 
mens,  de  Med.  et  de  Chir.,  Paris,  Feb.,  1878,  pp.  107  et  aeq. 


946  SYPHILIS. 

case  at  fifteen,  and  in  a  case  mentioned  by  Fournier  ^  at  twenty-four.  My 
own  experience  goes  to  show  that  these  lesions  occur  in  children  the  off- 
spring of  one  or  both  parents  in  a  tolerably  active  condition  of  syphilis, 
and  in  many  of  the  reported  cases  the  conditions  were  similar. 

The  orchitis  begins  slowly  and  insidiously.  Xo  pain  is  felt  by  the 
child,  and  attention  is  not  called  to  the  diseased  organ  until  its  dimensions 
have  become  so  marked  as  to  attract  the  notice  of  the  mother  or  nurse. 
As  usually  seen  in  practice  the  testis  is  of  the  size  of  a  pigeon's  egg,  of  a 
small  marble,  of  a  shelled  filbert,  of  an  olive,  or  even  of  a  walnut,  but  it 
is  usually  of  an  ovoid  shape.  As  a  rule,  the  organ  is  not  large,  and  in 
the  majority  of  cases  reported  it  was  of  the  size  of  a  shelled  or  of  an 
unbroken  filbert.  In  other  words,  there  is  no  tendency  to  the  develop- 
ment of  conspicuously  large  tumors.  To  the  touch  the  swelled  testis  is 
hard  and  firm  (less  hard  and  ligneous  than  in  the  adult),  indolent,  pain- 
less, and  decidedly  heavy.  It  can  usually  be  handled  with  impunity.  In 
some  cases  there  is  concomitant  hyperemia  of  the  scrotum.  In  rather  rare 
instances  the  surface  of  the  tunica  albuginea  is  uneven  and  irregular,  and 
the  sensation  as  if  small  shot  or  split  peas  Avere  seated  in  its  superficies  is 
conveyed  to  the  touch. 

The  epididymis  may  be  slightly  or  considerably  enlarged  in  part  or  in 
whole.  The  swelling  is  smooth  and  firm,  and  pressure  upon  it  sometimes 
causes  pain.  The  enlargement  of  the  vas  is  similar  in  all  respects  to  that 
of  the  epididvmis.  The  fact  of  the  coincident  involvement  of  the  epi- 
didymis has  been  clearly  brought  out  microscopically  and  clinically  in 
an  admirable  paper  by  Carpenter.^ 

As  a  general  rule,  the  enlargement  of  the  epididymis  or  vas  is  an 
accompaniment  of  a  testicular  lesion.  Comby,^  however,  reports  the  case 
of  a  child  six  weeks  old,  the  subject  of  hereditary  syphilis,  in  whom  the 
epididymis  was  especially  involved.  This  would  seem  to  show  that  the 
epididymis  alone  may  be  attacked 

These  affections,  uninfluenced  by  treatment,  usually  run  an  uneventful 
course,  and  may  end  in  resolution  or  in  atrophy,  particularly  of  the  gland- 
substance.  This  was  well  shown  in  my  second  case,  in  which  the  testis 
was  reduced  to  a  small  mass  of  fibrous  tissue.  Lewin*  reports,  as  an 
instance  of  atrophy  of  the  testes  from  hereditary  syphilis,  the  case  of  a 
lad  eighteen  3'ears  old  whose  testicles  were  the  size  of  a  child;  he  was 
puerile  in  demeanor  and  looked  like  a  boy  of  fourteen.  Eeclus^  speaks 
of  a  case  of  a  patient  (age  not  stated),  considered  by  Parrot  and  Fournier 
to  be  the  victim  of  hereditary  syphilis,  in  whom  a  gland  of  the  size  of  a 
small  nut  and  of  great  firmness  was  present.  Facts  therefore  warrant  the 
statement  that  hereditary  syphilis,  like  traumatisms,  mumps,  and  varico- 
cele, may  lead  to  atrophy  of  the  testes.  As  a  general  rule,  it  may  be 
stated  that  atrophy  is  the  chief  form  of  degeneration  in  this  form  of 
orchitis.  In  scmew^hat  rare  instances  fungus  of  the  testes  is  observed, 
and  it  folloAvs  the  same  chronic,  rebellious  course  that  it  does  in  the  adult. 
Abscess  and  necrosis  of  the  testes  also  occur,  in  which  case  we  observe  a 

^  Op.  cit.,  p.  435. 

^  "Affections  of  the  Testicle  in  Hereditary  Syphilis,"  The  Practitioner,  Sept.,  1892,  pp. 
201  et  seq. 

*  Annalex  de  Derm,  et  de  Sijphll..  vol.  x.,  1889,  p.  706. 

*  "Ueber  Syphilis  hered.  tarda,  etc,"  Bert.  klin.  Wochens.,  Nos.  2  and  3,  1876. 

*  De  la  Syphilis  du  Testicule,  Paris,  1882,  pp.  149  et  seq. 


HEREDITARY  SYPHILIS.  '947 

sinus  in  the  scrotum  (which  may  be  much  inflamed)  which  leads  down  to 
a  pus-cavity  of  varying  size  in  the  gland  itself.  I  once  saw  in  consulta- 
tion a  case  of  this  kind  which  was  cured  by  careful  treatment.  If  treated 
early  and  vigorously,  resolution  may  be  brought  about  and  a  testis  more 
or  less  damaged  may  be  left.  It  is  always  well  to  try  energetic  local  and 
general  treatment  before  thinking  of  ablation. 

Hydrocele  is  a  more  frequent  complication  than  has  heretofore  been 
conceded.  It  may  be  slight  or  well  marked.  Its  existence  in  the  infant 
should  always  excite  interest,  and  its  origin  in  syphilis  or  tuberculosis  be 
established. 

Carpenter  reports  three  cases  of  hereditary  syphilis  in  which  there 
was  hydrocele  of  the  cord,  but  no  appreciable  testicular  lesion.  This 
aflFection  of  the  cord  might  be  a  coincident,  but  Carpenter  says  "  there  is 
just  a  probability  that  hydrocele  of  the  cord  may  in  some  instances  owe 
its  origin  to  congenital  syphilis." 

The  concomitants  of  these  testicular  affections  vary  according  to  the 
age  of  the  child  and  the  intensity  of  the  infection.  In  very  early  months 
roseola,  papular  syphilides,  mucous  patches,  eye,  ear,  and  bone  lesions  may 
be  also  present.  In  later  months  there  will  be  fewer  and  perhaps  no  con- 
comitants. But  there  may  be  bone  or  joint  lesions,  and  perhaps  cuta- 
neous or  mucous  lesions  in  sparse  and  limited  development. 

Diagnosis. — As  a  rule,  an  intelligent  study  of  a  case  of  testicular 
lesion  in  a  young  child  will  lead  to  a  correct  diagnosis.  It  is  necessary 
to  obtain  the  history  of  both  father  and  mother  if  possible,  and  then  that 
of  the  child.  In  the  early  months  of  hereditary  syphilis  it  may  quite 
generally  be  possible  to  gain  a  knowledge  or  observe  a  vestige  or  sequela 
of  some  characteristic  lesion  or  to  see  some  lesion  itself.  In  this  event 
the  diagnosis  will  be  easy.  When,  however,  for  any  cause  we  can  obtain 
no  information  concerning  the  father  or  mother,  and  the  child  is  free  from 
all  syphilitic  lesions  or  their  traces,  difficulty  is  experienced.  Then  we 
must  consider  the  character  of  the  tumor,  and  see  whether  it  conforms  to 
the  description  already  given.  Deschamps,^  as  well  as  Hutinel,  lays 
stress  on  the  fact  that  in  syphilis  the  testes  are  usually  both  involved, 
while  in  tuberculosis  commonly  but  one  is  affected.  This,  however,  can- 
not be  accepted  as  a  general  rule,  since  we  not  uncommonly  find  that  the 
syphilitic  affection  is  unilateral.  Then,  again,  too  much  stress  cannot  be 
laid  upon  the  condition  of  the  epididymis  and  vas.  In  syphilis  these 
appendages  may  be  moderately  involved  in  whole  or  in  part ;  in  tuber- 
culosis it  is  common  to  find  them  much  enlarged  and  sometimes  nodu- 
lated. When,  therefore,  we  see  a  case  in  which  there  is  a  unilateral 
swelling,  very  marked  enlargement  of  the  epididymis,  and  perhaps  of  the 
vas,  particularly  if  the  enlargement  is  rugose  or  nodulated,  and  when  the 
testicular  lesion  is  less  developed,  we  may  suspect  syphilis.  In  all  such 
cases  it  is  absolutely  necessary  to  examine  the  prostate  and  seminal 
vesicles  by  rectal  touch,  and  if  they  also  are  found  to  be  SAVollen,  the 
presumption  will  be  warranted  that  the  case  is  one  of  tuberculosis.  On 
the  other  hand,  freedom  of  these  structures  from  diseases  points  in  a 
measure  to  the  existence  of  syphilis. 

No  absolute  criterion  can  be  drawn  from  the  conditions  attending  the 

^  "  Tuberculose  du  Testicule  chez  les  Enfunts,"  Arch.  gen.  de  Med.,  1891,  vol.  i.  pp.  257 
et  seq. 


948  SYPHILIS. 

invasion  of  the  disease.  In  syphilis  the  enlargement  as  a  rule  takes 
place  slowly,  but  sometimes  rather  rapidly.  In  tuberculosis  the  invasion 
may  be  slow  and  insidious  also.  But  it  is  well  to  remember,  as  Jullien  ^ 
has  shown  in  his  admirable  article,  that  the  most  common  mode  of  inva- 
sion is  the  brusque  and  rapid,  attended  with  marked  inflammatory  symp- 
toms.    This  is  rarely,  if  ever,  seen  in  syphilis. 

While,  therefore,  in  most  cases  a  clear  diagnosis  may  be  made,  in- 
stances will  occur  in  which  it  is  impossible  to  say  whether  the  lesion  is 
syphilitic  or  tuberculous.  This  point  has  been  prominently  brought  out 
by  Hutinel  and  Deschamps,  and  also  by  Carpenter  and  Colcott  Fox. 
These  observers  report  cases  in  which  the  syphilitic  history  is  clear  and 
the  testicular  symptoms  point  to  that  origin,  yet  intelligent  and  active 
antisyphilitic  treatment  fails  to  produce  resolution.  In  these  cases  we 
observe  what  is  so  frequently  seen  in  adults — namely,  a  tubercular 
infection  in  a  syphilitic  subject.  This  is  common  in  many  organs  and 
tissues,  notably  the  lungs,  bones,  joints,  meninges,  and  testes.  It  is 
always  well,  therefore,  to  remember  this  frequently  occurring  mixed 
infection.  Carpenter  very  properly  states  that  a  thickened,  indurated, 
and  enlarged  vas  is  strongly  indicative  of  tuberculosis.  The  same  may 
be  said  of  cases  in  which  there  are  multiple  ulcerations  and  adhesions  of 
the  scrotum  to  the  testicles. 

It  is  well  to  remember  that  the  testes  of  young  children  are  sometimes 
the  seat  of  carcinoma,  encephaloid  cancer,  and  sarcoma.  These  malignant 
growths  are  usually  seen  toward  the  end  of  the  first  year  of  life  and  later. 
They  are,  as  a  rule,  of  rapid  development,  of  large  size  (that  of  a  hen's 
egg,  a  mandarin,  and  larger),  may  be  accompanied  by  inguinal  aden- 
opathy and  usually  more  or  less  pain,  and  always  lead  to  death,  sooner  or 
later. 

Patliological  Anatoyny. — The  histology  of  the  diseased  testicle  in 
hereditary  syphilis  has  been  studied  by  Parrot,  Hutinel,  Reclus,  and 
Carpenter.  The  lesion  is  an  interstitial  and  diffuse  collection  of  round 
embryonic  cells  resembling  white  blood-cells.  In  the  interstitial  form,  in 
■which  the  gland  may  not  be  perceptibly  enlarged,  the  cell-growth  results 
in  small  tumors  of  various  sizes  irregularly  placed  around  the  arterioles 
which  traverse  the  trabeculae.  In  other  words,  it  is  the  same  coat-sleeve 
infiltration  which  we  see  in  the  adult.  In  the  diffuse  form,  in  which  the 
organ  is  much  enlarged,  a  smaller  cell-growth  is  found  permeating  the 
meshes  of  its  connective  tissue  generally.  The  process  begins  at  the 
mediastinum  testis,  follows  the  vessels  of  the  trabeculse  between  the  semi- 
niferous tubules,  and  finally  results  in  hypertrophy  and  sclerosis  of  the 
organ,  with  partial  or  entire  obliteration  of  the  tubules,  whose  lining 
epithelium    undergoes    granulo-fatty    degeneration.     Fatty    degeneration 

1  "  De  la  Tnberculose  Testiculaire  chez  les  Enfants,"  Archiv.  gen.  cleMecL,  April,  1890. 
It  may  be  interesting  to  note  that  in  20  of  Jullien's  cases  "  16  occurred  in  children  of  less 
than  five  years  of  age,  6  of  them  were  less  than  one  year  old,  and  6  ranged  from  one  to  two 
years.  Of  the  former,  1  was  one  month  old,  and  2  were  two  months  old  when  the  dis- 
ease was  detected.  Giraldes  {Lemons  cUniques  sur  les  3Ialadies  chirurgicales  des  Enfants, 
1869,  p.  524)  has  recorded  the  cases  of  infants  of  a  few  days  only,  and  Dreschfeld  {British 
Medical  Journal,  1884,  p.  860)  has  observed  a  case  of  congenital  tuberculosis  of  the 
testicle.  In  four  observations  by  ^I.  Lannois  (22ei'»e  mensuelle  des  Malad.  de  I'Enfance, 
1883,  p.  528)  the  testicular  tuberculosis  appeared  at  five  months,  six  months,  seven 
months,  and  thirteen  months  of  age."     (Quoted  from  Carpenter,  op.  cit.) 


HEREDITARY  SYPHILIS.  949 

and  final  absorption  of  the  new  growth  takes  place,  resulting  in  atrophy 
and,  in  rare  cases,  in  complete  destruction  of  the  organ.  Probably,  the 
cases  which  are  attributed  to  arrest  of  development,  in  which  the  testis  is 
small  or  entirely  absent,  are  those  in  which  the  organ  has  been  attacked 
in  early  life  by  hereditary  syphilis.  It  is  probable  that  the  ovaries  may 
be  attacked  in  a  similar  manner  to  the  testicles. 

Gummata  of  the  testicle  in  the  hereditarily  syphilitic  infant  are  very 
rare.  Hutchinson  ^  showed  at  the  meeting  of  the  London  Pathological 
Society  a  specimen  of  gumma  of  the  testis  from  a  boy  the  subject  of 
hereditary  syphilis.  The  testis  was  much  enlarged  and  thoroughly  infil- 
trated with  a  growth  of  opaque  yellow  color.  Henoch  ^  examined  after 
death  this  testes  of  an  hereditarily  syphilitic  boy  and  found  extensive 
connective-tissue  hypertrophy  of  the  corpus  Highmori.  Carpenter  also 
found  interstitial  new  growth  in  the  epididymis.  I  have  failed  to  find 
mention  of  other  similar  cases. 

Treatment. — My  experience  in  fifteen  cases  convinced  me  that  the 
mixed  treatment  in  goodly  and  increasing  doses  was  most  efficient  in  these 
testicular  lesions,  as  it  is  in  the  bone-and-joint  lesions  of  hereditary 
syphilis.  I  was  often  much  surprised  at  the  large  doses  which  infants 
could  take  with  impunity  and  marked  benefit.  This  treatment,  with  inter- 
missions, should  be  kept  up  at  least  two  or  three  years.  I  am  not  in 
accord  with  Cai'penter  and  other  English  authors  who  pin  their  faith  on 
gray  powder.  This  drug  may  be  useful  in  the  exanthematous  stage  or 
state  of  hereditary  syphilis,  but  it  has  in  my  hands  proved  very  feeble 
and  often  inert  in  the  lesions  of  the  fibrous  tissues  and  bones. 

Locally  much  good  can  be  derived  from  mercurial  frictions  to  the 
scrotum,  using,  with  great  care  as  to  the  avoidance  of  dermatitis,  white 
precipitate  or  blue  ointment. 

When  the  organ  is  much  destroyed  by  degenerative  processes  ablation 
may  be  necessary. 

Affections  of  the  Synovial  Sheaths. 

In  two  cases  of  hereditary  syphilis  under  my  observation  the  extensor 
tendons  of  the  hands  were  involved,  as  indicated  by  marked  fusiform 
swelling  over  the  metacarpal  bones,  of  doughy  consistence,  and  freely 
movable  under  the  skin,  which  was  slightly  distended  and  reddened.  Its 
development  was  rapid  and  associated  with  other  lesions,  particularly 
osseous,  its  subsequent  course  indolent  and  not  appreciably  affected  by 
mercurial  treatment.  In  one  case  cure  resulted  from  the  application  of  a 
compress  over  a  piece  of  mercurial  plaster  after  withdrawal  of  the  fluid 
with  the  hypodermic  needle.  Other  tendinous  sheaths  than  those  of  the 
hands  may  be  affected. 

Affections  of  the  Nails— Onychia. 

The  nails  are  not  as  frequently  involved  in  hereditary  as  in  acquired 
syphilis.  There  are  two  varieties  of  onychia  ;  the  ulcerative,  which  is  the 
more  frequent,  and  the  non-ulcerative. 

'  Transactions,  London,  vol.  xxxi.  p.  192. 

*  "  Ueber  Syphilis  der  Hoden  bei  kleineren  Kindern,"  Deutsch.  Zcitschriff.f.  pract.  Med., 
1877,  No.  2. 


950  SYPHILIS. 

Ulcerative  onychia  begins  at  the  side  or  base  of  the  nail  as  a  papule 
or  pustule,  which  soon  ulcerates,  the  process  extending  along  the  concave 
base  of  the  nail,  being  limited  indefinitely  to  that  location,  or  along  the 
lateral  margins  and  finally  involving  the  matrix  of  the  nail,  which  in  the 
latter  case  is  soon  cast  off.  The  distal  phalanx  becomes  very  painful  and 
enlarged,  the  finger  resembling  in  shape  an  Indian-club.  The  thickened 
everted  edges  of  the  ulcer,  its  sloughy  base  and  sanious  discharge,  and 
the  coppery  hue  of  the  surrounding  skin  are  characteristic. 

This  form  of  onychia  may  be  met  with  alone  or  associated  with  general 
papular  or  ulcerative  eruptions,  and  is  most  frequently  seen  during  the 
first  year  or  two  of  the  child's  disease.  In  cases  improperly  treated  it 
may  be  developed  later,  and,  though  its  course  is  generally  chronic,  it  may 
be  decidedly  shortened  by  appropriate  treatment.  The  nails  of  the  hands 
seem  to  be  more  often  affected  than  those  of  the  feet. 

The  growth  of  a  deformed  and  useless  nail  or  cicatrization  without 
a  new  nail  may  be  expected  in  severe  and  protracted  cases  not  sub- 
jected to  treatment.  In  such  cases  osteitis  of  the  phalanx  may  indicate 
amputation.  The  second  form  of  onychia  is  even  more  chronic  than  the 
preceding,  and  a  much  later  manifestation  of  the  disease.  It  begins  as  a 
swelling  of  a  coppery  hue  at  the  base  or  around  the  margins  of  the  nail, 
which  shades  off  into  the  surrounding  parts.  At  the  same  time  the  nail 
loses  its  smoothness  and  gloss  and  becomes  thickened,  fissured,  and 
brittle.  The  nail  has  a  dirty- white  color,  and  there  is  always  hypersemia 
of  the  matrix  and  the  surrounding  parts,  with  much  deformity  of  the 
phalanx,  which  may  not  be  permanent.  The  nail  may  be  finally  restored 
in  a  perfectly  healthy  condition,  and  the  bone  is  usually  not  involved. 

Affections  of  the  Hair. 

The  features  of  alopecia  in  hereditary  syphilis  are  similar  to  those 
of  the  shedding  form  in  the  acquired  disease.  It  occurs  also  in  connec- 
tion with  dermal  lesions  of  the  scalp,  particularly  pustular.  In  other 
cases  a  dry  condition  of  the  hair  seems  to  be  a  result  of  the  adynamic 
influence  of  syphilis,  rather  than  any  specific  process. 

Affection  of  the  Thymus  Gland. 

Paul  Dubois^  in  1850  first  called  attention  to  certain  pathological 
changes  which  are  found  in  the  thymus  gland  of  infants  who  are  born 
dead  or  who  die  a  few  days  after  birth  from  inherited  syphilis.  Ex- 
ternally, the  gland  appears  to  be  normal  in  size,  color,  and  consistency ; 
but  if  an  incision  be  made  into  its  substance,  pressure  will  cause  to 
exude  from  the  cut  surface  a  few  drops  of  yellowish  fluid,  which  under 
the  microscope  is  found  to  consist  of  pus.  In  the  cases  observed  by 
Dubois  the  purulent  matter  was  uniformly  diffused  throughout  the 
glandular  tissue,  but  Depaul,^  Weber, ^  and  Hecker,*  have  met  with 
abscesses  of  the  thymus.  The  thymus  gland  naturally  contains  a 
whitish,  viscid  fluid,  which  may  with  a  little  care  be  distinguished  from 

'  Gaz.  med.  de  Paiis,  1850,  p.  392. 

^  Bulletin  de  la  Societe  d'Analomie  de  Paris,  xxix.,  1854,  p.  47. 
^  Beitr.  zur  path.  Anat.  d.  Neugeborenen,  Kiel,  1852,  ii.  p.  75. 
*  Veraridl.  d.  Gesellsch.  f.  Geburtsh.,  in  JBerL,  viii.  p.  117. 


HEREDITARY  SYPHILIS.'  951 

the  suppuration  dependent  upon  syphilis.  Of  five  cases  of  this  lesion 
observed  by  Dubois  and  Depaul,  an  eruption  of  pemphigus  was  present 
in  four,  and  in  the  same  number  the  syphilitic  antecedents  of  the  parents 
were  clearly  established. 

The  more  recent  observations  of  Weisflog^  and  Widerhofer^  have 
confirmed  the  views  of  Dubois,  which  were  at  one  time  rejected  by  sev- 
eral German  authors,  who  claimed  that  Dubois  had  mistaken  the  normal 
secretion  of  the  gland  for  pus,  and  that  the  possible  changes  were  not 
necessarily  due  to  hereditary  syphilis.  Having  studied  the  literature 
of  the  subject,  as  well  as  the  lesion  itself,  Weisflog  arrives  at  the  follow- 
ing conclusions :  1.  It  is  certain  that  the  thymus  abscess  described  by 
Dubois  exists,  and,  although  not  a  constant  symptom  of  hereditary 
syphilis,  it  is  sometimes  met  with.  2.  This  lesion,  associated  with 
other  signs  of  congenital  syphilis,  indicates  that  the  father  or  mother 
of  the  infant  sufi"ers  or  has  suffered  from  syphilis.  3.  It  is  possible, 
but  not  proved,  that  this  affection  may  exist  in  children  in  whom  there 
are  no  symptoms  of  syphilis,  but  its  existence  renders  the  diagnosis  of 
hereditary  syphilis  probable  even  if  the  disease  of  the  parents  is  not 
proved.  4.  Such  is  the  great  similarity  in  the  appearance  of  pus  and 
of  the  secretion  of  the  thymus  that  they  cannot  always  be  distin- 
guished. 

Lesions  of  the  Umbilical  Vein. 

Oedmansson  and  Winckel  found  stenosis  of  the  umbilical  vein  in  the 
cord  of  certain  macerated  foetuses  whose  death  was  attributed  to  syph- 
ilis. The  former  thought  that  it  was  caused  by  the  atheromatous  pro- 
cess. Birch-Hirschfeld,  who  has  also  observed  this  condition,  thinks 
that  it  is  due  to  changes  similar  to  those  occurring  in  the  arteries  of  the 
brain,  as  described  by  Heubner.  Should  future  investigation  confirm 
the  view  of  Hirschfeld,  this  lesion  of  the  umbilical  vein  must  be  con- 
sidered an  important  element  in  causing  the  death  of  the  syphilitic 
embryo. 

Microbic  invasion  of  the  umbilical  cord  may  occur,  and  as  a  result 
septicaemia  may  be  produced. 

Hemorrhagic  Syphilis. 

Hemorrhagic  syphilis  in  infected  infants  is  sometimes  seen  in  the 
form  of  large  and  small  petechige  and  ecchymoses.  It  may  occur  into  the 
skin  and  mucous  membranes,  and  also  into  the  viscera  and  from  the 
umbilical  vein.  Mracek  ^  observed  19  cases,  in  18  of  which  the  infants 
were  born  alive.  In  most  there  were  visceral  hemorrhages.  In  many 
cases  of  hemorrhage  a  fatal  termination  may  be  expected.  Cases  of 
hemorrhage  in  newly  born  syphilitic  children  have  been  reported  by 
Petersen*  in  an  essay  in  which  he  treats  of  this  subject. 

^  "Ein  Beitrag  zur  Kenntniss  rler  Dubois'schen  Thymus  Abscesse  bei  angeborener 
Syphilis,"  Inanq.  Dissertation,  Ziirich,  1860. 

''  "Ueber  Thymus  Abscesse  bei  hereditiirer  Syphilis,"  siiparat-abdruck  aus  dem  J.  d. 
Kimlerheilk,  Wien,  1852. 

3  Deut.  med.  Zeitschr.,  No.  82,  1886. 

*  Vierteljahr.  fiir  Derm,  und  Sypk,  1883,  pp.  509  et  seq. 


952  SYPHILIS. 

Micro-organisms  in  Hereditarily  Stphilitic  Children. 

Observations  made  by  Kassowitz  and  Hochsinger^  and  by  Doutrele- 
pont  ^  show  that  the  tissues  of  syphilitic  infants  contain  many  micro- 
organisms. In  several  cases  of  infants  who  died  a  few  days  after  birth 
the  last-named  observer  found  streptococci  and  staphylococci  in  the 
skin  above  the  Malpighian  layer,  in  the  vessels,  and  lymphatics.  He 
thinks  that  these  microbes  penetrate  the  skin  and  mucous  membranes 
through  lesions  of  continuity  produced  by  the  infection.  Kassowitz 
and  Hochsinger  found  a  chain-coccus  in  the  blood,  bones,  and  viscera 
of  syphilitic  infants,  but  not  in  non-syphilitics.  Chotzen  ^  has  studied 
this  subject  carefully,  and  concludes  that  in  some  cases  the  microbes 
enter  the  system  through  the  nasal  mucous  membrane,  which  is  in  an 
inflamed  condition.  They  are  then  carried  by  the  circulation  to  all 
parts  of  the  body.     In  this  manner  septicemia  may  be  produced. 

Affections  of  the  Lymphatic  Ganglia. 

General  subacute  adenitis,  invariably  present  in  the  early  stages  of 
the  acquired,  is  always  absent  in  hereditary  syphilis,  and  is  an  import- 
ant feature  in  the  differential  diagnosis.  Swelling  of  the  cervical 
ganglia,  which  often  accompanies  active  lesions  in  the  mouth  and 
throat  and  upon  the  scalp,  frequently  results  in  abscess,  particularly 
in  cachectic  children,  when  the  condition  can  be  distinguished  from 
tuberculosis  only  by  the  history  of  the  case  and  by  concomitant  symp- 
toms. 

On  post-mortem  examination  Hutchinson  found  the  bronchial  gan- 
glia of  a  syphilitic  child,  five  months  old,  infiltrated  with  fibrinous  de- 
posits, and  cases  of  infiltration  of  cell-elements,  sometimes  in  the  form 
of  small  circumscribed  tumors,  have  been  reported  by  Barensprung. 
The  ganglia  of  the  gastro-hepatic  omentum  and  mesentery  were  found 
most  frequently  involved,  being  symptomatic  perhaps  of  visceral  lesions. 

Affections  of  the  Bones. 

Until  within  twenty  years  the  majority  of  bone  lesions  in  children 
were  attributed  to  rickets  or  scrofula.  In  1870  an  important  contribu- 
tion to  this  subject  was  published  by  Wegner^  of  Berlin,  in  Avhich  he 
described  certain  changes  found  at  the  junctions  of  the  diaphyses  and 
epiphyses  of  the  long  bones  of  infants  with  hereditary  syphilis.  Two 
years  later  Waldeyer  and  Kbbner '"  published  a  paper  in  which  they 
confirmed  Wegner's  discovery,  although  they  differed  with  him  in  their 
interpretation  of  the  pathological  appearances.  Following  these  German 
observers,  Parrot^  of  Paris  published  in  1872  an  elaborate  paper,  in 
which  he  gave  many  histological  facts  and  brought  out  one  important 

1  Wiener  Med.  Blatter,  Nos.  1,  2,  and  3,  1886. 

2  Centralblatt  fiir  Bakteriol.  unci  Parcmtenk,  Xo.  13,  1887. 

^  Archiv  fur  Derm,  und  Syphilis,  vol.  xix.,  1887,  pp.  108  et  seq. 

*  "  Ueber  hereditlire  Knockensyphilis  bei  jungen  Kindern,"  Arch.  f.  path.  Anat.,  etc., 

=  "  Beitnige  znr  Kenntniss  der  hereditaren  Knockensyphilis,"  Arch.  f.  path.  Anat.,  etc., 
Iv.,  1872. 

^  Arch,  de  Physiol,  norm,  et  path.,  Paris,  4  annee,  1872. 


■  HEREDITARY  SYPHILIS.  953 

symptom  of  these  affections.  In  1875,  I  published  a  work  containing 
a  full  description  of  these  affections,  their  pathology,  and  a  resume  of 
previous  contributions  concerning  them.' 

The  bones  are  affected  in  various  ways  by  hereditary  syphilis.  In 
the  early  months  of  infancy  the  morbid  change  is  peculiarly  frequent 
in  long  Jbones  at  the  junction  of  the  epiphysis  with  the  diaphysis.  In 
the  first  years  of  hereditary  syphilis  the  small  bones  of  the  fingers 
and  toes  are  also  quite  frequently  affected,  while  later  on  a  tendency 
to  invasion  of  the  shafts  of  long  bones  and  of  the  surfaces  of  flat 
ones  is  noticed.  We  shall  therefore  describe  the  diaphyso-epiphysal 
lesion  under  the  name  osteocliondi'itis  Hypliilitica^  and  the  affection  of 
the  long  bones  under  periostitis.  The  lesions  of  the  bones  of  the 
fingers  and  toes  are  somewhat  peculiar  and  require  a  separate  descrip- 
tion. 

Osteochondritis. — This  affection  is  claimed  to  be  one  of  the  most 
constant  manifestations  of  hereditary  syphilis.  It  is  often  the  only  one, 
and  frequently  its  presence  decides  the  syphilitic  nature  of  coexisting 
lesions.  A  knowledge  of  the  fact  that  this  affection  is  exclusively 
caused  by  syphilis  has  been  of  great  service  in  the  study  of  hereditary 
syphilis. 

If  we  remember  that  the  growth  of  the  bone  in  length  takes  place 
at  the  extremity  of  the  shaft,  Avhere  the  epiphysis  is  joined  to  it  by  a 
layer  of  cartilage,  and  that  here  syphilitic  changes  are  most  often 
found,  we  shall  see  how  the  normal  development  of  the  bone  may  be 
greatly  perverted  or  interfered  with. 

The  bones  most  commonly  attacked  are  those  of  the  forearm,  the 
leg,  the  arm,  and  the  thigh.  The  clavicle,  sternum,  and  ribs  are  also 
attacked,  as  well  as  the  metacarpal  and  metatarsal  bones.  The  num- 
ber of  bones  involved  varies.  It  has  been  noticed  that  in  stillborn 
infants  and  in  those  dying  soon  after  birth  the  majority  or  even  all 
of  the  long  bones  are  affected.  It  is  very  exceptional  for  the  victims 
of  multiple  bone  lesions  to  survive,  and  it  is  fair  to  assume  that  the 
number  of  bones  attacked  varies  with  the  intensity  of  the  syphilitic 
diathesis. 

In  these  cases  of  osteochondritis  we  find  at  the  diaphyso-epiphysal 
junction  a  swelling,  which  may  be  visible,  but  in  fat  children  is  often 
imperceptible.  On  palpation  the  bone  is  found  to  be  encircled  by  an 
abruptly  limited  collar  or  ring,  which  usually  extends  completely 
around.  In  some  cases  the  entire  epiphysis  may  be  expanded,  with 
or  without  a  distinct  ring,  at  its  junction  with  the  shaft.  The  surface 
of  these  swellings  and  rings  is  generally  smooth  ;  it  may  be  slightly 
irregular,  but  is  seldom  very  much  ridged.  When  two  contiguous  bones 
are  affected  they  often  seem  to  be  fused  together.  In  living  children 
the  distal  more  often  than  the  proximal  extremities  have  been  found 
affected,  and  the  affection  is  generally  symmetrical,  especially  in  very 
young  subjects.  In  some  cases,  particularly  at  the  lower  end  of  the 
humerus  and  at  the  upper  end  of  the  tibia,  the  lesion  does  not  surround 
the  bone,  but  is  limited  to  the  segment  of  the  diaphyso-epiphysal  junc- 
tion. 

The  swellings  on  the  clavicle  are  usually  found  at  its  sternal  end, 

*  Syphilitic  Lesions  of  the  Osseous  System  in  Injanls  and  Young  Children,  New  York,  1875. 


954  SYPHILIS. 

and  are  sometimes  of  large  size.  Those  of  tlie  sternum  are  not  com- 
mon in  very  young  children  ;  lesions  of  the  ribs,  which  occur  at  their 
junction  with  the  costal  cartilages,  are  also  infrequent,  and  are  gen- 
erally not  as  numerous  or  symmetrical  as  those  of  rickets. 

These  swellings  may  be  developed  slowly  or  quite  rapidly.  After 
reaching  their  full  size  they  usually  remain  in  an  indolent  condition, 
causing  little  if  any  pain,  and  interfering  but  slightly  with  the  motion 
of  the  joint.  Under  appropriate  treatment  they  promptly  subside.  The 
integument  undergoes  very  little  if  any  change,  and  becomes  tense  and 
thin  only  when  the  tumors  are  exceptionally  large.  The  joints  may  be 
secondarily  involved  and  become  the  seat  of  subacute  synovitis,  the 
effusion  being  slight  or  extreme.  Those  most  commonly  attacked  are 
the  elbow  and  knee ;  as  a  rule,  the  joints  with  short  epiphyses  are  most 
liable  to  hyperaemia  and  effusion.  Pressure,  accompanied  by  internal 
treatment,  speedily  disperses  the  joint  swellings,  which  usually  give  rise 
to  but  slight  inconvenience. 

Degenerative  changes  sometimes  take  place  in  these  osseous  lesions. 
In  their  mildest  form  they  consist  simply  of  a  superficial  breaking-down 
at  one  part  of  the  swelling.  We  first  observe  fluctuation,  soon  followed 
by  ulceration  of  the  skin,  resembling  in  appearance  that  Avhich  occurs 
in  gummy  tumors.  These  necrotic  changes,  however,  may  be  much 
more  active  and  extensive  in  the  bone  than  in  the  cutaneous  ulcer,  which 
shows  very  little  tendency  to  increase  in  size.  The  epiphysis  may  be 
entirely  separated  from  the  shaft,  and  if  the  superficial  ulcer  is  large,  it 
may  be  extruded.  In  most  cases  where  the  destructive  process  is  exten- 
sive the  syphilitic  diathesis  is  intense,  and  a  fatal  termination  ensues. 
In  others,  however,  reparative  changes  of  an  interesting  and  peculiar 
character  occur. 

The  intervening  cartilage  having  been  destroyed,  the  diaphysis  is 
united  to  the  shaft  only  by  fibres  of  periosteum.  This  membrane  be- 
comes much  thickened  and  forms  a  more  or  less  complete  cylinder, 
uniting  the  two  fragments  with  considerable  firmness.  Bony  spicules 
shoot  from  its  inner  surface  between  the  two  osseous  surfaces,  and 
eventually  bony  union  is  formed.  The  periosteum  continues  thickened 
for  a  long  time,  but  gradually  resumes  its  normal  proportions  as  the 
union  between  the  bones  grows  firmer. 

The  effect  of  these  swellings  upon  the  ultimate  shape  of  the  bone 
depends  on  the  intensity  of  the  morbid  process.  When  resolution 
takes  place  the  nutrition  of  the  bone  is  afterward  fully  restored,  but 
in  case  of  destruction  of  the  intermediate  layer  of  cartilage  the  bone  is 
usually  shortened.  These  lesions  are  usually  found  at  birth  or  within 
the  first  month  of  life.  They  may  appear  later,  even  as  late  as  the 
twelfth  year,  when  they  are  developed  very  slowly,  are  few  in  number, 
and  are  unsymmetrical.  The  occurrence  of  ossification  between  the  seg- 
ments of  a  bone  no  doubt  has  much  influence  upon  the  development  of 
the  lesions  ;  we  may  therefore  expect  to  see  them  at  the  time  when  bony 
union  occurs.  Identical  changes  have  been  observed  in  children  with 
acquired  syphilis,  but  the  affection  in  such  cases  was  limited  to  a  feAV 
bones  or  even  to  one. 

This  affection  results  from  interference  with  the  nutrition  of  the  bone, 
and  presents  three  stages.     In  the  first  the  intermediate  layer  of  car- 


HEREDITARY  SYPHILIS.  955 

tilage  is  thickened,  uneven,  and  irregular,  and  under  the  microscope  we 
find  simple  increase  of  the  cartilage-cells.  In  the  second  stage  the  car- 
tilage is  still  thicker,  and  is  nodulated  on  its  epiphyseal  surface,  and 
Avarty  or  papilliform  processes  of  calcified  cartilage  project  into  the 
hyaline  matrix.  Wegner  compares  them  with  the  papillae  of  the  cutis 
on  account  of  their  broad  bases  and  tapering  ends.  Deposits  of  lime 
are  also  found  in  the  hyaline  matrix  between  these  projections.  On  the 
periphery  the  infiltration  encroaches  farther  into  the  cartilage  than  at  its 
centre.  We  find  when  examining  the  relations  of  this  calcified  line  to 
the  spongy  bone  that  there  are  corresponding  depressions  into  which  the 
spongy  tissue  passes.  Under  the  microscope  we  find  the  longitudinal 
rows  of  cartilage  more  abundant  than  in  the  first  stage,  and  there  is 
very  little  intercellular  substance.  The  vessels  are  numerous,  and  at 
the  line  ,of  ossification  are  surrounded  by  a  considerable  quantity  of 
connective  tissue.  The  walls  of  the  cavities  are  broader  at  their  bases 
and  are  sclerotic.  In  many  places  an  osteoid  substance  is  developed 
from  the  cartilage  and  from  the  medulla  which  enters  with  the  vessels. 
This  substance  is  found  to  be  in  some  places  true  bone  which  passes  into 
the  spongioid  layer.  Beyond  the  couche  ehondroide  we  find  irregularly 
distributed  spots  of  calcified  cartilage  forming  a  zone  of  considerable 
breadth.  The  principal  points  in  the  second  stage,  therefore,  are  greater 
proliferation  of  the  cartilage  cells,  premature  sclerosis  of  the  intercellu- 
lar substance,  formation  of  bony  projections  beyond  the  normal  layer, 
and  delay  in  bone-formation  elsewhere ;  in  other  words  irregular  osteo- 
genesis, premature  in  some  regions  and  retarded  in  others.  In  the  third 
stage  there  is  a  general  enlargement  of  the  epiphyses,  with  thickening 
of  the  periosteum  and  perichondrium.  Under  the  microscope  the  fol- 
loAving  conditions  are  seen :  The  lowermost  layer  of  hyaline  cartilage  is 
bluish  and  transparent ;  this  layer  is  succeeded  by  an  irregular  and  wavy 
layer  with  serrated  processes  and  having  a  grayish-white  color  and  of 
homogeneous  formation.  This  layer  is  brittle  and  can  be  readily  re- 
moved. Next  to  this  is  placed  a  layer  of  grayish-red  or  yellow  sub- 
stance, soft  and  sometimes  viscid,  which  is  gradually  lost  in  the  spongy 
substance  of  the  diaphysis.  The  medullary  tissue  of  the  latter  continues 
for  some  distance,  and,  instead  of  being  normally  red,  is  gray  or  grayish- 
red.  This  layer  seems  to  destroy  the  firm  cohesion  of  the  epiphysis  to 
the  shaft.  In  this  stage  the  proliferation  of  cartilage-cells  and  the  lime- 
infiltration  is  excessive.  In  the  layer  next  to  the  bone  we  see  nucleated 
cells,  spindle-shaped  cells,  and  granular  detritus.  Waldeyer  and  Kobner 
consider  this  to  be  granulation  tissue  growing  into  the  cartilage  from 
the  medulla.  Wegner,  on  the  contrary,  denies  that  it  is  true  granula- 
tion tissue. 

Periostitis. — While  osteochondritis  occurs  in  early  infancy,  per- 
iostitis is  a  later  aifection,  attacking  the  bones  of  syphilitic  children  who 
have  already  begun  to  walk.  Whether  the  active  use  of  the  bones  has 
any  influence  in  developing  periosteal  inflammotion  we  cannot  say  posi- 
tively, although  its  occurrence  in  the  bones  of  the  leg  render  this  view 
probable.  In  the  majority  of  cases  the  femur  and  tibia  are  first  attacked, 
sometimes  as  early  as  the  second  year,  but  generally  at  the  fourth  or  fifth. 
When  long  bones  are  involved  thus  early  the  greater  part  of  the  shaft 
usually  suffers.     The  bone  becomes  very  tender,  and  soon  is  seen  to  be 


956 


SYPHILIS. 


much  enlarged,  even  to  twice  or  thrice  its  normal  thickness.  It  seems 
bent  anteriorly,  producing  marked  deformity.  The  fibula  is  also  some- 
times affected,  and  generally  both  legs  are  attacked.  The  bones  of  the 
forearm  are,  next  to  the  tibia,  most  prone  to  this  disease.  The  earlier  it 
appears,  the  more  likely  is  the  aflFection  to  involve  both  limbs  symmetri- 
cally ;  at  later  periods  it  may  be  unilateral  and  more  localized,  perhaps 
forming  circumscribed  nodes.  The  skull-bones  are  sometimes  the  seat  of 
these  nodes,  which  are  apt  to  be  quite  large  and  multiple.  In  very 
severe  cases  they  sometimes  break  down  and  form  troublesome  abscesses. 
Although  periostitis  usually  occurs  before  the  twelfth  year,  I  have  seen 
it  as  late  as  the  fifteenth  and  even  nineteenth  year. 

Dactylitis  Syphilitica. — In  the  early  months  of  hereditary  syphilis 
children  are  often  attacked  by  swelling  of  the  phalanges  and  the  meta- 
carpal and  metatarsal  bones.  These  lesions  are  of  the  same  character  as 
those  of  acquired  syphilis.  The  proximal  phalanges  are  most  often  at- 
tacked, and  the  distal  least  commonly ;  sometimes  all  three  phalanges  are 
involved  at  the  same  time.  The  bones  may  be  enlarged  greatly  beyond 
their  natural  size,  the  deformity,  of  course,  differing  with  the  phalanx 
involved.  One  or  more  bones  of  one  or  of  each  hand  may  be  involved; 
in  one  instance  I  have  seen  every  phalanx  of  each  hand  swollen.  Some- 
times the  metacarpal  bones  are  enlarged  ;  the  lesion  is  less  frequently 
seen  in  the  toes  and  metatarsal  bones.  The  swellings  progress  slowly  or 
with  surprising  rapidity.  In  their  early  stages  the  integument  is  un- 
changed ;  at  a  later  period  the  overlying  parts  become  inflamed  and  an 
abscess  is  formed.     The  condition  is  well  shown  in  Fig.  230. 

Fig.  230. 


Dactylitis  syphilitica  in  the  infant 


If  uninfluenced  by  treatment,  these  swellings  run  a  very  chronic 
course,  but  when  treated  early  they  gradually  subside.  In  some  cases 
exsection  of  the  bones  is  required,  but  generally  the  destructive  changes 
are  more  extensive  in  the  skin  than  in  the  bones.  Apparently  hopeless 
cases  often  yield  to  persevering  internal  and  local  treatment,  without  the 
necessity  of  an  operation.  At  the  termination  of  the  disease  the  shape 
of  the  phalanx  may  be  restored,  or  it  may  be  lengthened,  or  even  very 
much  thinned  and  shortened. 


HEREDITARY  SYPHILIS.  957 

Dactylitis  is  usually  observed  in  very  young  children ;  it  may  also 
occur  as  late  as  the  twentieth  year.  In  the  latter  case  it  is  usually  pre- 
ceded by  other  osseous  and  articular  lesions. 

Swelling  of  the  Metacarpal  and  Metatarsal  Bones. — These 
lesions  usually  occur  quite  early  in  hereditary  syphilis,  and  may  or  may 
not  coexist  with  dactylitic  enlargements.  They  may  appear  even  as  late 
as  the  twentieth  year.  A  single  bone  only  is  sometimes  affected,  but  in 
one  instance  I  have  found  all  of  the  metacarpal  and  metatarsal  bones  in- 
volved. These  swellings  usually  form  rapidly  and  attain  considerable 
size.  They  may  or  may  not  be  attended  by  pain.  In  the  early  years  of 
hereditary  syphilis  they  commonly  involve  the  entire  bone ;  in  later  years 
the  swellings  are  often  circumscribed.  They  do  not  occur  as  early  or  as 
frequently  as  the  dactylitic  swellings,  nor  have  I  observed  the  necrotic 
tendency  sometimes  seen  in  swellings  of  the  phalanges.  When  the  tumors 
reach  a  large  size  the  integument  becomes  tense,  inflamed,  and  may  ulcer- 
ate.    Such  cases  are  very  protracted. 

These  lesions  have  different  results  in  various  cases  and  according  to 
the  age  of  the  patient.  In  very  young  children  the  bones  may  be  left  in 
a  normal  condition ;  sometimes  they  are  a  little  thinned  or  shortened.  In 
later  stages  of  hereditary  syphilis  we  find  destruction  of  a  segment  of  the 
bone,  which  is  thus  divided  into  two  parts,  joined  firmly  by  a  band  of 
fibrous  tissue. 

The  treatment  of  all  bone  swellings  should  combine  mercury  with 
iodide  of  potassium. 

Affections  of  the  Nervous  System. 

Until  recently  our  knowledge  of  the  affections  of  the  nervous  system 
caused  by  hereditary  syphilis  was  very  fragmentary  and  incomplete, 
which  was  due,  beyond  doubt,  largely  to  the  fact  that  nearly  all  affections 
of  the  brain  in  infants  and  young  children  had  been  for  so  long  considered 
to  be  of  tubercular  origin  that  little  attention  had  been  paid  to  the  influence 
of  hereditary  syphilis  in  their  causation.  Though  the  pathological  facts 
which  have  been  learned  concerning  the  effect  of  this  diathesis  are  far 
from  complete,  their  suggestions  are  so  comprehensive  that  their  import- 
ance is  greatly  increased.  This  statement  is  borne  out  by  the  fact  that 
we  now  positively  know  that  in  hereditary  syphilis  there  have  been  found 
the  results  of  meningeal  inflammation,  such  as  thickening  and  adhesion 
of  the  membranes  by  the  development  of  fibrous  tissue  and  gummy 
material,  and  that  the  endoarteritis  so  frequently  found  in  the  acquired 
form  has  also  been  observed  in  hereditary  syphilis.  Gummata  on  the 
membranes  have  also  been  found.  This  knowledge  is  most  important  and 
far-reaching,  since  it  suggests  strongly  the  probability  that  there  may 
occur  during  the  course  of  hereditary  syphilis  the  same  numerous  and 
complex  affections  as  are  known  to  occur  in  the  acquired  form.  As  our 
present  knowledge  of  the  clinical  history  and  of  the  pathology  of  the 
several  hereditary  affections  is  not  complete,  I  can  only  give  a  general 
sketch  of  them.  The  observations  of  Jackson  and  others  have  conclusively 
shown  that  hereditai'ily  syphilitic  infants  and  young  cliildrcn  are  liable 
to  chorea.  This  may  be  of  a  mild  and  ephemeral  form,  or  it  may  be 
severe.  In  several  cases  it  has  coexisted  with  hemiplegia,  and  in  others 
there  has  been  superadded  epilepsy.     In  such  cases  Jackson  thinks  that 


958  SYPHILIS. 

the   hemiplegia  is  caused  by  the  plugging  up  of  the  middle  cerebral 
artery,  that  the  chorea  is  due  to   occlusion  of  its  small  distal  branches, 
while  the  epilepsy  is  due  either  to  thickening  of  the  meninges  or  a  gum- 
mous  growth  in  or  near  the  corpus  striatum.     The  occurrence  of  epilepsy 
alone,    without   hemiplegia,   is    very  frequently   observed    in    hereditary 
syphilis,  either  within  the  years   of  infancy   or  later  on   in   childhood. 
Indeed,  its  evolution  has  been  observed  as  late  as  the  twelfth  or  fifteenth 
year.      So  impressed  is  Jackson  with  the  relation  of  hereditary  syphilis  to 
epilepsy  that  he  says :   "  When  a  child  is  brought  to  us  for  an  affection  so 
painfully  obscure  as  general  epilepsy,  it  is  well  to  examine  the  patient's 
brothers  and  sisters  for  signs  of  syphilis."     We  would  add  even  more — 
that  the  child  should  be  thoroughly  examined  to  determine  whether  it  is 
syphilitic.     The  eye  must  be  examined  superficially  and  deep.     In  such 
cases  we  often  find  evidences  of  antecedent  keratitis,  of  choroiditis  and 
retinitis  ;  sometimes  of  optic  neuritis.     Then,  again,  we  may  find  evidence 
in  the  notched  state  of  the  teeth,  in  certain  small  white  linear  scars  at  the 
angles  of  the  mouth,  in  falling  of  the  nose,  and  in  a  bow-shaped  condition 
of  the  tibise.     All  or  some  of  these  symptoms  may  be  found  also  in  cases 
of  epileptic  hemiplegia  or  of  hemiplegia  alone.     Though  palsies  of  the 
cranial  nerves  do  not  occur  as  frequently  in   hereditary  as   in  acquired 
syphilis,  the   observations  of  Barlow  and  Dowse  have  positively  proved 
that  several   of  them   may   be  attacked   by  syphilis.     One  of  the  most 
suggestive  cases  published  is  that  of  Barlow,  of  an  hereditary  syphilitic 
child  four  months  old  Avho  presented  well-marked  lesions  which  were  im- 
proved by  mercury.     Then  she  began  to  run  down,  had  carpopedal  con- 
tractions, was   attacked  by  convulsions,   and  died.     At  the   autopsy  the 
membranes  were  found  to  be  slightly  thickened,  and  at  the  base   of  the 
optic  commissure  was  a  small  patch  of  greenish  lymph,  while  the  fissures 
of  Sylvius  were  glued  by  old  exudation.     In  many  places  on  the  vertex 
and   on  the  inferior  surface  of  the   temporo-sphenoidal  lobes   there  was 
thickening  of  the  membrane  from  fibrous  tissue,  while  on  the  upper  sur- 
face of  the  left  parietal  lobe  was  a  thin  patch  of  calcification.      The  small 
vessels  of  the  cortex  were  markedly  altered ;  being  at  first  natural,  they 
became  of  a  dirty-white  color,  Avithout  dilatation  or  narrowing,  and  looked 
like  threads.     There  Avas  no  granulation  of  the  pia  mater,  as  in  tubercle. 
There  were  also  a  few  patches  of  superficial  softening.     The  choroid  and 
retina  were  infiltrated  in  a  circumscribed  manner  by  corpuscles  as  large  as 
those  of  pus.     The  most  important  point  found  by  Barlow  was  in  the 
thickened  membranes,  which  contained  an  excess  of  fibrous  tissues  with 
cells,  not  mere  nuclei,  but  well-formed  lymphoid  cells,  each  containing  a 
nucleus  and  sometimes  a  nucleolus.     These  seemed  to  have  no  arrange- 
ment around  the  vessels,  and  retained  their  individuality,  Avith  no  massing 
into  heaps  and  central  degeneration,  thus  differing  from  tubercle.     In  the 
vessels  there  Avas  a  new  growth  of  the  inner  coat,  which  narroAved  and 
even  occluded  their  calibre. 

The  affections  of  the  nervous  system  of  hereditary  syphilis  resemble 
in  their  evolution  and  course  those  of  the  acquired  disease  in  the  com- 
plex and  disorderly  association  of  symptoms  and  in  the  frequent  coexist- 
ence of  eye  affections,  such  as  optic  neuritis  and  paralyses  of  one  or  more 
cranial  nerves.  In  the  hereditary  form  the  ocular  lesions  are,  in  general, 
more  complex  and  numerous  than  in  the  acquired  form. 


HEREDITARY  SYPHILIS.  959 

Treatment  of  Hereditary  Syphilis. — Though  the  treatment  of  heredi- 
tary syphilis  is  very  simihxr  in  many  particulars  to  that  of  the  acquired 
disease,  it  presents  many  divergencies  and  difficulties,  and  is  not  fol- 
lowed by  such  uniformly  good  results  as  are  obtained  in  adults.  Chil- 
dren born  syphilitic  are  in  various  degrees  tainted  through  and  through 
with  the  poison,  consequently  the  physician  is  at  the  outset  brought 
face  to  face  with  malnutrition  and  a  tendency  to  decay.  He  really  has 
little,  if  anything,  to  build  upon.  In  this  fact  lies  the  great  difficulty 
in  treating  the  victims  of  hereditary  syphilis,  and  to  it  largely  are  due 
the  many  failures  of  our  therapeutics.  In  acquired  syphilis,  as  a  rule, 
the  evolution  is  tolerably  orderly,  and  the  lesions  as  they  appear  give 
indications  which  guide  us  in  their  cure.  In  hereditary  syphilis,  how- 
ever, there  is  no  order,  and  many  of  its  manifestations  are  wrapped  in 
obscurity  and  doubt.  Thus  it  may  be  that  we  find  bone  and  articular 
lesions  present,  with  those  of  an  exanthematic  character  seated  on  the 
skin.  In  some  cases  no  skin  lesions  are  present,  while  affections  of  the 
mucous  membrane  may  exist,  and  then  be  in  a  doubtful  and  masked 
form.  In  other  cases  the  evolution  of  lesions  and  various  affections  is 
early  and  prompt,  and  their  general  physiognomy  may  point  to  their 
nature.  Then,  again,  in  lesions  equally  precocious  there  may  be  no 
decided  features.  Consequently,  doubt  and  uncertainty  as  to  their 
simple  or  specific  nature  may  exist.  This  remark  applies  to  ill-defined 
early  eruptions  and  to  affections  of  the  mouth  and  nose,  Avhich,  though 
caused  by  syphilis,  resemble  simple  afi"ections. 

Further,  the  evolution  of  hereditary  manifestations  may  be  much 
delayed,  so  that  the  suspicion  of  their  specificity  is  forgotten  or  not 
entertained.  Thus  we  may  see  delayed  cutaneous  and  mucous  erup- 
tions Avhich  are  atypical  and  cause  much  perplexity  of  mind. 

As  a  rule,  the  treatment  of  acquired  syphilis  is  progressively  orderly, 
while  that  of  the  hereditary  disease  is  very  often  begun  in  doubt  and 
uncertainty,  and  throughout  its  course  subject  to  all  manner  of  changes 
and  modifications.  A  condition  requiring  mercury  to-day  may  be  re- 
placed by  the  necessity  to  use  iodide  of  potassium  within  a  week,  and 
vice  versa.  Consequently,  no  specific  data  can  be  laid  down  for  a 
general  methodical  treatment  of  hereditary  syphilis.  It  is  incumbent, 
therefore,  upon  the  physician  to  watch  his  case  continuously,  and  always 
to  be  ready  with  such  measures  of  relief  as  may  be  indicated  by  the 
existing  lesions. 

It  must  be  clearly  understood  by  the  physician,  and  as  clearly  pre- 
sented to  the  parents  or  guardian,  that,  as  a  rule,  at  least  one  year  and 
more — generally  two — are  necessary  for  the  treatment  of  a  syphilitic 
infant.  The  disappearance  of  one  crop  of  manifestations  merely  means 
that  one  stage  of  the  disease  has  been  auspiciously  passed  over.  We 
must  then  keep  on  in  order  to  prevent  or  attenuate  the  severity  of  later 
outbursts.  It  is  always  well,  however,  to  temper  the  activity  of  treat- 
ment by  proper  intermissions. 

We  will  first  consider  the  (luestion  of  the  treatment  of  the  pregnant 
syphilitic  mother ;  then  the  expediency  of  treating  the  child  through 
the  medium  of  a  medicated  mother  or  nurse;  and  then  we  shall  come 
to  the  subject  proper — namely,  the  treatment  of  hereditary  syphilis  in 
its  various  forms. 


960  SYPHILIS. 

The  Treatment  of  the  Pregnant  Syphilitic  Mother  and  its  Effect  on 
the  Foetus. — An  important  question  in  the  therapeutics  of  hereditary 
syphilis  is  the  management  of  the  case  of  the  pregnant  mother.  On 
this  subject  the  views  of  the  profession  are  far  from  being  clear  and 
sharply  formulated,  and  while  we  find  some  who  recommend  that  the 
mother  should  be  treated  on  her  own  account  and  also  as  a  prophylactic 
measure  for  her  offspring,  others  are  in  a  state  of  doubt  as  to  the  wisdom 
and  probable  beneficial  outcome  of  such  a  course,  having  an  ill-defined 
fear  that  harm  may  thereby  come  to  both.  It  is  necessary,  therefore, 
that  this  question  should  be  studied  in  the  light  of  the  accumulated 
knowledge  of  to-day. 

When  it  is  possible  the  physician  should  endeavor  to  prevent  the 
marriage  of  a  syphilitic,  male  or  female,  until  he  or  she  shall  have  had 
a  well-regulated  general  methodical  treatment  for  at  least  two  or  two 
and  a  half  years.  At  the  end  of  that  time,  if  their  condition  warrants 
it,  they  may  marry.  Some  authors  plead  for  a  longer  period  of  time, 
but  I  am  fully  convinced  that  in  favorable  cases  treatment  followed  on 
the  lines  indicated  will  fit  patients  to  marry  and  to  produce  healthy 
ofi"spring.  I  have  seen  scores  of  infants  born  under  these  circumstances 
who  have  been  healthy  and  strong.  In  very  many  cases,  however, 
syphilitics  will'  marry  in  spite  of  the  physician's  remonstrance,  and  a 
vast  number  marry  who  either  do  not  know  or  do  not  realize  the  gravity 
and  danger  of  their  position.  So  that  w^hatever  the  profession  may  do 
in  trying  to  prevent  the  procreation  of  syphilitic  children,  these  weakly 
and  miserable  specimens  of  humanity  will  come  into  the  world,  and 
their  treatment  during  their  gestation  and  after  birth  will  be  a  source 
of  solicitude  and  a  tax  upon  the  therapeutic  resources  of  the  medical 
profession. 

In  this  connection  it  is  well  to  consider  what  is  the  efi"ect  of  hered- 
itary syphilis  upon  its  victims.     See  page  920. 

The  death-rate  is  so  great  that  the  resources  of  the  medical  art  cer- 
tainly should  be  taxed  to  the  utmost  to  reduce  it. 

Before  proceeding  to  the  question  of  the  treatment  of  syphilitic 
mothers,  it  is  important  to  consider  the  part  of  the  father  as  a  factor  in 
the  causation  of  hereditary  syphilis.  It  is  now  well  known  that  men  in  the 
grasp  of  active  syphilis  very  frequently  procreate  infected  children  whose 
mothers,  unless  infected  by  some  active  lesion,  may  remain  free  from  the 
disease.  Therefore  it  is  the  duty  of  the  physician  to  explain  to  a  syph- 
ilitic father  that  his  disease  is  liable  to  infect  his  ofispring,  and  to  urge 
him  to  avail  himself  of  all  possible  measures  to  rid  himself  of  it. 

The  necessity  of  treating  a  syphilitic  mother  being  therefore  so  ob- 
vious, the  question  arises,  Can  we  treat  such  a  mother  wdthout  danger  to 
herself,  and  will  that  treatment  be  beneficial  to  her  and  to  her  offspring  ? 
So  many  facts  have  been  accumulated  by  so  many  observers  in  medical 
literature — notably,  Massa,  Garnier,  De  Bl^gny,  Astruc,  Petit,  Fabre, 
Levret,  Rosen,  Underwood,  Swediaur,  Bell,  Bertin,  S.  Cooper,  Lagneau, 
Gibert,  Cazenave,  Cullerier,  and  Ricord — as  to  the  wisdom  and  benefit 
to  be  derived  both  by  mother  and  child  from  a  well-ordered  antisyphilitic 
course  of  treatment  during  pregnancy  that  I  will  answer  the  question  and 
its  subdivision  emphatically  in  the  affirmative.  I  know  of  no  condition 
in  the  course  of  syphilis   which  more  urgently  demands  an  active  and 


HEREDITARY  SYPHILIS.  961 

energetic  but  careful,  watchful,  and  conservative  treatment  than  does 
pregnancy  in  a  syphilitic  woman.  Huguier  and  others  thought  that  mer- 
curial treatment  predisposes  a  woman  to  more  serious  danger  in  abortion 
than  if  a  simple  treatment  had  been  followed.  Indeed,  the  idea  was  and 
is  prevalent  that  mercury  will  produce  abortion  in  pregnant  women.  If 
carelessly  and  unsparingly  used,  it  may  undoubtedly  produce  abortion  and 
imperil  a  woman's  life.  But  if  the  treatment  is  followed  on  the  lines  in- 
dicated in  this  chapter,  no  harm  will  be  done  and  infinite  good  will  cer- 
tainly result.  I  am  fully  in  accord  with  Sigmund,^  who  says  that  there 
is  not  the  slightest  danger  to  the  mother  or  child  by  the  use  of  a  careful 
inunction  treatment.  By  this  means  he  has  seen  (and  I  can  confirm  his 
statement)  living  and  healthy  children  brought  into  the  world.  As  cor- 
roborative evidence  I  may  here  give  Ricord's  views,  Avhich,  though  old, 
are  very  apposite.  He  says :  "  The  period  of  gestation  in  women,  far 
from  contraindicating  energetic  treatment,  demands  increased  attention 
and  promptitude  within  the  bounds  of  prudence.  I  have  seen  very  many 
more  abortions  among  syphilitic  women  who  had  not  been  treated  than 
among  those  who,  taken  in  time,  had  been  subjected  to  methodical  medi- 
cation." 

A  question  so  vitally  important  as  the  present  one  should  be  treated 
in  the  light  of  accomplished  facts,  and  something  more  than  mere  state- 
ments should  be  offered.  It  is  interesting,  therefore,  to  know  that  the 
effect  of  mercurial  treatment  upon  the  pregnant  syphilitic  woman  has 
been  carefully  and  extensively  studied  under  Sigmund's  guidance  and 
in  his  wards  by  Lowy^  and  Fonberg.^  Lowy's  observations  go  to 
show  that  by  treating  pregnant  syphilitic  women  by  inunctions  abortion 
was  reduced  to  13.5  per  cent.,  while  in  those  not  treated  the  ratio  was 
29.5  per  cent.  After  inunctions  there  were  75  per  cent,  of  living  chil- 
dren. His  observations  further  prove  that  the  treatment  exerts  no  bad 
influence  over  the  life  of  the  mother  and  of  the  foetus,  and  that  it  does 
not  cause  abortion  or  premature  labor,  and  further,  that  it  lessens  the 
severity  of  the  disease  in  both.  In  like  manner,  Fonberg  found  that  the 
inunction  treatment  reduced  the  number  of  abortions  from  28.5  to  14  per 
cent.  He  very  wisely  adds  that  a  too  energetic  treatment  may  be  injur- 
ious to  mother  and  child. 

Clinical  observation  has  the  support  of  a  fact  derived  from  careful 
chemical  analysis.  Cathelineau,*  at  Fournier's  suggestion,  made  a  careful 
analysis  of  the  viscera  of  a  foetus  whose  mother  was  treated  by  inunctions. 
He  found  unmistakable  evidence  of  mercury  in  the  liver,  heart,  kidneys, 
and  other  organs  as  well  as  in  the  amniotic  fluid. 

These  conclusions,  the  outcome  of  careful  and  extended  observation 
and  study,  supported  by  the  testimony  of  the  observers  mentioned,  cer- 
tainly should  be  accepted,  and  this  beneficent  medication  should  be 
administered  to  the  pregnant  Avoman. 

1  Op.  cIl,  1878,  p.  lOSetseq. 

^  "  Beobachtungen  an  einen  Reihe  von  Syphilitischen  Schwangeren  welche  der 
Einreibungscur  unterzogen  Werden,"    Wiener  med.    Woche7ischrift,'No.  39,  18(^9. 

^  "  Einige  statische  Daten  ueber  Syphilis  der  Schwangeren  niit  Riicksicht  aiif 
Hereditiit  und  Behandlung,"  ibirL,  Nos.  49-51,  1872. 

*  "  Passage  du  Mercure  de  la  Merc  au  Fnc tus  dans  le  Traitement  antisyphilitique  fait 
pendant  la  Grossesse,"  BuUelin  de  la  Socieie  Fran^aise  de  Deimn.  el  de  Syph.,  1890,  vol.  i. 
pp.  167  et  seq. 

61 


962  SYPHILIS. 

Pregnancy,  therefore,  is  an  exigency  in  whicli,  as  shoAvn  on  p.  824,  the 
very  early  administration  of  antisyphilitic  treatment  is  indicated.  The 
management  of  syphilis  in  the  pregnant  woman  requires  of  the  physician 
skill,  care,  and  watchfulness.  As  soon  as  the  chancre  is  diagnosticated  it 
should  be  treated  carefully  and  efficiently.  Lesions  of  any  kind  on  the 
genitals  of  the  pregnant  woman  indicate  the  necessity  for  great  cleanli- 
ness. This  is  especially  necessary  when  chancre  is  present.  Therefore 
frequent  mild  antiseptic  injections  and  ablutions  should  be  made  to  the 
parts,  in  order  to  avoid  any  complicating  inflammatory  conditions.  Then 
mercurial  ointment  on  cotton  or  lint  should  be  applied  continually  to  the 
chancre.  Throughout  the  course  of  gestation  this  antisepsis  of  the  exter- 
nal genitals  should  be  regularly  followed. 

It  is  important  that  the  physician  should  have  an  accurate  knowledge 
of  the  eifect  of  the  various  preparations  of  mercury  upon  the  pregnant 
woman,  in  order  that  he  may  adopt  a  proper  treatment.  There  is  no  fact 
in  syphilography  more  deeply  engraved  upon  my  mind  than  that  of  the 
utter  futility  of  treating  a  pregnant  syphilitic  woman,  and  of  endeavoring 
to  prevent  or  render  more  mild  the  disease  in  the  child,  by  the  use  of 
mercurial  pills.  I  can  look  back,  ten  to  twenty  years  ago,  to  many  cases 
in  which  mothers  thus  treated  were  not  at  all  benefited,  often  much  incon- 
venienced and  troubled,  and  in  which  no  effect  upon  the  syphilis  in  the 
child  was  produced.  Many  failures  with  the  protoiodide  in  this  direction 
convinced  me  of  its  feeble  powers,  and  my  clinical  results  find  their 
explanation  in  the  experiments  of  Welander.^  This  observer  found  that 
by  mercurial  .inunctions  and  hypodermic  injections  the  drug  was  rapidly 
absorbed  by  the  mother  and  transmitted  to  the  foetus,  but  that  when  pills 
of  the  protoiodide  were  administered  the  absorption  was  very  slow  and 
the  action  very  feeble,  owing  to  the  smallness  in  quantity  of  the  mercury 
absorbed.  Therefore,  in  general  it  is  a  waste  of  time  to  treat  a  syphilitic 
woman  either  by  the  protoiodide,  by  gray  powder,  blue  pill,  the  tannate, 
or  any  other  preparation  which  is  swallowed  in  pill  form.  Further  than 
this,  disaster  may  follow  such  a  course.  Many  a  man  has  thus  treated  a 
pregnant  syphilitic  woman  and  innocently  imagined  that  he  was  doing  all 
in  his  power  for  her. 

It  is  well,  therefore,  to  institute  a  systematic  inunction  treatment  Avith 
all  the  precautions  and  safeguards  spoken  of  in  the  section  upon  this 
branch  of  the  subject.  No  pains  should  be  spared  in  watching  the 
woman  to  learn  that  all  goes  well  and  that  the  therapeutic  effect  is  being 
obtained.  In  this  way  course  after  course  of  inunction  should  be  given, 
with  proper  intervals  of  rest,  during  the  whole  period  of  pregnancy.  If 
the  treatment  is  carefully  administered  and  the  general  condition  and  sur- 
roundings of  the  woman  are  favorable,  there  will  be  no  trouble  in  keeping 
on  to  the  end. 

In  like  manner,  if  admissible,  hypodermic  injections  of  sublimate  will 
be  found  of  especial  benefit.  They  should  be  given  for  a  week  or  two  at 
a  time,  in  the  retro-trochanteric  regions  principally.  One  very  great 
advantage  of  the  inunction  and  of  the  injection  methods  is  that  the 
stomach — so  prone  to  rebel — and  the  intestines  are  spared. 

But  it  often  happens  that  objections  to  these  methods  are  offered,  and 

^  "  Recherches  sur  1' Absorption  et  sur  I'EIimination  du  Mercure  dans  I'Organisme 
humain,"  Annales  de  Derm,  et  de  Syph.,  188G,  p.  412  et  seq. 


HEREDITARY  SYPHILIS.  963 

that  the  condition  of  the  patient  will  not  permit  of  their  employment. 
On  the  principle  that  half  a  loaf  is  better  than  no  bread,  the  physician 
may  sometimes  compromise  matters  and  have  the  patient  take  a  few 
inunctions  for  a  time  or  a  few  injections,  and  then  fill  in  the  balance  of 
the  time  by  medicine  given  internally.  He  should  make  it  very  clear  to 
the  patient  that  if  she  can  possibly  use  the  inunctions  or  submit  to  the 
injections  for  short  periods  and  at  odd  times,  she  will  be  much  the  gainer. 

Internally,  the  mixture  of  mercury  and  iodide,  the  formula  of  which 
is  to  be  found  on  p.  843,  may  be  given  if  stomach  ingestion  is  found  to  be 
the  most  acceptable  method. 

The  foregoing  considerations  concern  chiefly  early  and  active  syphilis, 
in  Avhich  condition  mercury  is  especially  indicated.  In  the  case  of  women 
in  later  periods  of  syphilis,  who  are  either  the  subjects  of  repeated  abor- 
tion or  whose  children  show  evidence  of  hereditary  taint,  iodide  of  potas- 
sium in  good-sized  and  perhaps  increasing  doses,  combined  Avith  mercury, 
should  be  given  with  proper  intermissions  during  the  whole  pregnancy. 
Pregnant  women  in  an  advanced  stage  of  syphilis  are  greatly  benefited 
by  the  iodide  alone,  but  particularly  in  combination  with  mercury.  The 
embryos  of  these  women  of  course  have  a  more  advanced  form  of  syphilis, 
and  these  drugs  given  to  the  mother  exert  beneficial  therapeutic  efiects 
upon  the  child  she  carries. 

In  this  connection  it  is  well  to  remember  the  teachings  of  the  case  of 
Moreau,^  which  was  that  of  a  Avoman  who,  after  several  successive  preg- 
nancies always  ending  in  premature  birth  and  death  of  the  foetus,  in 
despair  as  to  the  cause  was  submitted  to  an  active  syphilitic  treatment, 
and  who  thereafter  gave  birth  to  healthy  children  at  full  term. 

As  claimed  by  Dubois,  Depaul,  Moreau,  Vidal  de  Cassis,  and 
Put^gnat,  parents  who  procreate  syphilitic  children,  even  though  they 
themselves  may  appear  healthy  and  show  no  signs  of  the  disease,  should 
undergo  a  regular,  methodical  antisyphilitic  treatment. 

Indirect  Treatment  hy  Means  of  the  Milk  of  the  Mother  or  of  the 
Nurse. — As  early  as  1699,  Garnier  proposed  to  treat  syphilitic  children 
by  means  of  the  milk  of  the  mother  or  nurse,  to  whom  mercury  was  being 
administered.  This  method  is  called  "  the  indirect  Avay  of  treating  hered- 
itary syphilis,"  and  it  has  many  advocates,  and  perhaps  as  many  oppo- 
nents. It  is  a  subject  which  often  arises  in  the  practice  of  medicine, 
and  is  one  concerning  which  few  physicians  have  definite  ideas. 

The  adoption  of  this  treatment  Avas  really  the  outcome  of  the  difficul- 
ties experienced  in  administering  antisyphilitic  treatment  to  young  infants. 
The  older  physicians  not  only  treated  the  mother  or  the  nurse,  but  in  the 
case  of  the  absence  or  defection  of  either  of  these  parties  they  caused  the 
hair  to  be  shaved  off  a  female  goat  or  ass,  had  the  animal  Avell  rubbed 
with  mercurial  ointment,  and  then  the  child  Avas  made  to  nurse  it,  and 
thus  simultaneously  get  sustenance  and  medication.  SAvediaur  says  that 
in  one  of  the  reigning  families  of  Europe  no  child  survived  a  certain  age 
until  this  treatment  Avas  adopted.  Though  benefit  was  noted  in  many 
cases  as  folloAving  this  treatment,  it  Avas  claimed  by  some  that  no  mercury, 
or  only  an  insignificantly  insufficient  quantity,  Avas  conveyed  by  the  milk, 
and  that  the  seeming  improvement  in  the  child's  condition  was  due  to  the 
auspicious  course  of  its  disease.     Leaving  aside  the  older  analyses  of  milk 

*  Lancereaux,  Traite  historique  el  pratique  de  la  Syphilis,  Paris,  1873,  p.  562. 


964  SYPHILIS. 

from  mercurialized  women  and  animals,  in  some  of  which  it  was  stated 
that  mercury  was  found,  and  in  others  that  it  did  not  exist,  we  come  to 
those  of  a  later  date.  Thus,  Kahler^  resorted  to  very  delicate  electro- 
lytic analysis  of  the  milk  of  women  in  whom  mercury  had  been  used  so 
thoroughly  that  existing  syphilitic  lesions  had  been  cured,  yet  no  trace  of 
the  drug  could  be  found.  Still,  he  states  that  in  certain  cases  in  which 
no  mercury  was  given  to  the  children  improvement  followed  their  nursing 
a  mother  who  was  taking  that  agent  by  inunction.  This  fact  has  been 
observed  over  a  long  stretch  of  years,  and  I  have  seen  many  striking 
instances  of  it.  On  the  other  hand,  Klink  ^  of  Warsaw,  with  the  aid  of 
Professor  Tudakowski,  submitted  such  milk  to  very  delicate  and  elaborate 
tests,  and  found  in  that  fluid  a  small  but  unmistakable  quantity  of  mer- 
cury. In  Klink 's  case  also  the  child  had  derived  benefit  from  the  mer- 
curialized milk.  On  this  subject  Welander^  says:  "I  have  only  made 
three  observations  on  the  elimination  of  mercury  by  the  milk.  A  woman 
who  had  taken  only  ninety  pills  of  the  protoiodide  had  mercury  in  the 
urine  as  well  as  in  the  milk.  The  urine  of  her  child,  which  she  nursed, 
and  had  received  no  other  treatment  whatever,  also  contained  mercury. 
To  a  woman  who  had  no  mercury  in  the  urine  an  injection  of  the  bichlo- 
ride was  administered  and  five  days  after  I  found  mercury  in  the  urine  of 
her  child.  In  another  case  mercury  was  found  in  the  urine  of  a  child 
each  time  after  six  experiments  with  bichloride  injections  given  to  its 
mother.  These  facts  are  in  accord  Avith  the  results  of  many  other  inves- 
tigators, and  they  seem  to  prove  conclusively  that  mercury  may  be  con- 
veyed to  the  child  by  its  mercurialized  mother's  milk."  The  evidence 
obtained  through  chemical  analysis  by  many  competent  observers  is  in 
striking  accord  with  the  results  of  clinical  observation,  and  the  combined 
knowledge  I  think  proves  the  benefit — never,  however,  absolute — of  the 
mercurialized  milk  of  a  syphilitic  mother. 

In  all  probability  other  conditions  besides  the  mercury  contained  in  the 
milk  are  involved  in  the  child's  improvement.  Undoubtedly,  the  syph- 
ilitic woman's  health  and  nutrition  are  improved  by  the  systematic  inunc- 
tion-treatment which  she  receives,  and  as  a  consequence  her  milk  is  purer 
and  more  sustaining  to  the  child  than  it  would  be  without  the  treatment. 
She  then  gives  a  more  competent  milk,  and  dissolved  in  it  is  the  remedy 
which  the  infant  so  sorely  needs. 

The  practical  deduction  to  be  drawn  from  these  facts,  accumulated 
during  a  period  of  several  hundred  years,  is  that  Ave  should  treat  the 
syphilitic  mother  whenever  we  can,  particularly  by  inunctions,  not  only 
for  her  own  sake,  but  also  for  that  of  her  child,  for  it  benefits  the  one 
that  receives  and  the  one  that  gives. 

We  must  not  forget  that  in  many  cases  syphilis  is  transmitted  directly 
from  an  infected  father  to  his  offspring,  and  that  the  mother  remains  to 
all  appearances  free  from  the  disease.  The  question,  therefore,  arises. 
What  shall  we  do  in  the  event  of  a  non-syphilitic  Avoman  having  a 
syphilitic  child  by  paternal  transmission  ?     It  will  be  found  that  some 

1  "  Untersuchungen  der  Milch  von  Frauen  wahrend  der  Inunctionen,"  Vierteljahr.  fur 
die  Prak.  Heilkunde,  vol.  xxxii.,  1875. 

*  "Untersuchungen  iiber  den  Nachweis  der  Quecksilber  in  der  Frauenmilch  wahrend 
einer  Einreibungskur  mit  grauer  Salbe,"  VieHeljahr.  fur  Demi,  und  Sypliilis,  1876,  pp.  207 
et  seq. 

3  Op.  eit.,  p.  415. 


HEREDITARY  SYPHILIS.  965 

of  these  mothers  are  thin,  sickly-looking  women,  while  others  are  well- 
developed  and  robust.  In  these  cases  it  has  been  my  practice,  when 
there  was  difficulty  in  administering  mercurials  to  the  child,  to  explain 
the  condition  of  affairs  to  the  mother,  and  with  her  consent  (which  is, 
as  a  rule,  readily  gained)  to  try  a  tentative  course  of  treatment  upon 
her.  When  inunctions  cannot  be  used,  hypodermic  injections  may  be 
given  or  the  mixed  treatment  may  be  taken.  The  question  of  utility 
and  of  benefit  will  be  settled  in  a  week  or  two. 

We  may  conclude,  therefore,  that  the  indirect  treatment  of  heredi- 
tary syphilis  by  mercury  should  not  be  regarded  as  one  of  the  stand- 
ard methods,  but  rather  as  a  resource  to  fall  back  upon,  or  as  an  adju- 
vant to  be  instituted  in  cases  in  which  it  is  admissible  or  seems  to  offer 
probabilities  of  benefit. 

Indirect  Administration  of  Iodide  of  Potassium  to  the  Syphilitie 
Child  by  Means  of  the  Milk  of  the  Mother  or  Nurse. — Not  only  is  mer- 
cury administered  to  the  syphilitic  child  by  means  of  the  milk,  but 
several  authors  have  adopted  this  method  of  employing  iodide  of  potas- 
sium as  the  therapeutic  agent.  La  Bourdette  and  Dumesnil,^  many 
years  ago,  showed  by  quantitative  analysis  the  presence  of  iodine  in  the 
milk  of  animals  to  whom  the  iodide  of  potassium  had  been  adminis- 
tered. This  observation  was  later  confirmed  by  Schafer,^  who  found 
iodine  in  the  milk  of  a  woman  two  hours  after  the  ingestion  of  15 
grains  of  the  iodide.  These  results  were  fully  confirmed  by  a  number 
of  experimenters,  among  whom  was  Welander,^  who  observed  an  iodic 
coryza  and  iodic  eruption  in  a  nursing  infant  whose  mother  was  taking 
15  grains  of  the  iodide  daily. 

In  clinical  practice  the  indirect  treatment  with  iodide  of  potassium 
does  not  possess  a  rich  literature,  but  the  reported  results  are  certainly 
worthy  of  record  and  consideration.  Lazansky*in  Pick's  clinic  thus 
treated  a  four  months'  old  child  whose  mother  took  15  grains  of  the 
iodide  daily.  The  eruption  quickly  left  the  child  and  the  mother 
became  healthier.  Chemical  analysis  of  the  milk  and  of  the  infant's 
urine  showed  the  presence  of  iodine.  This  observation  is  supported  by 
the  results  obtained  by  Link,^  who  thus  treated  four  cases  in  Gang- 
hofer's  clinic  in  Prague.  In  the  first  case,  a  child  ten  weeks  old, 
having  snufiles,  general  exanthem,  and  ulcers,  was  promptly  benefited 
and  cured  of  its  visible  lesions  in  thirty-three  days.  In  the  second 
case,  a  four-months'-old  girl,  with  exanthematic  symptoms,  and  bad 
diarrhoea,  was  relieved  of  her  existing  lesions  in  five  weeks.  The  third 
case  was  that  of  a  premature  girl,  who  had  two  days  after  birth  had  a 
general  exanthematic  condition.  During  the  ensuing  fourteen  days,  in 
which  the  mother  took  30  grains  of  the  iodide  daily,  the  child  increased 
in  weight,  and  its  rash  slowly  vanished.      In  the  fourth  case,  a  child  at 

^  "Du  Passage  de  I'Tode  par  Assimilation  digestive  dans  le  Lait  de  quelques  Mam- 

miferes,"  Gazette  des  Hopitaux,  1S56. 

^"Anfsaugung   und  Ausscheidiing  der   offic.  lodpriiparate,"   Zeitschri/t  der  Wiener 
Aerzte,  1859,  No.  5. 

*  Nordhkt  Medichmkt  Arr.hiv.  t.  vi.  No.  31,  1874. 

*  "  Ueber  die  therapeiitische  Verwendiing  von  iodhilltiger  Ammenmilch,"  Vierteljahr. 
fur  Derm,  und  StjphUh,  1878,  pp.  43  et  seq. 

^  "  Ueber  die  Behandlung  der  Syphilis  bei  Siliiglingen,"   Praqer  med.  Wochenschrift, 
1883,  pp.  305  et  seq. 


966  SYPHILIS. 

nine  weeks  presented  active  symptoms  of  hereditary  syphilis.  For  two 
weeks  it  was  treated  non-specifically  and  then  it  was  subjected  to  the 
indirect  treatment.  At  the  end  of  five  weeks  its  health  and  weight 
were  improved  and  its  rash  had  disappeared.  Link  thinks  these 
results  very  gratifying,  for  the  reason  that  the  disease  was  active  in  the 
infants,  and  was  accompanied  with  such  complications  as  diarrhoea  and 
stomatitis. 

It  is  claimed  by  Stumpf  ^  and  others,  on  theoretical  grounds,  that 
the  use  of  iodide  of  potassium  in  such  cases  is  contraindicated,  for  the 
reason  that  it  tends  to  diminish  the  quantity  of  the  milk  and  to  induce 
atrophy  of  the  mammary  glands.  It  is  very  probable  that  a  prolonged 
course  of  the  iodide  will  produce  the  effects  claimed  to  result  from  this 
drug,  but  such  will  rarely  be  necessary  in  practice.  This  treatment,  if 
it  is  adopted  by  any  one,  need  not  of  necessity  be  very  long  continued, 
but  its  effects  on  mother  and  child  should  be  carefully  watched.  If 
beneficial  it  may  be  used  until  the  child  is  far  enough  along  to  do  with- 
out treatment  for  some  time  or  until  it  can  bear  direct  treatment. 
Contraindicating  conditions  should  cause  its  prompt  rejection. 

The  indirect  treatment  of  hereditary  syphilis  by  means  of  the  iodide 
is  therefore  a  measure  of  reserve  and  utility,  to  be  employed  only  in 
some  cases  when  other  methods  are  impracticable  or  temporarily  contra- 
indicated. 

As  in  the  chapter  on  the  General  Methodical  Treatment  of  Syphilis 
I  take  the  ground  that  in  most  cases  iodide  of  potassium  is  powerless, 
and  often  harmful,  it  may  seem  inconsistent  for  me  thus  in  a  measure  to 
recommend  this  drug  for  women  and  children.  But  it  is  well  to  remem- 
ber that  in  some  cases  there  seem  to  be  two  conditions  to  treat — namely, 
the  essential  syphilis  and  the  symptoms — which  are  explainable  only  on 
the  theory  advanced  by  Finger,^  that  in  addition  to  the  syphilitic  virus 
the  system  is  poisoned  by  ptomaines  or  tissue-products  which  result  from 
the  action  of  the  virus.  Besides  the  symptoms  already  mentioned  as 
being  probably  caused  by  tissue-products,  it  seems  very  probable,  judg- 
ing from  clinical  observation,  that  in  pregnant  syphilitic  women  and 
their  children  these  morbid  secretions  are  very  often  active  and  potent. 
At  any  rate,  the  theory  seems  rational,  and  it  is  an  undisputed  fact  that 
in  some  of  these  cases  the  iodide  acts  favorably. 

It  is  also  necessary  to  emphasize  the  fact  that  the  mixed  treatment, 
either  with  an  excess  of  the  iodide  or  of  mercury,  is,  as  said  before,  very 
often  a  most  valuable  agent  in  the  treatment  of  pregnant  syphilitic  women. 
Useful  and  efficacious  before  childbirth,  it  is  also  in  some  cases  beneficial 
to  the  mother  and  also  to  the  child.  The  indirect  method,  employing  the 
mixed  treatment,  should  be  remembered  by  physicians  in  the  category  of 
inunctions  and  of  iodide  of  potassium. 

The  Treatment  of  the  Syphilitic  Infant. — The  treatment  of  the  syphi- 
litic infant  is  in  many  cases  a  question  which  necessitates  great  delicacy, 
tact,  and  prudence  on  the  part  of  the  physician,  and  in  every  case  a  good 
knowledge  of  the  disease,  of  medicine  in  general,  and  of  therapeutics  is 
required.     The  subject  can  best  be  presented  by  a  consideration  of  the 

'  "  Ueber  die  Veriinderungen  der  Milchsecretion  unter  dem  Einfliisse  einiger  Medica- 
mente,"  Deutsches  Archiv  fur  klin.  Med.,  vol.  xxx.,  1881  and  1882,  pp.  201  et  seq. 
2  Op.  cit. 


HEREDITARY  SYPHILIS.  967 

condition  of  the  infant  from  its  birth  onward.  The  first  question  to  settle 
is  when  to  begin  to  treat  the  child.  So  eminent  an  authority  as  Archam- 
bault^  thinks  that  the  offspring  of  a  known  syphilitic  father  or  mother 
should  be  put  upon  treatment  at  once,  even  if  it  appears  healthy  and 
presents  no  visible  syphilitic  lesions.  Should  such  a  child  present  any 
evidence  of  cachexia,  the  prompt  adoption  of  treatment  is  imperative. 
However,  as  it  is  not  very  uncommon  for  a  syphilitic  woman  to  beget,  or 
a  syphilitic  father  to  procreate,  a  seemingly  healthy  child,  which  as  it 
grows  up  may  show  no  evidence  of  hereditary  infection,  it  is  always  well, 
if  medication  is  commenced  very  early,  that  it  should  not  be  too  active  or 
energetic.  A  baby  may  be  puny  at  birth  and  not  be  syphilitic,  but  it  is 
fair  to  assume  that  a  puny  baby  whose  father  or  mother  is  syphilitic  is  so 
far  syphilitic  itself  that  it  needs  the  intervention  of  rational  treatment. 

It  may  be  stated  as  a  general  rule  that  syphilitic  infants  who  have  a 
chance,  even  slender,  for  their  life  come  into  the  world  with  little  or  no 
sign  of  their  inheritance  upon  them.  Therefore  for  a  time  important 
objective  phenomena  are  wanting.  Then  in  many  cases  the  physican  can 
get  no  information,  for  the  reason  that  the  parents  may  forget  that  they 
have  had  syphilis  or  they  (one  or  both)  conceal  the  fact,  or,  again,  they 
may  be  ignorant  of  the  possibility  and  danger  of  hereditary  transmission. 
In  hospitals  we  frequently  see  women  who  give  birth  to  tainted  children, 
but  who  can  give  no  facts  relating  to  the  father  from  whom  the  disease 
had  been  derived.  Then  in  infant  and  foundling  asylums  children  in  the 
very  early  latent  period  of  syphilis  are  left  for  care,  concerning  whom  no 
history  whatever  is  obtainable.  So  that  in  private  and  in  public  practice 
the  diagnosis  of  hereditary  syphilis  in  the  new-born  is  commonly  very 
difficult,  and  ready  knowledge  and  acumen  on  the  part  of  the  physician 
are  very  essential. 

In  private  practice,  in  many  cases  Avhere  no  data  are  volunteered  by 
either  father  or  mother  as  to  their  condition  before  the  birth  of  the  infant 
the  physician's  position  is  very  delicate,  and  sometimes  very  trying. 
Under  these  circumstances,  he  should  act  with  great  prudence  and  tact, 
keeping  his  own  counsel,  but  he  should  at  once  place  the  child  upon  proper 
treatment,  and  then  await  developments.  Generally,  the  child's  illness 
will  cause  the  father  or  the  mother  to  think  of  his  or  her  previous  condi- 
tion, and  then  a  ray  of  light  may  be  shed.  As  a  general  rule,  in  this 
complication  of  affairs  the  physician  had  better,  if  necessary,  approach 
the  father  on  the  subject  of  the  child's  disease,  since  he  Avill  commonly 
be  found  to  be  the  guilty  person,  or  his  past  history  will  be  such  that  a 
suspicion  of  syphilis  having  been  derived  from  him  will  in  all  probability 
not  greatly  shock  or  surprise  him.  In  general,  he  will  do  very  little  in 
the  way  of  recrimination  of  his  wife,  and  will  prefer  to  keep  silent. 

Before  considering  general  methodical  treatment,  something  should  be 
said  concerning  the  management  of  young  infants  and  children  thus 
infected.  First,  as  to  the  nourishment.  If  possible,  the  child  should 
be  nursed  by  its  mother,  who  sliould  be  subjected  to  proper  treatment, 
and  placed  in  such  a  condition  that  slie  can  supply  nutritious  milk.  If 
the  mother  cannot  suckle  her  child,  it  must  be  put  upon  cow's  milk  prop- 
erly sterilized,  and  care  must  be  taken  to  sustain  its  nutrition  in  every 

^  "  Traitement  de  la  Syphilis  infantile,"  Journal  de  Medecine  ei  Chirurc/ie  praliques, 
June,  1878. 


968  SYPHILIS. 

possible  way.  In  no  instance  should  a  syphilitic  child  be  put  to  the  breast 
of  a  healthy  ■woman.  Though  Diday  has  long  advised  and  sanctioned 
such  a  course,  the  condemnation  of  it  by  all  other  authors  is  unanimous. 
On  this  subject  I  can  with  advantage  quote  the  words  of  Grassi^  on  the 
responsibility  of  the  physician  concerning  the  employment  of  a  wet-nurse 
for  a  syphilitic  child.  He  says  :  "  It  is  the  peremptory  duty  of  the  parents 
to  inform  the  wet-nurse  of  the  danger  she  is  exposing  herself  to.  This  is 
especially  the  duty  of  the  physician,  as  there  are  cases  on  record  in  which 
such  Avet-nurses  have  infected  their  husbands,  their  children,  and  other 
persons  in  their  neighborhood.  But  even  if  a  wet-nurse  knowingly  con- 
tracted for  such  service  in  consideration  of  large  pay,  it  would  be  the  duty 
of  the  physician  to  prevent  this,  for  individual  liberty  must  be  restricted 
as  soon  as  others  suffer  from  it :  Salus  jniblica  siqjrema  lex  esto."  Four- 
nier  has  also  spoken  emphatically  in  the  same  vein.  If  possible,  a  well- 
nourished  wet-nurse  should  be  obtained.  This  is  usually  a  less  difficult 
task  than  might  be  supposed,  for  syphilitic  mothers  can  usually  be  found 
in  infant  asylums  and  in  large  public  hospitals.  In  some  rare  cases,  for 
various  reasons,  the  urgency  is  very  great,  and  parents  are  willing  to  make 
any  sacrifice  to  save  their  child.  On  this  subject  Steiner^  says  "that  a 
syphilitic  child  should  not  be  given  to  a  wet-nurse.  I  must,  however, 
confess  that  there  are  exceptions  to  the  rule.  I  myself  have  been  obliged 
to  allow  this  in  certain  cases  where  life  could  only  be  preserved  by  the 
employment  of  a  wet-nurse.  But  I  never  do  this  without  informing  the 
nurse  of  the  danger  she  is  likely  to  expose  herself  to.  If,  thus  warned, 
she  is  prepared  to  undergo  the  risk,  I  have  at  least  done  my  duty  as  a 
man  and  as  a  physician."  The  foregoing  so  clearly  brings  out  the  neces- 
sities and  duties  in  these  cases  that  nothing  remains  to  be  added. 

On  the  Continent  the  practice  of  suckling  syphilitic  children  by  means 
of  a  she-goat  or  she-ass  has  been  in  vogue  from  an  early  date,  but  it  has 
not,  to  my  knowledge,  been  employed  in  this  country.  In  a  recent 
brochure  Bellaserra^  strongly  advocates  the  use  of  animals  in  nursing 
syphilitic  infants,  and  he  makes  the  suggestion  that  she-goats  and  she- 
asses  should  be  kept  ready  for  such  use  at  maternity  hospitals  and  at 
infant  asylums.  If  this  method  is  adopted  in  any  case,  due  care  must  be 
taken  that  the  quantity  and  quality  of  the  milk  shall  be  in  keeping  with 
that  of  the  human  female. 

The  general  hygiene  of  the  child  should  be  upon  as  high  a  plane  as 
possible.  Hereditary  syphilis,  being  accompanied  with  atrophy,  wasting, 
and  many  debilitating  influences,  requires  more  than  any  other  infantile 
disease  every  possible  healthy  surrounding  and  aid.  Then  stress  should 
be  laid  upon  the  actual  care  of  the  infant.  The  physician  should  en- 
deavor to  bring  intelligent  antisepsis  to  its  aid  in  every  possible  direction. 
The  mouth,  tongue,  and  nose  should  receive  attention,  and  for  this  pur- 
pose there  is  nothing  better  than  a  solution  of  boric  acid  (10  to  20  grains 

^  "Un  Appunto  all'  Articnlo  di  Diday:  Sulla  Eesponsibilita  del  Medico  verso  11 
neonato  e  verso  la  Nutrice,"  Giornale  Ital.  delle  Mai.  Ven.  e  delle  Pelte,  vol.  11.,  1868,  pp. 
233  at  seq. 

'^  "Zur  Behandlung  der  Heredltaren  Syphilis,"  Oexter.  Jahrbuch.  fib-  Padiatrick,  1870, 
N.  F.  1,  pp.  95  et  seq. 

^  "  Prophylaxia  de  la  Sifilis  en  el  Nifio  y  en  la  nodeyza  por  I\Iedio  de  la  lactencia 
Animal,  particnlarmente  en  las  iVlaternidades  y  Casas  de  exposltos,"  Pevista  de  Ciencias 
Medicaa  de  Barcelona,  1887,  o,  pp.  129  et  seq. 


HEREDITARY  SYPHILIS.  969 

to  the  ounce).  With  this  the  nose,  if  snuffles  are  present,  may  be  gently 
irrigated,  and  the  mouth  carefully  washed  three  or  four  times  a  day. 
Great  care  should  be  exercised  to  prevent  septic  infection.  The  tissues 
of  the  young  child,  particularly  when  it  is  syphilitic,  are  very  vulnerable 
to  the  inroads  of  pyogenic  and  septic  cocci,  which  luxuriate  in  them. 
These  gain  access  to  the  system  through  the  skin  and  mucous  membrane, 
also  through  the  intestines,  and  probably  through  the  lungs.  Therefore,- 
great  care  should  be  taken  to  heal  up  quickly  any  fissure,  abrasion,  or 
cut  surface.  Thus  any  lesion  about  the  scalp,  face,  mouth,  eyes,  and 
anus  or  on  any  part  of  the  body  should  be  looked  upon  as  a  source  of 
danger,  and  promptly  healed.  In  very  early  days  the  navel  should  be 
carefully  watched  and  kept  in  an  aseptic  condition  by  irrigations  of  car- 
bolic-acid water,  followed  by  drying  and  dusting  with  powdered  boric 
acid  or  some  other  absorbent  powder.  Then,  further,  the  anus  and  its 
folds  should  be  looked  after.  Attention  to  the  alimentary  canal  may 
perhaps  restore  that  to  a  satisfactory  condition,  and  thus  rid  the  child  of 
a  serious  source  of  danger. 

As  before  stated,  in  most  cases  of  hereditary  syphilis  in  which  the 
child  is  born  alive  there  may  be  no  evidence  of  its  disease  at  birth  or  for 
some  time  after.  But  in  some  cases  soon  after  birth  syphilitic  lesions  are 
seen  in  the  infant.  The  most  precocious  evidence  of  hereditary  syphilis 
is  the  bullous  eruption,  and  it  is  always  the  expression  of  profound  sys- 
temic poisoning.  This  eruption  brings  up  the  question  of  the  very  ear- 
liest treatment  of  hereditary  syphilis.  For  very  young  infants,  as  a  rule, 
some  mercurial  salt  in  powder  form,  internally  administered,  is  the  one 
best  borne  and  most  commonly  productive  of  good,  if  such  is  attainable. 
For  this  purpose  many  prefer  calomel,  and  they  administer  it  in  doses  of 
I  to  ^  grain  three  times  daily  for  very  young  children.  It  is  well  to  give 
a  small  dose  to  a  very  weakly  child,  and  then  to  increase  it  as  fast  as 
possible.  For  well-nourished  infants  J  or  J  grain  may  be  given  three 
times  daily.  Calomel  can  be  rubbed  up  with  a  little  sugar  of  milk,  and 
the  powder  placed  on  the  child's  tongue  before  it  is  put  to  the  breast.  In 
case  of  diarrhoea,  colic,  or  sleeplessness,  a  little  Dover's  powder  may  be 
added  to  the  mercurial  preparation  which  is  to  be  used.  When  it  is  pos- 
sible to  administer  them,  adjuvant  tonics  should  be  combined  with  the 
mercurial.  For  this  purpose  the  saccharated  carbonate  of  iron  is  much 
praised  by  Steiner  and  other  authorities  in  chidren's  diseases.  It  is 
palatable  and  well  borne  by  the  stomach,  and  may  often  be  employed  with 
marked  benefit,  particularly  in  children  who  have  reached  their  third  or 
fourth  month.  Many  years  ago  Monti  ^  proposed  the  saccharated  iodide 
of  iron  in  the  treatment  of  syphilis,  either  with  or  without  the  addition 
of  calomel.  It  is  a  remedy  which  may  be  given  with  benefit  when  the 
child  is  six  months  or  a  year  old,  but  considerable  difficulty  will  be  expe- 
rienced in  giving  it  to  very  young  infants  in  whom  it  may  also  produce 
vomiting.  Within  a  few  years  Monti  ^  has  proposed  a  combination  of 
calomel  and  lactate  of  iron,  which  I  have  found  of  especial  benefit  in 
children  three  months  and  more  old.      The  prescription  is  as  follows : 

*  "  Ueber  die  Behandlung  der  Angebornen  Lues  mit  Ferri  iod.  Saccliarat,"  Journal  fib- 
KinderheUkundp,  1876,  vol.  ix.  pp.  335  et  seq. 

^  "  Ueber  iiltere  und  Neiiere  Methoden  der  Behandlung  der  Angebornen  Lues," 
Archivfixr  Kinderheilkunde,  vol.  vi.,  1885. 


970  SYPHILIS. 

I^.   Hydrarg,  chlor.  mit.,  gr.  jss  ; 

Ferri  lactatis,  gr.  v  ; 

Sacchari  albi,  gr.  xlv. — M. 

Ft.  in  pulv.  No.  x. 

From  one  to  four  of  these  powders  may  be  given  daily,  according  to  the 
weight  of  the  child. 

Calomel  may  be  given  for  a  considerable  time  with  benefit  and  with- 
out deranging  the  stomach  and  bowels.  However,  its  action  should  be 
carefully  watched,  and  if  anaemia  shows  itself  the  drug  should  be  dis- 
continued. 

Following  a  course  of  calomel  powders  it  is  well  to  allow  an  interrup- 
tion in  the  specific  treatment,  during  which  the  saccharated  carbonate  of 
iron  may  be  given  or  the  saccharated  iodide  of  iron,  according  to  the 
formula  of  Monti,  as  follows : 

I^.  Ferri  iodidi  saccharat.,  gr.  xv. 

Sacchari  albi,  gr.  xxx. — M. 

Ft.  pulv.  No.  x. 
One  to  three  powders  should  be  given  daily,  according  to  circumstances. 

Gray  powder  (hydrargyrum  cum  creta)  is  also  used  by  many.  It  is 
sometimes  quite  efficient  in  its  action,  and  commonly  it  is  less  liable  to 
produce  gastro-intestinal  reaction  than  any  other  mercurial.  Its  use  is 
indicated  in  very  weak  infants  with  a  tendency  to  great  disturbance  of 
the  stomach  and  bowels.  It  is,  however,  not  uniformly  efficacious.  It 
may  be  given  in  doses  from  |  to  |^  of  a  grain  three  times  daily. 

The  protoiodide  of  mercury  has  been  used  in  the  treatment  of  hered- 
itary syphilis  with  more  or  less  benefit  for  many  years.  Bednar  ^  used 
it  largely  in  |-  to  |-grain  doses,  and  considered  it  very  efficient.  Later 
experience  has  shown  that  in  general  these  doses  are  too  large,  and  are 
apt  to  be  followed  by  bowel  troubles  and  ansemia.  Monti  thinks  that 
this  salt  is  especially  beneficial  in  the  bone  lesions  of  hereditary  syphilis, 
and  uses  the  following  formula  : 

I^.  Hydrarg.  iodidi  virid.,  gr.  jss  ; 

Ferri  lactatis,  gr.  iij  ; 

Sacchari  albi,  gr.  xlv. — M. 

Ft.  in  pulv.  No.  x. 
One  to  three  powders  may  be  given  daily. 

In  very  young  children  it  is  well,  if  the  protoiodide  is  used,  to_  begin  with 
the  dose  of  ^  grain,  which  may  be  increased  according  to  indications. 
Though  it  is  an  active  and  efficient  remedy  in  children,  its  use  is  com- 
monly attended  with  colic  and  intestinal  derangements,  which  necessitates 
the  admixture  of  powdered  opium  or  Dover's  powder. 

Henoch  prefers  the  black  oxide  of  mercury,  according  to  the  follow- 
ing formula : 

'  Die  Krankheiten  der  Neugebornen  und  Sduglingen,  Wien,  1853. 


HEREDITARY  SYPHILIS.  971 

I^.  Hydrarg.  oxid.  nigri,   *  gr.  jss; 

Sacchari  albi,  gr.  xlv. — M. 

Ft.  pulv.  No.  X. 
One  powder  morning  and  evening. 

Monti  has  found  this  preparation  less  efficient  than  calomel. 

The  tannate  of  mercury  is  well  thought  of  by  some  authorities,  and 
it  will  be  found  to  be  very  prompt  in  its  action,  and  to  cause  syphilitic 
lesions  to  disappear  rapidly.  It  may  be  given  in  doses  of  ^V  to  ^  grain 
three  times  daily,  according  to  the  age  and  weight  of  the  child. 

I  have  recently  seen  a  mild  and  efficient  action  follow  the  use  of  the 
thymolo  acetate  of  mercury  in  two  cases  of  hereditary  syphilis,  and  I 
think  that  this  preparation  should  be  borne  in  mind,  for  it  is  capable  of 
producing  good  results. 

In  administering  these  mercurial  powders  the  physician  should  always 
be  on  the  watch  as  to  their  action  and  as  to  the  condition  of  the  little 
patient.  In  general,  interrupted  courses  of  a  month  or  six  weeks'  dura- 
tion should  be  followed,  during  which  the  child  should  have  plenty  of 
fresh  air  and  every  conceivable  hygienic  benefit. 

By  many  authors  corrosive  sublimate  is  held  in  high  esteem  in  the 
treatment  of  hereditary  syphilis.  It  is  used  chiefly  in  the  very  early 
weeks  of  life  and  throughout  the  child's  first  year.  If  used,  it  is  best 
given  in  the  form  of  Van  Swieten's  liquid  in  combination  with  a  little 
milk.  For  very  young  children  the  dose  of  this  liquid  is  5  to  10  drops 
two  or  three  times  a  day,  which  is  to  be  increased  considerably  for  older 
children. 

Thiry  of  Brussels  recommends  a  solution  of  corrosive  sublimate  in 
emulsion  of  bitter  almonds  as  preferable  to  any  other  preparation.  There 
can  be  no  doubt  that  some  benefit  may  result  from  this  mercurial  salt 
when  taken  by  the  mouth  in  some  cases,  but  in  my  judgment  it  is  far 
inferior  to  the  salts  already  mentioned,  and  cannot  be  compared  for  cer- 
tainty of  effect  with  inunctions.  In  whatever  form  given^  corrosive  sub- 
limate is  exceedingly  liable  to  derange  the  stomach  and  bowels ;  hence  it 
is  at  best  a  very  uncertain  remedy.  Given  subcutaneously,  it  is  fre- 
quently very  efficient.  It  may  be  well  to  remark  that  most  of  the  authors 
who  recommend  this  agent  by  the  mouth  add  as  a  rider  to  their  remarks 
that  it  may  be  necessary  also  to  employ  inunctions  simultaneously,  or  give 
the  child  in  addition  baths  of  corrosive  sublimate. 

Iodide  of  potassium  has  a  rather  limited  sphere  in  the  treatment  of 
hereditary  syphilis.  It  may  be  of  benefit  in  bone,  joint,  and  cerebral 
affections  and  in  lesions  of  the  eye  and  ear.  On  this  subject  Steiner,^ 
who  made  comparative  studies  of  the  treatment  of  syphilis  by  mercury, 
by  iodine,  and  by  the  expectant  plan,  says :  "From  my  experiments  on 
children  I  am  convinced  that  iodine,  as  well  as  mercury,  causes  the  symp- 
toms of  hereditary  syphilis  to  disappear,  yet  with  the  important  difference 
that  this  happens  more  slowly  under  the  administration  of  iodine  than  of 
mercury.  Whatever  improvement  is  attained  in  days  with  mercury  is  not 
accomplished  in  weeks  with  iodine." 

As  already  stated,  the  limits  of  employment  of  tlie  iodide  are  restricted, 
and  its  use  in  children  as  in  adults  is  attended  by  more   or  less  severe 

'  Op.  cit. 


972  SYPHILIS. 

symptoms  of  iodism.  In  some  children  small  doses  produce  prompt  toxic 
effects,  while  in  others  saturation  of  the  system  may  occur  before  untoward 
symptoms  show  themselves.  The  main  symptoms  of  iodic  derangement 
in  children  are — gastric  and  gastro-intestinal  irritations,  catarrh  of  the 
nasal  mucous  membrane,  angina,  headache,  trembling,  increased  temper- 
ature, emaciation  and  weakness,  and  sometimes  dermatitis  of  varying 
sevei'ity.  These  possible  complications  should  be  remembered  by  the 
physician.  It  should  be  mentioned  that  some  physicians  who  recommend 
the  iodide  also  state  that  it  is  well  to  combine  its  administration  with 
inunctions.  Monti  makes  the  significant  remark  that  the  iodide  is  only 
suitable  for  cases  in  which  an  energetic  treatment  is  not  indicated,  or 
where  sublimate  baths  are  used. 

The  dose  of  the  iodide  for  very  young  infants  is  from  |^  to  1  grain, 
well  diluted,  three  times  a  day.  For  children  of  a  year  or  older,  5  grains 
or  more  may  be  given  three  times  daily. 

The  mixed  treatment,  however,  is  very  efficient  in  many  cases  of  hei'ed- 
itary  syphilis,  particularly  of  the  bones  and  viscera,  and  in  syphilitic 
subcutaneous  tumors.  My  experience  with  the  following  formula,  which 
I  gave  in  my  book  ^  years  ago  has  been  uniformly  favorable  in  the  cases 
in  which  a  combination  treatment  is  indicated : 

1^.  Hydrarg.  chloridi  corrosiv.,  gr.  j-ij  ; 

Potassii  iodidi,  Sss ; 
Syrup,  aurantii  cort., 

Aquae,  da.  ^ij. — M. 

For  young  children  the  dose  is  5  to  10  drops  (always  well  diluted)  three 
times  a  day.  This  preparation  is  practically  the  same  as  Gibert's  syrup, 
which  is  much  employed  by  French  physicians. 

In  addition  to  this  treatment  by  the  mouth,  other  methods  of  using 
mercury  are  employed  in  the  treatment  of  hereditary  syphilis.  As  a 
general  rule,  mercury  by  stomach  ingestion  is  to  be  recommended  for  the 
first  year  of  the  child's  life.  As  it  grows  older  we  can  resort  to  mercurial 
inunctions.  This  method  of  treatment  is  as  efficient  for  the  infant  and 
child  as  for  the  adult,  and  its  administration  to  the  former  requires  all  the 
care  and  circumspection  laid  down  as  necessary  for  the  latter.  (See  chap- 
ter on  Inunctions.)  There  is  a  marked  lack  of  unanimity  of  opinion  in 
the  minds  of  medical  men  as  to  the  value  and  usefulness  of  inunctions  in 
hereditary  syphilis.  Thus  we  find  their  use  strongly  deprecated  by  Wider- 
hofer,^  who  says  that  they  produce  bad  results,  and  that  he  has  seen  fatal 
bleeding  from  the  ears  and  marasmus  produced  by  them,  Avhile,  on  the  other 
hand,  Simon  ^  and  many  others  speak  warmly  in  their  praise.  The  truth 
is,  that  much  benefit  may  be  derived  from  their  use,  provided  due  caution 
and  care  are  exercised.  The  inunctions  should  be  given  daily,  using  15 
or  20  grains  of  the  strong  mercurial  ointment,  going  over  the  whole  body 
after  the  plan  already  described.     At  the  same  time,  the  child   should 

1  Op.  cit.,  1876. 

''"Ueber  Syphilis  und  deren  Behandlung,"  Allg.  Wien.  med.  Zeiiung,  ]886,  Nos.  30 
and  31. 

^  "  De  la  Syphilis  infantile  congenitale:  de  son  Traitement  compare  avec  celui  de  la 
Syphilis  des  Adultes,"  Rev.  inens.  des  Maladies  de  i'Enfance,  June,  1886,  pp.  245  et  seq. 


HEREDITARY  SYPHILIS.  973 

receive  an  iron  tonic,  and  perhaps  some  cod-liver  oil.  Should  signs  of 
debility,  restlessness,  and  sleeplessness,  of  weakness  or  ansemia,  show 
themselves,  the  inunctions  should  be  stopped  at  once.  In  some  cases, 
particularly  in  children  a  year  or  more  old,  the  local  use  of  mercurial 
ointment  or  of  mercurial  plasters  is  productive  of  much  benefit.  The 
ointment  may  be  spread  upon  canton  flannel  or  buckskin,  and  bound 
around  the  child's  body.  By  this  means  mercury  is  absorbed,  and  fre- 
quently benefit  is  noted,  particularly  in  cases  of  enlarged  liver  or  spleen. 
Mercurial  inunctions  and  plasters  are  very  effective  in  many  cases  of 
hereditary  bone  and  joint  disease.  In  intracranial  syphilis,  meningeal 
inflammation,  gummy  tumors,  and  hydrocephalus  internus,  this  method, 
particulai-iy  when  combined  with  iodide  of  potassium  given  internally, 
is  often  productive  of  surprising  results.  The  quantity  of  mercurial 
ointment  (50  per  cent.)  for  each  inunction  is  about  15  grains  for  a 
young  child,  and  this  quantity  may  be  increased  to  30  grains,  provided 
there  are  no  contraindicating  conditions,  and  that  improvement  is  noted. 
Elsenberg  in  a  recent  essay  ^  advises  full  doses  of  the  iodide  internally, 
and  the  inunctions  to  be  pushed  until  slight  gingivitis  or  salivation  is 
produced  ;  then  the  dose  should  be  diminished  or  the  treatment  tem- 
porarily stopped.  It  may  be  necessary  and  expedient  thus  to  push 
this  combination  treatment,  but  it  should  only  be  done  when  the  case 
is  under  the  careful  observation  of  the  physician. 

Widerhofer  prefers  an  ointment  of  red  precipitate  (1  :  100  of  lanolin) 
to  mercurial  ointment  for  children.  About  the  head  a  white  precipitate 
ointment  (1  drachm  to  1  ounce  of  vaseline)  will  be  found  of  decided  bene- 
fit, and  in  the  case  of  infants  with  very  fastidious  parents  this  ointment 
may  take  the  place  of  blue  ointment.  White  precipitate  is  readily 
absorbed  by  the  adult  or  infant  integument. 

Hypodermic  injections  of  mercurial  preparations  have  long  been  used 
in  the  treatment  of  hereditary  syphilis.  Monti  ^  was  one  of  the  first  ex- 
perimenters with  this  method,  and  he  employed  it  in  cases  of  intestinal 
troubles,  of  laryngitis,  and  where  a  quick  result  was  necessary.  His 
doses  of  the  sublimate  thus  used  were  from  -^-^  to  -g-  of  a  grain.  In  chil- 
dren under  a  year  old  the  smallest  dose  is  used  ;  in  those  under  five 
years  of  age  -g^  of  a  grain  ;  and  in  large,  well-developed  children  -^ 
of  a  grain  may  be  injected.  My  colleague.  Professor  Jacobi,  informs  me 
that  he  has  used  these  injections  in  very  young  infants  and  in  older  ones 
for  many  years  in  severe  cases  when  a  prompt  and  efficient  action  was 
necessary.  He  has  seen  benefit  in  very  bad  cases  of  children  recently 
born.  The  resulting  nodosities  are  said  to  be  not  painful,  to  cause  little 
if  any  inconvenience,  and  to  disappear  promptly.  I  can  well  understand 
that  in  some  private  and  hospital  cases  this  method  may  be  employed 
with  signal  success  when  the  child  is  fully  under  the  control  of  the  phy- 
sician. But  it  should  always  be  employed  with  care  and  watchfulness. 
Monti,  Smirnoff",  and  others  advocate  the  use  of  calomel  injections,  while 
others,  again,  employ  the  albuminate,  the  peptonate,  and  other  prepara- 
tions of  mercury.  No  preparation  of  mercury,  however,  is  superior  to 
the  sublimate  for  this  purpose. 

^  "  Die  Behandlung  der  Syphilis,"  Wiener  Klinik,  Aug.  and  Sept.,  1891,  pp.  277  et  seq. 
■' "  Beobachtungen  iiber  die  Behandlung  der  Syphilis  congenita  et  acquisita  mittelst 
subcutanen  sublimat  Injectionen,''  Juhrb.  far  Kinderheilkunde,  1869,  4  Heft. 


974  SYPHILIS. 

This  treatment  will  never,  to  my  mind,  be  a  success  in  dispensaries 
and  clinics.  Moncorvo  and  Ferreira^  in  an  out-door  clinic  at  Rio 
Janeiro  used  gray  oil,  calomel,  salicylate  of  mercury,  and  yellow  oxide  on 
forty-seven  children  from  thirty-eight  days  to  fourteen  years  old,  taking 
the  retro-trochanteric  regions  for  the  sites  of  injection.  They  found  that 
the  sublimate  and  gray  oil  were  easily  borne  and  most  eflBcient.  But  we 
find  at  the  end  of  nearly  every  clinical  history  these  significant  words : 
"  Le  malade  ne  revient  plus  au  service,"  "nous  avous  perdu  de  vue  cette 
fillete."  In  my  experience  in  out-door  services,  as  a  rule,  patients  submit 
to  one  or  two  hypodermic  injections  of  mercurials,  and  perhaps  more,  and 
then  they  disappear. 

Baths  of  corrosive  sublimate  are  frequently  of  great  benefit  in  the 
treatment  of  hereditary  syphilis,  and  it  is  important  that  the  physician 
should  know  their  scope  and  their  limitations.  They  should  never  be 
relied  upon  as  a  methodical  treatment,  though  Cassel  ^  claims  that  by  the 
use  of  from  twelve  to  thirty-six  baths  he  has  cured  obstinate  cases  of 
bone-lesions,  sometimes  with  the  aid  of  calomel.  These  baths  are  partic- 
ularly indicated  in  the  cases  of  the  bullous  syphilide,  of  syphilitic  roseola, 
of  papular  syphilides,  condylomata  about  the  genitals,  and  in  cases  in 
which  there  are  complicating  ulcerations.  In  some  children  with  a  thin, 
atrophic  skin,  icterus,  and  enlarged  spleen  they  may  produce  benefit. 
The  quantity,  as  stated  by  Elsenberg,^  will  be  found  to  be  beneficial. 
Thus  1^  to  30  grains  of  sublimate,  according  to  the  age  and  size  of  the 
child,  with  an  equal  quantity  of  chloride  of  ammonium,  dissolved  in  a 
glass  of  hot  water,  should  be  added  to  7  or  8  gallons  of  warm  water.  The 
child  should  stay  in  this  from  five  to  ten  minutes,  and  then  should  be 
wrapped  up  Avarmly  and  put  to  bed.  If  erythema  follows  this  treatment, 
the  surface  should  be  dusted  with  infant  powder.  But  if  the  reaction  is 
severe  and  persistent,  it  may  be  necessary  to  discontinue  the  baths.  The 
suitability  of  the  treatment  may  be  ascertained  after  three  or  four  baths. 
If  the  general  condition  of  the  child  and  its  lesions  are  benefited,  they 
may  be  kept  up.  But  any  signs  of  resulting  depression,  weakness,  sleep- 
lessness, and  refusal  of  food  should  lead  to  their  discontinuance.  The 
baths  may  be  given  every  second  day,  or  perhaps  every  third  or  fourth 
day.  Though  some  authors  recommend  this  method  of  treatment  for 
very  young  infants,  as  a  rule  it  will  be  found  of  most  service  in  children 
from  one  to  three  years  old.  lodide-of-potassium  baths  have  been  used, 
but  no  one  has  claimed  to  have  obtained  conspicuously  brilliant  results. 

Local  applications  to  the  lesions  of  hereditary  syphilis  are  similar  to 
those  used  in  the  acquired  form  of  the  disease.  The  ulcers  and  encrusted 
surfaces  left  by  the  bullous  syphilide  and  other  eruptions  of  an  ulcerative 
character  should  first  be  washed  with  a  1  or  2  per  cent,  carbolic  solution, 
and  then  dressed  with  the  following : 

i^i.  Zinci  oxidi, 

Pulv.  amyli,  da.  3ij  ; 
Hydrarg.  chloridi  mite,  ^s-sj  ; 

Vaselini,  5ss. — M. 

^  "Du  Traitement  de  la  Syphilis  infantile  par  les  Injections  souscutanees  de  Sels  mer- 
curielles,"  Revue  mem^uelh  des  Med.  de  I'Evfance,  Jnne  and  July,  1891. 

'^  "  Beitriige  zur  Hereditaren  Syphilis,  besonders  der  Knockenerkrankungen  bei  des- 
selben,  Archiv  filr  Kinderheilkunde,  1885,  Bd.  6,  pp.  1 7  et  seq.         ^  Op.  cit.,  pp.  244,  277. 


LESIONS  OF  THE  PLACENTA.  975 

This  ointment  may  be  used  for  fissures  about  the  mouth,  nose,  and 
anus.  If  a  stimulant  is  admissible,  10  drops  of  carbolic  acid  may  be 
added  to  each  ounce  of  ointment. 

White  precipitate  ointment  and  a  combination  of  protoiodide  of  mer- 
cury and  cold  cream  (10  to  20  grains  to  the  ounce)  may  be  useful  in  scaling 
papular  eruptions,  particularly  of  the  palms  and  soles. 

Rhinitis  may  be  treated  by  the  use  of  dilute  Dobell's  solution,  injected 
sloAvly  and  carefully  into  the  nostrils  once  or  twice  a  day.  This  may  be 
followed  by  the  similar  application  of  a  solution  of  nitrate  of  silver  (|-  to 
1  grain  to  the  ounce  of  water).  In  some  cases  a  mild  solution  of  boric 
acid  or  of  borax  is  beneficial  in  removing  mucus  and  crusts.  Mild  solu- 
tions of  nitrate  of  silver  are  necessary  for  mouth  and  lingual  ulcerations. 
Condylomata  lata  of  the  genitals  should  be  kept  clean  and  dry,  and  should 
be  dusted  with  a  powder  like  the  following : 

^i.  Ilydrarg.  chloridi  mite,  Siss  ; 

Pulv.  amyli,  §j. — M. 

If  these  lesions  have  become  hypertrophic,  they  may  be  carefully 
touched  with  a  solution  of  nitrate  of  silver  (20  grains  to  the  ounce),  or 
with  the  ordinary  acetic  acid,  or  half-strength  carbolic  acid.  When  stim- 
ulating applications  are  made  to  these  lesions,  great  care  should  be  taken 
to  prevent  inflammatory  reaction. 

Bone,  joint,  and  fascial  lesions  should  be  treated  by  plasters  formed 
of  strong  mercurial  ointment  and  Lassar's  paste,  of  each  equal  quantities. 
In  the  management  of  hereditary  ocular  and  aural  aifections,  besides  an 
energetic  internal  treatment,  such  local  measures  are  necessary  as  may  be 
indicated  by  the  condition  present. 

In  general,  the  treatment  of  acquired  syphilis  in  infants  and  young 
children  is  the  same  as  that  given  for  the  hereditary  form  of  the  disease. 
In  acquired  syphilis  of  the  young  the  physician  has  less  trouble,  for  he 
usually  is  not  confronted  with  the  atrophic  condition  and  the  tendency  to 
marasmus  which  are  so  common  in  the  hereditary  disease. 


CHAPTEK    LXXXVII. 

LESIONS  OF  THE  PLACENTA. 

Our  knowledge  of  the  effects  of  syphilis  upon  the  placenta  is  still 
incomplete  in  many  particulars.  Previous  to  the  publication  of  Virchow's 
lectures  on  tumors  the  subject  was  little  understood,  and  its  literature 
consisted  only  of  a  number  of  papers  by  various  authors,  in  none  of 
which  Avas  there  any  approach  to  full  and  scientific  investigation.  In 
1873,  however,  Ernst  Frankcl  ^  published  an  elaborate  article,  reviewing 

^  "Ueber  Placentar  Syphilis,"  Arch.  f.  GynilL,  Berl.  v.,  1-54,  1873. 


976  SYPHILIS. 

the  cases  whicli  had  already  appeared  and  giving  the  results  of  his  own 
careful  studies.  An  abstract  of  his  paper  will  give  a  better  idea  of  the 
subject  than  it  is  possible  to  offer  in  any  other  manner. 

Frankel  believes  that  our  want  of  knowledge  of  placental  syphilis  has 
been  due  in  a  measure  to  the  attempt  to  include  all  cases  under  a  single 
form,  and  that  the  portion  of  the  placenta  first  affected  must  vary  accord- 
ing as  the  father  is  alone  syphilitic,  and  according  as  the  mother  con- 
tracted syphilis  before  conception  or  shortly  after ;  and  finally,  that  the 
foetus  can  be  but  little,  if  at  all,  affected  if  the  mother  contracts  the 
disease  late  in  pregnancy. 

Virchow  admits  two  forms  of  placental  affection :  endometritis  decid- 
ualis;  endometritis  placentaris. 

To  these  Frankel  adds  a  third:  disease  of  the  villous  portion  of  the 
foetal  placenta. 

Frankel  founds  his  conclusions  on  the  examination  of  over  one  hun- 
dred placentae,  including  those  of  stillbirths,  those  of  abortion,  and  those 
of  mothers  having  recent  or  old  syphilis.  The  histories  of  the  father  and 
mother  were  obtained  whenever  possible,  and  a  record  of  the  macroscopic 
and  microscopic  appearances  was  kept.  The  post-mortem  examinations 
of  the  foetus  were  made  by  Prof.  Waldeyer  and  his  assistant. 

He  groups  his  cases  into  the  following  classes : 

A.  Disease  of  the  villi  of  the  foetal  placenta. 

B.  Mixed  form  of  placental  disease,  the  disease  of  the  villi  encroaching 
upon  the  adjacent  portions  of  the  placenta  materna. 

C.  Disease  of  the  foetus  only,  without  involvement  of  the  placenta. 

D.  Primiary  disease  of  the  placenta  materna  (endometritis  placentaris 
gummosa). 

The  characteristic  lesions  of  the  placenta  are  changes  in  volume, 
weight  and  consistency,  and,  microscopically,  the  thick,  plump  form  of 
the  foetal  villosities,  which  is  due  to  the  filling-up  of  the  villous  spaces 
with  an  abundant  proliferation  of  moderately-sized  cells  proceeding  from 
the  blood-vessels,  complicated  with  a  proliferation  of  the  cell-contents  of 
the  villi.  Obliteration  of  the  blood-vessels,  and,  finally,  complete  destruc- 
tion of  the  villi,  ensue.  This  affection  may  appropriately  be  called 
"  Deformino;  Proliferation  of  Granulation-cells  of  the  Placental  Villi." 

The  following  is  a  more  detailed  description  of  the  above  changes : 
Macroscopic  Appearances. — Increased  size  and  weight  (up  to  1000 
grammes)  of  the  placenta,  in  strong  contrast  to  the  slight  development  of 
the  foetus. 

Closer  and  firmer  texture  of  the  placental  tissue,  yet  differing  from 
that  of  old  extravasations  of  blood  and  fibrinous  nodules.  Color,  pale 
yellowish-gray,  resembling  gray  nerve-matter:  this  color  was  uniformly 
diffused  in  some  cases ;  in  others  it  was  circumscribed  in  larger  or  smaller 
wedge-shaped  processes,  extending  from  the  uterine  surface  toward  the 
foetus.  A  point  of  special  importance  was  the  constant  marked  opacity 
of  this  abnormally  colored  portion  of  the  placenta,  especially  noticeable 
in  the  circumscribed  form.  In  this  latter  case  the  healthy  villous  tissue 
which  lay  between  these  portions  was  markedly  hypergemic  and  livid  in 
its  color  near  the  transitional  portion.  Old  and  recent  extravasations  of 
blood  in  all  stages,  from  organized  fibrin  to  cysts  of  dark  grumous  blood, 
were  also  found. 


LESIONS  OF  THE  PLACENTA.  977 

The  uteri7ie  surface  of  the  ijlaceiita  had  indistinct,  faded,  patchwork 
appearances,  which  were  due  to  opacity  and  thickening  of  the  decidual 
covering.  The  color  was  often  yellowish-gray.  Immediately  beneath 
these  spots  lay  the  wedge-shaped  processes  or  areas  above  referred  to, 
and  when  the  latter  extended  to  the  foetal  surface  they  also  appeared  of  a 
yellowish  color  through  the  chorial  covering. 

The  amnion  and  chorion  were  thickened  and  rendered  opaque  by 
deposits  of  finely  granular  masses,  and  they  Avere  adherent  to  each  other 
in  spots  Avhich  Avere  occasionally  the  seat  of  extravasated  blood.  The 
umbilical  arteries  were  only  once  atheromatous  to  any  extent;  their 
intima  was  colored  yellow,  fatty,  and  thickened ;  this  change,  however, 
extended  but  a  short  distance  from  the  placenta  toward  the  foetus.  On 
the  foetal  surface  of  the  placenta,  in  many  cases,  were  numerous  miliary 
whitish  nodules  about  the  size  of  a  hempseed,  which  closely  followed  the 
course  of  the  vessels,  and  were  simple  hyperplasia  of  the  connective  tissue 
of  the  chorion. 

Microscopic  Appearances. — In  preparing  specimens  for  the  micro- 
scope it  was  first  noticed  that  the  villi  of  the  changed  placenta  required 
much  more  teasing  and  pulling  apart  than  usual.  They  appeared  thick- 
ened and  opaque  even  to  the  naked  eye,  and  under  a  low  power  of  the 
microscope  it  was  evident  that  they  were  swollen,  plump-looking,  irregular 
in  their  form,  and  bulbous.  Their  ends  were  enlarged  into  knob-like 
processes,  and  the  branches  were  irregularly  formed.  Their  normal  trans- 
parency had  entirely  disappeared.  They  were  filled  with  round  and 
spindle-shaped,  occasionally  polygonal,  small  and  moderate-sized  cells, 
which  were  finely  granular  and  contained  one  or  two,  and  sometimes  three 
nuclei.  These  cells  were  especially  abundant  in  the  centre  of  the  villous 
spaces  along  the  axis  where  the  vessels  usually  take  their  course.  In  the 
villous  trunks  and  branches  the  spindle-shaped  cells  predominated  ;  in  the 
ends  of  the  villi,  the  round  cells.  Many  of  these  cells  were  undergoing 
fatty  degeneration,  and  the  villous  space  was  often  filled  by  fatty  and 
molecular  detritus.  The  blood-vessels  of  the  villi  were  sometimes  com- 
pletely obliterated,  often  circularly  compressed,  while,  again,  no  traces  of 
them  could  be  found. 

The  epithelium  of  these  villi  was  often  wholly  wanting;  when  present, 
it  was  denser  than  usual,  its  cells  strongly  granular  and  opaque.  In  one 
case  the  change  Avas  confined  to  the  epithelium  alone,  Avhile  the  villous 
space  was  SAvollen  by  oedematous  transudation  from  the  dilated  villous 
blood-vessels. 

When  healthy  places  still  existed  in  these  placentae,  the  normal  villi 
were  usually  found  near  the  foetal  surface,  but  even  these  had  a  stroma 
rich  in  cells,  which  at  the  same  time  exhibited  numerous  connective-tissue 
fibres.  Their  vessels  Avere  dilated,  tortuous,  very  full,  and  ruptured  in 
spots. 

The  most  frequent  complication  of  this  change  in  the  villi  Avas  ex- 
travasation of  blood,  Avhich  was  either  superficial  or  deep-seated,  and 
which  occurred  in  streaks  along  the  borders  of  the  vessels  or  oftener  still 
in  the  form  of  sharply-defined,  firm  nodules  Avhich  extended  to  one  of  the 
placental  surfaces.  The  exuded  blood  exliibited  the  most  varied  transi- 
tional stages  ;  the  enclosed  villi  AA^ere  atrophied  and  fatty  and  degenerated 
into  fibrous  tissue. 

62 


978  SYPHILIS. 

In  explanation  of  the  origin  and  course  of  these  changes,  Frankel 
states :  Owing  to  the  irritation  caused  by  syphilis,  proliferation,  in  a 
greater  or  less  number  of  villi,  begins  in  the  cells,  which,  in  the  normal 
stroma  of  the  villi,  are  only  sparingly  found.  Their  nuclei,  and  still  later 
the  cells  themselves,  undergo  manifold  division;  and  the  increase  in 
number  of  the  cells  is  attended  by  an  increase  in  their  size.  This  pro- 
liferation is  chiefly  seated  about  the  vessels  of  the  villi  and  about  the 
deeper  ones  of  the  parenchyma,  as  well  as  around  the  more  superficial 
and  also  about  the  fine  capillary  network  lying  directly  beneath  the 
epithelium. 

Homologous  products  arise  in  every  tissue  of  the  villus  in  consequence 
of  this  hyperplasia, — cell-prolifei-ation  of  connective  tissue  in  the  stroma, 
epithelial  proliferation  in  the  epithelial  covering.  The  cell-proliferation 
causes  compression  of  the  vessels,  interferes  with  the  circulation,  and 
finally  leads  to  thickening  of  their  walls  and  obliteration  of  the  vessels 
themselves.  The  villi  themselves  are  filled  up  with  cells,  become  hyper- 
distended,  plump,  and  thickened.  The  vascular  spaces  into  which  they 
dip  become  filled  up  and  narrowed,  and  in  the  most  advanced  stage  they 
entirely  disappear.  By  this  means  and  by  the  proliferation  and  thicken- 
ing of  the  epithelial  covering,  the  interchanges  between  the  maternal  and 
foetal  blood  is  interfered  with,  and  finally  is  wholly  obstructed.  The  villi, 
having  lost  their  function,  undergo  fatty  degeneration.  The  cells  of  the 
stroma  and  epithelium  become  filled  with  fat-globules  and  finally  break 
down  into  granular  matter. 

If  the  process  is  diffuse  and  continuous  over  the  whole  placenta,  the 
foetus  has  in' the  mean  time  perished;  if  limited  to  circumscribed  foci,  it 
may  have  continued  to  live.  In  the  latter  case  the  degeneration  fre- 
quently appears  to  have  advanced  from  the  uterine  toward  the  foetal  sur- 
face;  the  contrary,  however,  has  been  noted.  The  relatively  healthy 
portions  of  the  placenta  between  the  diseased  parts  are  the  seat  of  deep 
congestion ;  their  blood-vessels  are  dilated  and  gorged  with  blood.  Ex- 
travasations of  blood  in  all  stages  of  retrograde  change  occur,  and  now 
and  then  connective  tissue  formation  in  the  interstitial  tissue  is  super- 
added. Thickening  of  the  intima  of  the  umbilical  vessels  has  been  found 
but  once  by  Frankel,  Avho  considers  it  the  result  of  the  resistance  met 
with  by  the  circulation  in  the  deformed  and  compressed  villi,  and  not  a 
truly  syphilitic  lesion.  Although  this  process  might  be  considered  a 
chronic  inflammation  or  one  due  to  new  formation  of  granulation-tissue, 
yet,  on  the  whole,  it  must  be  conceded  that  it  begins  as,  and  runs  the 
course  of,  a  chronic  inflammatory  process. 

The  reasons  for  calling  this  lesion  syphilitic  are — 

1.  It  was  found  in  all  of  Frankel's  cases  in  which  autopsies  showed 
the  existence  of  syphilitic  lesions  of  the  bones  in  the  foetus. 

2.  The  proof  of  the  existence  of  syphilis  in  the  parents  in  many 
cases. 

3.  That  this  lesion  was  not  due  to  the  death  of  the  foetus  is  shown  by 
its  existence  in  several  cases  in  which  the  foetus  was  living. 

4.  Absence  of  this  lesion  in  every  other  case  of  diseased  placenta  ever 
examined  by  Frankel. 

5.  Club-shaped  hypertrophy  and  cell-infiltration  are  constant  accom- 
paniments of  syphilis. 


LESIONS  OF  THE  PLACENTA.  979 

Predisposing  Causes. — It  appears  that  this  condition  of  the  villi  is 
developed,  even  if  the  health  of  the  mother  is  in  a  fair  condition  at  the 
time  of  conception,  and  that  it  is  certainly  due  to  a  direct  transfer  of  the 
paternal  syphilis  to  the  foetus,  as  shown  by  the  fact  that  its  almost  exclu- 
sive seat  is  in  the  foetal  portion  of  the  placenta,  the  maternal  portion  not 
always  presenting  characteristic  appearances. 

It  may  be  objected  that  the  ovum  may  have  been  infected  through 
diseased  ovaries  on  the  part  of  the  mother,  without  any  lesion  of  the 
remainder  of  the  genital  tract.     To  this  it  is  to  be  said : 

1.  Syphilitic  disease  of  the  ovaries  rarely  occurs. 

2.  In  Frankel's  case  V.  the  disease  existed  in  the  foetal  placenta,  yet. 
post-mortem  examination  of  the  mother  failed  to  reveal  any  ovarian, 
disease. 

3.  In  case  XVI.,  that  of  a  markedly  syphilitic  child,  villous  degen- 
eration was  present,  together  with  gummous  degeneration  of  the  adjoin- 
ing maternal  tissues,  and  yet  the  decidual  covering  of  the  convex  surface 
of  the  placenta  was  not  involved — a  portion  which  by  Winkler  is  con- 
sidered "the  great  highway"  from  the  mother  to  the  foetus  through  the 
placenta, 

Frankel  next  inquires  whether  the  origin,  progress,  and  course  of 
the  disease  can  be  inferred  by  reasoning  from  the  exclusive  seat  of  the 
syphilitic  affection  in  the  foetus  and  foetal  portion  of  the  placenta,  taken 
in  connection  with  the  history  of  the  case.  Of  17  mothers,  14  were 
free  from  disease  at  and  before  their  confinement ;  1  died,  the  autopsy 
revealing  no  syphilitic  lesion ;  2  mothers  became  diseased,  1  on  the  fifth 
day,  the  other  during  the  fourth  week  after  confinement.  The  lesions 
in  the  mothers  before  confinement  were:  in  1,  condylomata  lata;  in  1, 
psoriasis  at  time  of  confinement,  the  chancre  having  been  acquired  in 
the  second  month  of  pregnancy ;  in  1,  syphilis  denied,  but  glandular 
lesions  afforded  strong  suspicion. 

Frankel  relates  one  case  in  which  the  maternal  portion  of  the  pla- 
centa was  primarily  affected.  This  he  calls  "  primary  disease  of  the 
placenta  materna  "  (endometritis  placentaris  gummosa).     The  case  reads 

as  follows :  Bertha  B has  suffered  since  youth  Avith  eruptions  and 

suppurating  glandular  enlargements.  Has  marked  leucorrhoea ;  was 
never  under  syphilitic  treatment.  Husband  not  syphilitic.  Now  has 
swollen  post-cervical  glands  and  pigment-spots  on  forehead.  Has  had 
five  children  in  five  years  ;  one  macerated  foetus  at  eight  months ;  one 
born  living  which  died  at  the  age  of  five  weeks  with  ulcers,  etc. ;  third 
and  fourth,  abortions  in  early  months ;  fifth,  child  born  at  eight  months, 
breathed  feebly  and  died  in  half  an  hour.  Autopsy  of  fifth  child 
showed  infant  atrophic,  general  induration,  especially  of  lungs,  liver, 
and  spleen.  Spleen  very  large.  Osteochondritis  syphilitica  present. 
Placenta  weighed  480  grammes,  of  a  brownish-red  color;  its  diameter 
16  and  15  cms. ;  thickness  1.3  cm. ;  cord  normal.  Convex  surface  of 
placenta  covered  by  coagula ;  markings  of  lobuli  obliterated  through 
thickening  of  placenta  materna.  Vertical  section  showed  yellowish-gray 
spots  or  nodules  of  the  placenta  materna,  which  seemed  continuous  and 
inseparable  from  the  foetal  placenta. 

Under  the  microscope  dccidua  showed  slight  and  localized  fatty 
degeneration,  while  the   thickened  portions  were  the   seat  of  cell-pro- 


980  SYPHILIS. 

liferation.  The  nodules  were  composed  of  connective  tissue,  studded 
with  granulation-cells,  and  their  interior  contained  finely  granular 
detritus,  but  no  normal  villi.  The  villi  are  found  between  them  and 
compressed  by  them ;  they  are  atrophied,  devoid  of  blood-vessels,  very 
fatty,  and  calcified.  The  foetus  had  visceral  and  bone  syphilis,  and 
the  mother  suffered  with  syphilis  before  conception ;  the  direct  influ- 
ence of  the  disease  in  the  mother  upon  the  placenta  is  apparent.  In 
the  previous  cases  referred  to  the  villi  were  the  seat  of  the  disease, 
while  here  it  was  the  maternal  placenta. 

In  all  the  seven  cases  reported  up  to  the  present  time  of  endometri- 
tis placentaris  gummosa,  the  mothers  presented  Avell-marked  symptoms 
of  syphilis,  but  Frankel  states  that  he  has  met  with  cases  in  which  the 
syphilitic  mother  had  a  healthy  placenta.  He  thinks  that  in  these 
latter  cases  the  disease  circulates  through  the  blood  without  leaving  any 
trace  of  it  at  any  point,  Avhile  in  other  instances  it  is  localized  in  the 
endometrium  and  is  then  transmitted  to  the  foetus. 

That  syphilitic  endometritis  occurs  is  beyond  question ;  it  only  re- 
mains to  prove  that  this  endometritis  decidua  or  placentaris  gummosa 
recurs  every  time  that  an  abortion  takes  place  in  the  same  woman. 
In  this  case  the  fact  of  local  transmission  would  be  established,  and 
local  treatment  of  the  uterine  cavity  would  be  demanded  as  well  as 
general  constitutional  treatment. 

The  influence  upon  the  foetus  of  placental  disease  is  of  course  preju- 
dicial. In  all  seven  cases  the  infants  were  premature ;  six  were 
already  macerated,  and  one,  though  born  alive,  was  so  atrophic  that 
it  died  soon  after  birth. 


INDEX 


A. 

Ablation  of  scrotum,  466 
Abortion  of  syphilis  by  early  mercurializa- 
tion,  813 
Bronson  on,  814 
Hutchinson  on,  813 

of  hard  chancres,  809 

syphilis,  809 
Abortive  treatment,  806 
Abscess  of  Bartholin's  glands,  304 

of  Cowper's  glands,  202 

of  follicles  of  urethra,  198 

of  neck  of  bladder,  gonorrhoeal  pyaemia 
from,  272 

of  prostate,  212 

treatment  of,  217 

of  testis,  237 

urinary,  391 

of  vulvo-vaginal  glands,  304 
Abscesses,  periurethral,  196 
Accidental  syphilis,  538 
Achard  and  Hartmann  on  urinary  infection, 

389 
Acneform  chancroid,  498 

syphilide,  625 
Acorn-pointed  bougies,  344 
Acute  anterior  gonorrhoea  or  urethritis,  112 

articular  rheumatism  in  early  syphilis, 
587 

gonorrhoeal  epididymo-orchitis,  233 

peritonitis  in  the  female  from  gonor- 
rhoea, 307 

seminal  vesiculitis,  221 

yellow  atrophy  of  liver  in  syphilis,  760 
Addison's  disease  and  early  syphilis,  641 

and  gummata  of  suprarenal  cap- 
sules, 766 
Adenitis,  278 
Affections  of  the  hair,  syphilitic,  656 

of  the  larynx  in  early  syphilis,  649 

of  the  nails,  syphilitic,  660 

of  the  nose  in  early  syphilis,  649 
Agents  of  mediate  infection  in  syphilis,  539 
Albuminuria  in  early  syphilis,  591 
Ami)utation  of  the  penis,  453 
Analgesia  in  secondary  syphilis,  584 
Aneurysm  in  syphilis,  678 
Angina  pectoris  in  secondary  syphilis,  589 
Ankylosis  in  gonorrhieal  rheumatism,  265 
Annular  chancre,  546 

forms  of  erythematous  syphilides,  607 

tubercular  syphilide,  731 
Antiblennorrhagics,  eruptions  from,  276 
Antimercurialists  in  America,  825 


Antimercurialists  in  England,  825 

Antisyphilitic  remedies,  methods  of  admin- 
istering, 844 

Anus,  chancre  of,  552 
chancroid  of,  500 

Aphasia,  syphilitic,  802 

Aponeuroses,  syphilis  of,  770 

Appearances  of  female  urethra  in  gonor- 
rhoea, 291 

Arachnoid,  syphilis  of,  793 

Arning  on  the  bacteriology  of  gonorrhoea 
of  the  vulvo-vaginal  gland,  306 

Arteries  of  brain,  syphilis  of,  794 

Arteritis  and  gangrene,  744 

Aspirators,  Emmet's,  387 

i^sthenia  in  secondary  syphilis,  582 

Atrophy  of  tongue  in  sy|»hilis,  748 

Aubert  on  gonorrhoea  in  the  female  urethra, 
289 
on  lavage  of  the  anterior  urethra,  123 
on  micro-organisms  in  the  urethra,  93 

Aufuso,  inoculation  of  the  gonococcus  by, 
62 

Auto-infection  in  syphilis,  539 

B. 

Bacterie  pyogene  in  urinary  infection,  389 
Bacterioh)gy  of  chancroid,  491 

of  gonorrhoea  of  the  os  uteri,  294 

of  the  vagina,  296 
of  gonorrhoeal  vaginitis,  299 

vulvo-vaginitis,  321 
of  herpes  progenitalis,'  428 
of  pelvic  gonorrhoea,  308 
Bumm  on,  308 
Wertheim  on,  308 
Bacterium,  question  of  a,  in  syphilis,  528 
Bacterium  coli  commune  in  urinary  infec- 
tion, 388 
Balanitis  and  balano-posthitis,  392 
acquisita  diabetica,  394 
Bokai  on,  393 
causes  of,  396 
chronic,  395 
circinate  erosive,  393 
complications  of,  397 
Cordier's  ibrm  of,  393 
croupous,  393 
(lellnition  of,  392 
(lialietic,  394 
in  (lial)etics,  394 
diphtheritica,  393 
gangrene  of  prepuce  in,  397 
micotic,  394 

981 


982 


INDEX. 


Balanitis    and    balano-posthitis,    micro-or- 
ganisms in,  o94 
prognosis  of,  399 
symptoms  of,  396 
in  syphilitic  subjects,  395 
treatment  of,  399 
Balano-posthitis  and  phimosis,  403 
Banks  on  fulminating  urethral  fever,  388 

whalebone  bougies,  344 
Bardinet's  method  of  reduction  of  paraphi- 
mosis. 423 
Bartholin's  glands,  283 
abscess  of,  304 
anatomy  of,  303 
gonorrhcea  of,  305 
inflammation  of,  303 
Bartholinitis,  simple  acute,  304 
causes  of  304 
course  of,  304 
symptoms  of,  304 
Bassereaii's  confrontations,  22 

on  the  origin  of  svphilisand  chancroid, 
21 
Beaurae's  law,  929 
Beneque's  sound,  342 
Bennett  on  varicocele,  460 
Berggriin   on   the    bacteriology   of    vulvo- 
vaginitis, 321 
Bergh  on  herpes  piogenitalis  in  women,  425 
Bergmann's  operation  for  hydrocele,  476 
Bicoude  catheter,  347 
Bidenkap  on  inoculation  in  syphilis,  23 
Bigelow's  divulsor,  352 
Bladder,  anatomy  of  39 
Blandin-Xuhn  gland,  syphilis  of,  766 
Blood-serum  in  treatment  of  syphilis,  871 
Bockhart  on  micro-organisms  in  the  urethra, 

94 
Boeck  on  inoculation  in  syphilis,  23 
Bokai  on  diphtheritic  balano-posthitis,  393 
Bouton  de  regie,  428 
Bones,  gummata  of,  774 

hereditary  syphilis  of,  952 
syphilis  of,  772 
Cornil  on,  772 
Bougies  a  boule  in  chronic  gonorrhoea,  175 
in  stricture,  344 
acorn-pointed,  344 
Banks'  whalebone,  344 
filiform,  343 
olivary,  342 
Brain,  syphilis  of,  794 
Brain-tumors,  syphilitic,  797 
Breast,  chancre  of,  568 

female,  gummata  of,  727 
Broese  on  prophvlaxis  of  gonorrhoea  in  the 

female,  3(J9 
Bronchi,  tertiary  syphilis  of,  755 

syphilitic  stricture  of,  755 
Bronson  on  abortion  of  syphilis  by  early 

mercuriaiization.  814 
Brown's  urethral  speculum,  181 
Buboes,  cancerous,  449 
cliancroidal,  515 

treatment  of,  518 
definition  of,  513 
inguinal,  513 


Buboes,  inguinal,  clinical  forms  of,  514 
pathogenesis  of,  513 
simple,  514 

strumous,  so-called,  515 
sympathetic,  513 
treatment  of,  515 
abortive,  516 

by  antiseptic  injections.  516 
by  carbolic  injections,  516 
by  extirpation,  516 
Fontan  on,  517 
Hayden  on,  517 
by  incision,  516 
primary  healing  after,  518 
Scott  Helme  on,  517 
AVelander's,  516 
Watson's,  518 
tubercular.  513 
virulent,  514 

Strauss  on,  514 
Bubon  d'emblee,  513 
Bullous  hereditary  syphilide,  935 
syphilide,  742 
tertiary  syphilides,  742 
Bumm  on  the  bacteriology  of  pelvic  gonor- 
rhoea, 308 
cultivation  of  the  gonococcus  by,  88 
on  gonorrhoea  of  the  uterus,  292 
on  gonorrhcea  of  the  vagina,  295 
on  gonorrhceal  infection  in  women,  283 
Bumstead  on  the  etiology  of  gonorrhcea,  103 
Buret  on  syphilis  in  ancient  times,  18 
BurscC  attacked  in  gonorrhceal  rheumatism, 
263 
gummata  of,  771 
syphilis  of,  770 
forms  of,  771 

c. 

Cachexia  in  secondary  syphilis,  581 
Calibre  of  urethra,  48 

exaggerated  statements  as  to,  365 
Calomel  plasters  in  treatment  of  svphilis, 
868 
soap  in  treatment  of  syphilis,  869 
Cancer  and  gummata,  726 
of  penis,  442 

amputation  in  continuity  in,  453 
and  removal  of  testes  in,  456 

course  of,  444 

date  of  onset,  442 

distortions  from,  448 

diagnosis  of,  450 

etiology  of,  443 

extirpation  in,  455 

inguinal  ganglia,  449 

metastases  in,  450 

modes  of  death  from,  450 

modes  of  onset,  445 

pathological  anatomy  of,  452 

prognosis  of,  45 1 

recurrence  of,  452 

statistics  of,  442 

symptoms  of,  447 

treatment  of  453 

and  vegetations,  446 


INDEX. 


983 


Cancer  and  syphilis,  676 

of  tongue  and  syphilis,  677 
of  the  urethra,  primary,  450 
Cancerous  buboes,  449 
Cardiac  affections  in  gonorrhoea,  270 
Castex  on  micro-organisms  in  the  urethra, 

94^ 
Catheter  fever,  387 

Catheters,  method  of  introduction  of,  357 
Catheterization  in  pouchy  bulb,  359 

in  enlargement  of  the  prostate,  360 
Catheters,  346 
bicoude,  347 
conde,  Mercier's,  347 
curved  blunt,  346 
curved  olivary,  346 
silver,  347 
velvet-eye,  346 
Cephalic  chancroids.  502 
Chadwick's  statistics  of  gonorrhceal  pelvic 

disease,  288 
Chancre,  540 

abortive,  hard,  809 
annular,  546 
of  anus,  552 
appearance  of,  541 
of  bi-east,  568 

modes  of  infection  in,  569 
statistics  of,  570 
varieties  of,  571 
dry  papular,  544 
duration  of,  550 
ecthymatous,  545 
excision  of,  S07 
results  of,  810 
of  external  ear,  558 
extragenital,  statistics  of,  558 
of  eyelids.  558 
of  finger,  553 
forms  of,  553 

in  form  of  balano-posthitis,  546 
of  fossa  navicularis,  551 
of  gun)s,  556 
of  hard  palate,  556 
indurated  nodular,  546 
and  induration,  547 
induration  of,  547 

incorrect  ideas  as  to,  541 
of  integument,  552 
of  lips,  555 
of  meatus,  551 
necrotic,  nodular,  545 
of  the  OS  uteri,  567 
parchment-like,  545 
and  phagedena,  650 
redux,  548 
of  scrotum,  551 
secretions  of,  449 
silvery  spot,  544 
so-called  diphtheritic,  543 
of  tongue,  556 
of  tonsil,  557 
transformation  of,  550 
treatment  of,  816 
umbilicated  or  follicular,  544 
of  urethra,  551 
of  vagina,  566 


Chancre  with  the  cream  and  green   mem- 
brane, 543 
in  women,  559 

diffuse  exulcerated,  565 

division  of,  559 

elevated  ulcerous,  563 

incriisted,  564 

nodular,  565 

raw-beef  form  of,  664 

scaling  papular,  562 
tubercular,  562 

seat  of,  566 

superficial  erosion,  560 
Chancrous  erosion,  542 

forms  of,  543 

in  women,  560 
Chancroid,  481 
acneform,  498 
of  anus,  500 
appearances  of,  493 
bacteriology  of,  491 
cephalic,  502 
chronic  in  women,  501 
course  of,  481,  496 
development  de  novo  of,  489 
diagnosis  of,  505 
duration,  495 
ecthymatous.  498 
etiology  of,  486 
extragenital,  502 
exulcerous,  498 
follicular,  498 
of  frsenum,  501 
frequency  of,  485 
inoculations,  481 
of  integument  of  penis,  501 
and  lymphangitis,  500 
of  meatus,  500 
mediate  contagion  of,  484 
modes  of  contagion  of,  483 
nature  of,  481 
origin  of,  485 
peculiarities  of,  481 
phagedenic,  500 
prognosis  of,  506 
of  rectum,  500 
seat  of,  497 
serpiginous,  499 
and  streptobacillus,  491 
stricture  at  the  meatus  following,  364 
subpreputial,  502 
treatment  of,  506 
of  vagina,  500 
various  sources  of,  491 
varying  features  of,  498 
Chancroidal  buboes,  515 
treatment  of,  518 
paraphimosis,  421,  424 
phimosis,  407 

treatment  of,  408 
ulcus  elevatum,  543 
Chloro-anremia  of  secondary  syphilis,  582 
Chorea,  syphilitic,  802 
Choroiditis,  syphilitic,  700 
Chronic  inflammation  of  corpora  cavernosa, 
786 
orchitis,  treatment  of,  253 


984 


INDEX. 


Chronic  paraphimosis,  421 
seminal  vesiculitis,  219 
Chvostek  on  tertiary  syphilis  of  liver,  758 
Chylocele,  471 
Cicatricial  phimosis,  405 
Ciliary  body,  syphilitic  affections  of,  700 
Circumcision  for  phimosis,  410 

operation  of,  410 
Circumscribed  hydrocele,  472 
Civiale's  concealed  bistoury,  348 

urethrotome,  349 
Clavicle,  gummata  of  the,  775 
Cochlea,  syphilis  of,  713 
Cock's  operation,  383 
Colles's  law,  929 

metliod  of  reduction  of  paraphimosis, 
423 
Compressor  urethrse  muscle,  45 
Concealed  bistoury,  348 
Condylomata  acuminata,  431 
lata  of  the  anus,  655 

treatment  of,  655 
of  genital  organs,  653 
hereditary,  933 
Condylomatous  stage  of  syphilis,  524 
Congenital  hydrocele,  467 
phimosis,  401 
stricture,  339 
Congestion  of  prostate,  211 
symptoms  of  212 
treatment  of,  217 
Conical  steel  sounds,  341 
Conjunctiva,  syphilitic  affections  of,  685 
Conjunctivitis,  sero-vascular,  259 
Constitutional  syphilis,  524 
Copaiba  and  cubebs  in  gonorrhoea,  139 

eruptions  from,  276 
Cord,  syphilis  of,  794 
Cordier's  form  of  balanitis,  393 
Cornea,  syphilitic  affections  of,  687 
Cornil  on  syphilis  of  bones,  772 
Coi'nua  cutanea  syphilitica,  621 
Corona  veneris,  614 
Corpora  cavernosa,  anatomy  of,  31 

chronic  inflammation  of,  786 
gummata  of,  786 
syphilis  of,  785 
Corpus  spongiosum,  anatomy  of,  32 
Cotes's  method  of  treatment  in  gonorrhoea, 

146 
Cowper's  glands,  abscess  of,  202 
Crypts  of  Morgagni,  37 
Cseri   on   etiologv   of   urethritis   in    young 

boys,  163  ' 
Cubebs,  eruptions  from,  276 
Cultivation  of  the  gonococcus,  88 
Curvature  of  penis  from  cutting  and  over- 
dilatation,  368 
from  paraphimosis,  419 
permanence  of,  368 
phimosis,  405 
Curve  of  sounds,  342 
Curved  blunt  catheter,  346 

olivary  catheter,  346 
Cutaneous  affections  in  gonorrhoea,  275 
Cylindrical  epithelium  and  the  gonococcus, 
283 


D. 

Dactylitis  in  hereditary  syphilis,  956 
syphilitica,  778 

Dangers  of  over-dilatation  of  urethra,  368 

Danielssen  on  inoculation  in  syphilis,  25 

Deformities  of  the  teeth  in  hereditary  syph- 
ilis, 940 

De  Luca  on  the  etiology  of  gonorrhoea,  103 

Dementia,  syphilitic,  803 

Dermal  lesions  from  iodide  of   potassium, 
852 

Diabetes  insipidus  in  syphilis,  785 

Diabetic  balano-posthitis,  394 

Dilatability  of  the  normal  urethra,  331 

Dilatation,  gradual,  advantages  of,  373 
method  of,  372 
results  of,  374 
sequelfe  of,  374 
of  urethra  behind  stricture,  336 

Diphtheritic  balano-posthitis,  393 

Diphtheroid  of  gians,  so-called,  544 

Disturbances  in   the  reflexes  in  secondary 
syphilis,  585 

Divulsion  of  strictures,  351 

Divulsor,  Bigelow's,  352 
Gouley's,  352 

Doderlein  on   streptococcus   and   staphylo- 
coccus in  the  vagina,  288 

Donovan's  solution  in  syphilis,  853 

Dorsal  incision  of  prepuce  in  phimosis,  414 
failure  of,  414 

Dropsy   of  joints  in   gonorrhoeal    rheuma- 
tism, 265 

Dry  papular  chancre,  544 

Duality  of  syphilis  and  chancroid,  22 

Ducrey-Unna  streptobacillus,  491 

Dura  mater,  syphilis  of,  793 

Dystocia  from    syphilitic  stenosis  of  the  os 
uteri,  787 

E. 

Ear,  hereditary  syphilis  of,  714 
syphilitic  afiections  of,  709 
Ecthymaform  syphilide,  631 

varieties  of  syphilides,  632 
Ecthymatous  chancre,  545 

chancroid,  498 
Ectopia,  epididymitis  complicated  by,  236 
Elderly  people  and  syphilis,  668 
Electric  sublimate  baths  in  syphilis,  915 
Electrolysis  in  stricture  of  urethra,  385 
Elephantiasis  of  genitals,  457 
course  of,  457 
definition  of,  457 
and  lymph-scrotum,  458 
treatment  of,  460 
Elytritis,  298 

Encrusted  syphilide,  treatment  of,  918 
Encysted  hydrocele,  471 
Endarteritis   obliterans    and    gangrene    in 

syphilis,  744 
Endocarditis,  gonorrhoeal,  malignant   form 
of,  271 
syphilitic,  757 
Endometritis,  gonorrhoeal,  295 
Endoscope,  Mathieu's,  181 


INDEX. 


985 


Endoscope,  Otis's,  181 
use  of,  179 

in   treatment    of  chronic  urethritis    or 
gonorrhoja,  179 
Endoscopic  findings  in  the  urethra,  183 
Endoscopy  of  female  urethra  in  gonorrhoea, 

291 
English  scale  for  urethral  instruments,  340 
Ephemeral  nephritis  in  early  syphilis,  591 
Epididymis  in  secondary  syphilis,  788 

in  tertiary  syphilis,  789 
Epididymitis,  acute,  228 

causes  of,  246 
chronic,  237 
complicated  by  ectopia,  236 

by  hernia,  236 

by  varicocele,  236 
in  the  course  of  stricture  of  the  urethra, 

335 
date  of  onset  of,  230 
and  gonorrhceal  peritonitis,  269 
induration  of  the,  246 
inflammation  of  vas  deferens,  236 
and  misplaced  testis,  247 
modes  of  infection  in,  229 
symptoms  of,  232 
treatment  of,  248 
in  undescended  testis,  236 
Epididymo-orchitis,  acute  gonorrhceal,  233 

causes  of,  246 
in   the   course  of  stricture   of  urethra, 

335 
diagnosis  of,  247 
in  gout,  242 
in  influenza,  241 
in  malaria,  240 
in  mumps,  239 

from  operations  in  the  urethra,  242 
in  pneumonia,  241 
prognosis  of,  247 
in  pyaemia,  242 
reflex  neuralgias  in,  238 
in  rheumatism,  242 
in  small-pox,  240 
in  tonsillitis,  239 
treatment  of,  248 

carbolic  acid  in,  251 

compression  in,  252 

Corbett's  bandage  in.  252 

deep  urethral  injection  in,  251 

guiacol  ointment  in,  252 

heat  and  cold  in,  250 

iodoform  in,  251 

Langlebert's  suspensory  in,  252 

leeches  in,  253 

nitrate-of-silver  in,  251 

opium  in,  248 

Paquelin's  cautery  in,  250 

Pulsatilla  in,  249 

quinine  in,  254 

salicylate  of  sodium  in,  249 

strapping  in,  252 

stypage  in,  252 

support  in,  248 

tapping  tunica  vaginalis  in,  251 
in  typhoid  fever,  242 
in  whooping  cough,  240 


Epilepsy,  syphilitic,  800 
Epithelioma  and  vegetations,  435 
Epitheliome  benin  de  la  Verge,  447 
Epstein  on  catarrhal  vulvo-vaginitis  in  in- 
fants and  young  children,  316 
Eraud  on  frequencv  of  posterior  urethritis, 
124 
on  gonorrhoea  in   the  female  urethra, 

289 
on  the  specificity  of  the  gonococcus,  95 
Erosion,  chancrous,  542 
Eruptions  from  antiblennorrhagics,  276 
copaiba,  276 
cubebs,  276 
erythematous,  276 
oil  of  sandal-wood,  277 
scarlatiniform,  276 
urticarial,  276 
Erythema  of  muc;ous  membranes  in  early 
syphilis,  645 
multiforme  and  syphilis,  644 
Erythematous  eruptions,  276 
from  gonorrhoea,  275 
hereditary  syphilide,  932 
syphilide,  604 

coexisting  lesions  with,  609 
course  of,  609 
diagnosis  of,  610 
duration  of,  609 
treatment  of,  916 
Erytheme  indure  and  gummata,  729 
Eustachian  tubes,  syphilis  of,  712 
Examination  of  strictures,  353 
Excision  of  chancre,  807 
results  of,  810 
of  spermatic  veins,  463 
of    stricture-tissue  and  transplantation 
of  mucous  membrane,  384 
Exostoses,  syphilitic,  773 
Exploration  of  the  urethra,  340 

by  sounds,  341 
External  auditory  canal,  exostosis  of,  711 
syphilis  of,  710 
ear,  chancre  of,  558 
urethritis  in  the  female,  301 
urethrotomy,  Cock's  method,  383 
for  drainage,  377 
Gouley's  method  of,  378 
indications  for,  378 
Syme's  method  of,  381 
various  operations  of,  377 
Wheelhouse's  method  of,  381 
Avithout  a  guide  in   urethra,  381, 
383 
Extirpation  of  ganglia  for  abortion  of  syph- 
ilis, 812  ' 
of  the  penis,  455 
Extragenital  chancre,  558 

chancroids,  502 
Extravasation  of  urine  from   stricture   of 
urethra,  337 
symptoms  of,  338 
treatment  of,  390 
Exulcerative  hvpertrophy  of  neck  of  uterus, 

786 
Exulcerous  chancroid,  498 
Eye,  hereditary  syphilis  of,  708 


986 


INDEX. 


Eye,  syphilitic  affections  of,  679 
Eyelids,  chancre  of,  558 

syphilitic  affections  of,  683 

F. 

Fallacies  of  the  urethrameter,  366 

Stewart  on,  366 
Fallopian  tubes,  syphilis  of,  787 
Fasciae  attacked  in  gonorrhoeal  rheumatism, 

263 
Feliki  on  latent  gonorrhoea  in  women,  286 
Female  urethra,  anatomy  of,  283 
Fever,  catheter,  387 
syphilitic,  580 
urethral,  387 
Fig-warts,  431 
Filiere  charriere,  340 
Filiform  bougies,  343 
French,  344 
English,  344 
Finger,  chancre  of,  553 

inoculation  of  the  gonococcus  by,  62 
Finger  on  the  gonococcus,  100 

on  infection  by  utero-placental  circula- 
tion, 928  _ 
on  inoculation  with  pus,  28 
Fingers,  late  syphilis  of,  778 

forms  of,  779 
Fistulse   following   gonorrhoeal    folliculitis, 
303 
following  para-urethral   folliculitis   in 
the  female,  303 
Fistula,  urinary,  391 
Fluhrer-Maisdnneuve's  urethrotome,  348 
Follicular  abscess  of  the  prepuce,  192 
chancroid,  498 
(sebaceous)  vulvitis,  301 
Folliculitis,  gonorrhoeal,  302 

para-urethral,  in  the  female,  303 
Fontan  on  the  treatment  of  buboes,  517 
Forms  of  gonorrhcea  in  women,  282 
Fournier  on  the  etiology  of  gonorrhoea,  102 
Fournier's  method  of  treating  syphilis,  831 
Fossa  navicularis,  chancre  of,  551 
Frsenum,  chancroid  of,  501 
Fragility  of  syphilitic  bones,  776 

histology  of,  776 
Frankel  on  the  bacteriology  of  gonorrhoeal 

vulvo-vaginitis,  321 
French  scale  for  urethral  instruments,  340 
Frequency  of  gonorrhoea  in  the  female,  281 
Fumigation,  mercurial,  in  the  treatment  of 

syphilis,  869 
Furuncular  hereditary  syphilide,  935 

G. 

Galloping  syphilid,  635 
course  of,  635 
Ganglia,  hyperplasia  of,  572 
Gangrene  of  extremities,  syphilitic.  744 
foot  in  syphilis,  744 
and  paraphimosis,  420 
and  phimosis,  405 

of    prepuce   in    balanitis   and   balano- 
posthitis,  394 


Gangrene  of  scrotum,  238 

symmetrical  in  syphilis,  744 
in  tertiary  syphilis,  743 
of  testis,  238 

of  tongue  in  syphilis,  744 
Gangrenous  ulcers  in  tertiary  syphilis,  743 
Gebhard,  cultivation  of  the  gonococcus  bv, 

88 
General  hyperplasia  of  superficial  and  deep 
lymphatic  ganglia,  578 
paralysis,  syphilitic,  803 
Genitals,  elephantiasis  of,  457 
Gerrainative  infection  in  syphilis,  925 
Gerster's  urethrotome,  348 
Gjor  on  inoculation  in  syphilis,  23 
Glands,  Bartholin's,  283,  303 
of  Littre,  37 
Skene's,  283 
vulvo-vaginal,  283 
Glans  penis,  anatomy  of,  32 
Glycosuria  in  early  syphilis,  592 

in  late  syphilis,  784 
Goll  on  the  frequency  of  occurence  of  gono- 
coccus in  chronic  urethritis,  71 
Gommes  scrofuleuse,  729 
Gonocele,  264 

Gonococcus  in  blood  in  gonorrhoeal  rheuma- 
tism, 262 
cultivation  of,  88 
bv  Bumm,  88 
by  Gebhard,  88 
by  Wertheim,  88 
Eraud  on  the  specificity  of,  95 
Finger  on  the,  100 

frequency  of  occurrence  of,  in  chronic 
urethritis,  71 
in  gonorrhoeal  rheumatism,  261 
Gram-Eoux  method  of  staining,  60 
inoculations  of,  by  Aufuso,  62 
by  Finger,  62 
by  Wertheim,  62 
invasion  of  tissue  by,  76 
methods  of  staining,  58 
morphology  of,  57 
Neisser  on,  87 
pathogenic  action  of,  62 
role  of,  in  gonorrhoea  in  the  female,  287 
Welander's  experiments  on,  90 
Gonorrhoea,  acute  anterior,  or  urethritis,  112 
declining  stage  of,  121,  137 
dressing  of  penis  in,  130 
method  of  examination  in,  121 
prodromal  stage  of,  113 
secretions  in,  119 
symptoms  of,  115 
syringes  for,  134 
technique  of  injections,  135 
temperature  in,  116 
treatment  of,  alumnol  in,  149 
antipyrine  in,  150 
antrophores  in,  152 
bougies  in,  152 
cai'bonic-acid  water  in,  151 
citric  acid  in,  1 50 
creoline  in,  150 
cupped  sound  in,  152 
dermatol  in,  150 


INDEX. 


987 


Gonorrhoea,   acute   anterior,   treatment   of 
erections  and  chordee  in,  132 
ergotine  in,  151 
insufflators  in,  155 
lysol  in,  150 
naphthol  in,  151 
natrium  chloroborosumin,  151 
ointments  in,  152 
ointment-syringe  in,  152 
pyoktanin  in,  149 
pyridin  in,  151 
pyrogallic  acid  in,  151 
quinine  in,  150 
retinol  in,  149 
salicylate  of  cadmium  in,  150 

of  mercury  in,  150 
sea-water  in,  151 
silico-fluoride  in,  151 
sozoidol  of  zinc  in,  150 
tannin  in,  151 

thermal  sulphur-waters  in,  151 
two-glass  test  in,  121 
Gonorrhoea,  atrophy  of  testis  from,  237 
of  Bartholini's  gland,  305 
caused   by   staphylococci   and   strepto- 
cocci, 61 
chronic,  bougie  a  boule  in,  175 

relapsing,  72 
Cotes's  method  of  treatment  of,  146 
declining,  injections  in,  137 

syringes  for,  134 
its  distinction  from  vaginitis,  298 
erythematous  eruptions  from,  275 
etiology  of,  85 

Bumstead  on,  103 
De  Luca  on,  103 
Fournier  on,  102 
Kicord  on,  101 
in  the  female,  279 

as  a  cause  of  pelvic  disease,  287 

chronicity  of  course,  287 

class   of  women   from  whom   de 

rived,  280 
frequency  of,  280 
forms  of,  282 
invasion  of,  289 
Laser  on,  281 

nature  of  morbid  processes,  282 
prophylaxis  in,  309 

treatment  of,  310 
pyelo-nephritis  in,  291 
the  role  of  the  gonococcus  in,  287 
Siiiiger  on,  281 
Schwartz  on,  281 
state  of  knowledge  of,  279 
Steinschneider  on,  281 
treatment  of,  310 
urethral,  289 

Aubert  on,  289 
chronic,  291 
course  of,  290 
declining  stage  of,  291 
Eraud  on,  289 
Horand  on,  289 
invasion  of,  290 
microscopy  of,  290 
pus  in,  290 


Gonorrhoea   in   the  female,  Steinschneider 
on  urethral,  289 
symptoms  of,  290 

warts  as  symptomatic  of,  298 
follicles,  treatment  of,  315 
irrigations  in,  143 
Janet's  irrigations  in,  144 

method  of  treating,  145 
long  incubation  in,  110 
loss  of  nails  from,  275 
in  the  male,  55 
meningitis  from,  275 
of  mouth,  208 

modes  of  origin  of,  208 
optic  neuritis  from,  275 
of  OS  uteri,  292 

bacteriology  of,  294 

course  of,  293 

mode  of  infection,  292 

objective  features  of,  293 

Ricord  on,  294 

symptoms  of,  293 

treatment  of,  314 
of  ovaries,  307 
pathology  of,  78 
pelvic,  mixed  infection  in,  308 

organs,  symptoms  of,  307 
period  of  incubation  of,  107 
of  peritoneum,  307 
predisposing  conditions  and  causes  of, 

110 
purpura  due  to,  375 
of  rectum,  204 

diagnosis  of,  206 

etiology  of,  205 

prognosis  of,  207 

symptoms  of,  207 

treatment  of,  207 

retrojections  in,  143 

syringes  for,  134 
technique  of  injections  in,  135 
of  the  tubes,  306 
treatment,  alumnol  in,  149 

Cotes's  method,  146 

gallobromol  in,  148 

ichthyol  in,  147 

iodoform  in,  146 

Janet's  method,  145 

oil  of  cinnamon  in,  146 

resorcin  in,  147 

ihallin  in,  147 
of  the  urethra,  treatment  of,  311 

speculum  for,  311 

antiseptic  treatment  of,  311 
or  urethritis,  acute,  abortive  treatment 
of,  126 
general  considerations  on  treat- 
ment of,  128 
treatment  of,  125,  129 

chronic,  165 

of  the  anterior  urethra,  167 

bougie  a  boule  in  the  diagnosis  of, 
175 

pathological  appearances  in,  170 

of  the  posterior  urethra,  167 

question  of  infectiousness  in,  171 

symptoms  of,  166 


988 


INDEX. 


Gonorrhcea  or  urethritis,  treatment  of,  172 

author's  syringe  in,  175 

endoscope  in,  179 

Guyon's  syringe  in,  175 

Ultzmann's  syringe  in,  177 
of  the  uterus,  292 

Bumm  on,  292 

Martineau  on,  292 

Kollet  on,  292 

Sfeinschneider  on,  292 

treatment  of,  314 
of  the  vagina.  295 

acute  stage  of,  297 

age  at  which  found,  296 

bacteriology  of,  296 

Buram  on,  295 

clinical  features  of,  296 

course  of,  296 

and  of  Douglas's  cul-de-sac,  297 

extent  of  invasion  of,  296 

localization  of  297 

Schwartz  on,  296 

Schwartz's  treatment  of,  313 

speculum  for,  318 

Steinschneider  on,  295 

subacute  stage  of,  297 

symptoms  of,  296 

treatment  of,  312 

methods  of  application  in,  312 
of  the  vulva,  300 
causes  of,  301 
complications  of,  301 
course  of,  301 
follicular,  301 
mode  of  onset  of,  300 
symptoms  of,  300 
treatment  of,  310 
of  vulvo-vaginal  glands,  305 

acute,  305 

bacteriology  of,  306 

Touton  on  the,  306 
Arning  on  the,  306 

chronic,  305 

course  of,  306 

morbid  appearances  of,  305 

symptoms  of,  305 

treatment  of,  315 
Gonorrhceal  adenitis,  278 
course  of,  278 
symptoms  of,  278 
affections  of  the  spinal  cord,  273 
cases  of,  273 
clinical  features  of,  274 
Hayem  and  Parmentier  on,  273 
lesions  of,  274 
micro-organisms  in,  275 
and  muscular  atrophy,  274 
and  paraplegia,  274 
sciatica  and,  274 
symptoms  of,  273 
cardiac  afl'ections,  270 
symptoms  of,  270 
cutaneous  affections,  275 

micro-organisms  in,  276 
Perrin  on,  275 
question  of,  275 
endocarditis,  malignant  form  of,  271 


Gonorrhcfial  endocarditis,    micro-organisms 
in,  271_ 
endometritis,  295 

chronic,  295 

course  of,  295 

symptoms  of,  295 
folliculitis,  302 

appearances  of,  302 

course  of,  302 

fistulse  of,  303 

Martineau  on,  302 
.seat  of  302 

sinus  following,  303 

symptoms  of,  302 
infection  in  women,  283 
ophthalmia,  254 

Andrews's  treatment  of,  258 

diagnosis  of,  257 

frequency  of,  254 

method  of  examination  in,  256 

modes  of  infection  in,  254 

prognosis  of,  257 

symptoms  of,  254 

treatment  of,  258 
pelvic  disease,  statistics  of,  288 

Chadwick's.  288 

Thornburn's,  288 
pericarditis,  270 
peritonitis,  268 

acute,  in  female,  307 

course  of,  269 

development  of,  268 

and  epididymitis,  269 

inflammation    of    lumbar    ganglia 
and,  269 
of  vas  deferens,  269 

post-mortem  findings  in,  269 

prognosis  of,  269 

and  prostatitis,  269 

seminal  vesicle  in,  269 

sources  of,  268 

symptoms  of.  269 

treatment  of,  270 

Zeissl  on,  269 
phimosis,  405. 
pyEemia,  272 

from   abscess   of  neck  of  bladder, 
272 

acute,  273 

chronic,  273 

in  the  female,  272 

forms  of,  273 

and  joint-abscesses,  273 

from  old  stricture,  272 

from  prostatic  abscess,  272 

from  seminal  vesiculitis,  272 

symptoms  of,  272 
rheumatism,  260 

ankylosis  in,  265 

burs;e  attacked  in,  263 

complications  of,  265 

course  of,  265 

date  of  onset,  262 

diagnosis  of,  266 

dropsy  of  joints  in,  265 

fascife  attacked  in,  263 

Finger  on,  261 


INDEX. 


989 


GonorrhcBal   rheumatism   following  vulvo- 
vaginitis in  children,  319 
forms  of,  264 
gonocoecus  in,  261 

in  the  blood  in,  262 
Guyon  on,  261 

inflammation  of  burspe  in,  265 
Janet  on,  261 

of  knee,  called  gonocele,  264 
mixed  infection  in,  261 
monoarticular,  263 
number  of  joints  attacked  in,  263 
pathogenesis  of,  261 
phlebitis  complicating,  266 
polyarticular,  263 
prognosis  of,  267 
sciatica  in,  266 
streptococcus  in,  261 
symptoms  of,  263 
tendons  attacked  in,  263 
tojcines  in,  261 
treatment  of,  267 
various  joints  attacked,  263 
threads,  73 

ulcero-raembranous  stomatitis,  209 
urethritis  in  women,  290 
vaginitis  in  young  girls,  299 

fallibility   of    the    gono- 
coecus, 299 
Hardy  on,  299_ 
mode  of  infection  in,  300 
Welander  on,  299 
vulvo-vaginitis  in  children,  318 
in  asylums,  320 
bacteriology  of,  321 

Berggriin  on  the,  321 
PVankel  on  the,  321 
Koplik  on  the,  321 
conclusions  as  to  the,  321 
course  of,  318 
epidemics  of,  320 
etiology  of,  319 

gonorrhoeal  rheumatism  in,  319 
infectiousness  of,  319 
modes  of  infection  in,  320 
objective  symptoms  of,  318 
origin  of,  318 
prophylaxis  of,  322 
from  rape,  320 
symptoms  of,  318 
treatment  of,  322 
Gouley's  divulsor,  352 

method  of  external  urethrotomy,  378 
Gout,  epididymo-orchitis  in,  242 
Gradual  dilatation,  advantages  of,  373 
method  of,  372 
results  of,  374 
sequelte  of,  374 
Gram-Roux  method  of  staining  the  gono- 
coecus, 60 
Gummata  of  bone,  774 
of  bursse,  771 
and  cancer,  726 
of  the  clavicle,  775 
of  corpora  cavernosa,  786 
of  the  female  breasts,  727 
of  heart,  757 


Gummata,  immense  size  of,  727 
of  oesophagus,  753 
pathology  of,  533 
of  pericardium,  757 
of  pharynx,  750 
precocious,  642 

forms  of,  643 
of  rectum,  763 
of  ribs,  775 
of  scapula,  775 
of  spleen,  760 
of   suprarenal   capsule   and  Addison's 

disease,  766 
of  testis,  790 
of  tongue,  746 
of  trachea,  754 
of  uterus,  786 
of  vertebrae,  775 
Gummatous  hereditary  syphilide,  936 
infiltration  into  fingers,  780 

in  hereditary  syphilis,  938 

of  penis,  786 
osteomyelitis,  774 
osteoperiostitis,  774 
syphilide,  723 

course  of,  724 

diagnosis  of,  729 

of  female  breast,  727 

in  form  of  tumors,  727 

infiltration  of  soft  palate,  748 

mistaken  for  sarcoma  and  lipoma, 
727 

over  nerves,  728 

prognosis  of,  729 

seats  of,  725 

surgically  considered,  727 

treatment  of,  918 
tertiary  syphilides,  723 
Gums,  chancre  of,  556 
Guyon  on  acute  anterior  urethritis,  123 
on  gonorrhoeal  rheumatism,  261 
syringe,  175 

in  treatment  of  chronic  urethritis 
or  gonorrhoea,  175 

H. 

Hsematocele,  479 
of  the  cord,  480 

diagnosis  of,  480 
symptoms  of,  480 
treatment  of,  480 
of  the  testis,  479 

diagnosis  of  479 
treatment  of,  479 
Hsemoglobinuria  in  secondary  syphilis,  593 
Hair,  hereditary  syphilis  of,  950 
Halld  on  urinary  infection,  388 
Hard   chancre,  stricture  at  the  meatus  fol- 
lowing, 363 
and  paraphimosis,  421 
pathology  of,  529 
palate,  chancre  of,  556 
Hardy  on   gonorrhoeal  vaginitis  in   young 

_  girls,  299 
Harrison's  dilators,  344 
whips,  344 


990 


INDEX. 


Hayden  on  the  treatment  of  buboes,  517 
Hayeni  and  Parmentier  on  gonorrhceal  affec- 
tions of  the  spinal  cord,  273 
Healthy  mothers  of  syphilitic  infants,  929 
Heart,  gummata  of,  757 

syphilis  of,  757 

symptoms  of,  758 
Heat  in  the  treatment  of  syphilis,  913 
Heisler  on  frequency  of  posterior  urethritis, 

124 
Helme  Scott   on  the  treatment  of  buboes. 

Hemiatrophy  of  tongue  in  syphilis,  748 
Hemiplegia,  syphilitic,  798 
Hemorrhagic  syphilis,  593 

hereditary,  951 
Hepatitis,  syphilitic,  760 
Hereditary  condylomata  lata,  933 
syphilides,  bullous,  935 

erythematous,  932 

furuncular,  935 

gummatous,  936 

papular,  933 

pustular,  934 

tubercular,  935 

vesicular,  934 
syphilis,  920 

affections  of   mucous    membranes 
in,  936 

of  bones,  952 

dactylitis  in,  956 

dangers  of,  920 

duration  of,  922 

of  ear,  714 

eruptions  of,  932 

evolution  of,  931 

of  the  eye,  708 

gummatous    affection    of    mucous 
membranes,  937 

of  hair,  950 

influence  of  father  in,  924 
mother  in,  926 

of  intestines,  941 

invasion  of,  931 

of  kidney,  944 

lesions,  921 

of  liver,  941 

of  lungs,  939 

lymphatic  ganglia,  952 

metacarpal  bones  in,  957 

metatarsal  bones  in,  957 

of  nails,  949 

of  nervous  system,  957 

osteochondritis  in,  953 

of  pancreas,  944 

periostitis  in,  955 

of  peritoneum,  941 

process  of  procreation  in,  924 

progress  of,  922 

of  spleen,  943 

statistics  of,  920 

of  suprarenal  capsules,  945 

of  synovial  shenths,  949 

of  testicles,  945 

of  thymus  gland,  950 

treatment  of,  959 

black  oxide  of  mercury  in,  970 


Hereditary  syphilis,  treatment  of,  corrosive 
sublimate  in,  971 
gray  powder  in,  970 
iodide  of  potassium  in,  971 
local,  974 

mercurial  inunctions  in,  972 
mixed  treatment  in,  972 
protoiodide  of  mercury  in,  970 
sublimate  baths  in,  973 
tannate  of  mercury  in,  971 
in  the  umbilical  vein,  951 
Hernia,  epididymitis  complicated  by,  236 
Herpes  progenitalis,  bacteriology  of,  428 
course  of,  425 
definition  of,  424 
diagnosis  of,  428 
etiology  of,  427 
menstruation  and,  425 
neuralgic,  426 

concomitants  of,  427 
course  of,  426 
Mauriac  on,  426 
in  puellse  publicse,  428 
treatment  of,  429 
in  women,  425 
Bergh  on,  425 
Unna  on,  425 
Horand  on  gonoi'rhcea  in  the  female  urethra, 

289 
Horny  or  corneous  vegetations,  434 
growths  of  penis,  440 
causes  of,  441 
development  of,  441 
forms  of,  440 
Hot  baths  in  the  treatment  of  syphilis,  912 
springs  of  Arkansas  and  the  treatment 
of  syphilis,  908 
Hutchinson  on  abortion  of  syphilis  by  early 
mercnrialization,  813 
teeth,  940 
Hydrocele,  of  adults,  468 
B^raud's,  473 
bilocularis,  472 
causes  of,  474 
chronic,  in  orchitis,  238 
and  chylous  fluid,  471 
circumscribed,  472 
congenital,  467 
course  of,  470 
date  of  development,  468 
definition  of,  467 
diagnosis  of,  475 
disappearance  of,  470 
diverticular,  473 
en  bissac,  472 
encysted,  471 

of  the  testis,  471 

treatment  of,  477 
features  of,  467 
and  filaria  sanguinis,  471 
forms  of,  467 
graisseuse,  471 
laiteuse,  471 
light  test  in,  469 
pathological  anatomy  of,  474 
of  seminal  vesicles,  221 
simple,  468 


INDEX. 


991 


Hydrocele  of  spermatic  cord,  477 
treatment  of,  478 
suppurating,  471 

symptoms  of,  468 
treatment  of,  475 

by  injection,  476 
by  incision,  476 
unusual  forms  of,  472 
Plyperfemia  of  pharynx  in  early  syphilis, 
588 
of  spleen  in  secondary  syphilis,  590 
Hyperplasia  of  ganglia,  572 
course  of,  574 
diagnosis  of,  574 
from  irritation,  574 
seat  of,  573 
of  pharynx  in  early  syphilis,  588 
of  spleen  in  secondai-y  syphilis,  590 
Hypertrophic  syphiloma  of  face,  726 
Hypodermic    injections    in     treatment    of 
syphilis,  872 
advantages  of,  872 
of  alanalate  of  mercury,  904 
of  beiizoate  of  mercury,  901 
of  black  oxide  of  mercury,  886 
of  blood-serum  mercury,  895 
of  calomel,  874,  875 

contraindications  of,  879 
dangers  of,  878 
indications  for,  880 
sequel*  of,  877 
technique  of,  875 
of  carbolate  of  mercury  in,  899 
chloro-albuminate  of  mercury,  893 
of  cinnabar,  887 
of  corrosive  sublimate,  887 
dose  of,  889 
indications  for,  888 
sequelae  of,  892 
sites  of,  891 
technique  of,  890 
of  cyanide  of  mercury,  895 
of  forma mide  of  mercury,  901 
of  glutin-peptone  sublimate,  894 
of  glycocol  of  mercury,  903 
of  gray  oil,  881 

dangers  of,  883 
of  iodide  of  potassium,  906 
of  iodoform,  905 
of  iodo-tannate  of  mercury,  897 
of  mercuric  peptone,  894 
of  mercury  and  iodide  of  potas- 
sium, 897 
of  metallic  mercury,  880 
of  sal  alembroth,  893 
of  salicylate  of  mercury,  898 
of  succinimide  of  mercury,  904 
of  thymolo-acetate  of  mercury,  900 
of  urea  mercury,  905 
of  yellow  oxide  of  mercury,  884 
Hysteria  in  secondary  syphilis,  583 


Idiosyncrasy,  iodide  of  potassium,  850 

Ignored  syphilis,  720 

Immunity  of  animals  to  syphilis,  670 


Immunity  of  mothers,  929 

in  hereditary  syphilis,  930 
Impetigoform  syphilide,  629 
Incontinence  of  urine  in  stricture  of  urethra, 

335 
Incrusted  chancres  in  women,  564 
Indirect   treatment  of  syphilitic   child  by 
means   of    the   milk    of    mother    or 
nurse,  963 
Indurated  nodule,  546 
Indurating  oedema,  pathology  of,  533 
Induration  of  the  epididymis,  246 
treatment  of,  253 
of  the  lymphatics,  575 

features  of,  575 
as  a  symptom  of  chancre,  547 
course  of,  547 
de  voisinage,  548 
relapsing,  548 

forms  of,  549 
Infecting  balano-posthitis,  546 
Infection,  urinary,  387 

by  utero-placental  circulation,  927 
Finger  on,  928 
Infectious  secretions  and  matter  in  syphilis, 

535 
Infectiousness  of  chronic  urethritis  or  gonor- 
rhoea, 171 
of  tertiary  syphilis,  722 
Inflammation  of  Bartholin's  gland,  303 

of  bursse   in   gonorrhoeal   rheumatism, 

265 
of  follicles  of  skin  of  penis,  193 
of    lumbar    ganglia    and    gonorrhoeal 

peritonitis,  269 
of  penis,  278 

symptoms  of,  278 
of  preputial  follicles,  190 
of  seminal  vesicles,  219 

symptoms  of  acute,  219 
of  vas  deferens  and  gonorrhoeal  perito- 
nitis, 269 
Inflammatory  stricture  of  the  urethra,  330 
Influenza,  epididymoorchitis  in,  241 
Inguinal  adenitis  and  cancer  of  penis,  449 
Initial  lesion,  540 

Injections  of  blood-serum  in  the  treatment 
of  syphilis,  871 
in  declining  gonorrhoea,  137 
Inoculation  in  syphilis,  23 
Insomnia  in  secondary  syphilis,  577 
Integument,  chancres  of,  552 
Internal  ear,  syphilis  of,  712 

urethrotomy,  375 
Intestines,  hereditary  syphilis  of,  941 

tertiary  sy[)hilis  of,  762 
Intravenous  injections  in  syphilis,  893 
Intolerance  to  iodide  of  potassium,  850 
Inunction  method  of  treating  syphilis,  856 
advantage  of,  857 
bad  eflects  of,  867 
care  as  to  use  of,  858 
in  combination  with  iodide  of  po- 
tassium, 866 
drawbacks  to,  857 
indications  for,  864 
locations  for,  865 


992 


INDEX. 


Inunction  method,  necessity  for,  864 
ointments  suitable  for,  859 
by  oleates  of  mercury,  860 

and  quinine,  861 
and    sulphur-waters, 
863 
technique  of,  863 
at  thermal  springs,  860 
Invasion  of  tissues  by  gonococcus,  76 
Iodide  of  potassium,  eruptions,  852 
idiosyncrasy,  850 
intolerance  to,  850 
toxic  effects,  852 
of  rubidium  in  the  treatment  of  syphi- 
lis, 853 
lodol  in  the  treatment  of  syphilis,  853 
Iritis,  syphilitic,  690 
forms  of,  691 
infantile,  698 

J. 

Janet  on  gonorrhoeal  rheumatism,  261 
irrigations  in  gonorrlioea,  144 
method  of  treating  gonorrho?a,  145 
Janovsky  on  endoscopy  of  female  urethra 

in  gonorrhoea,  291 
Jaundice  in  earlv  syphilis,  591 

late,  759 
Joints,  abscesses  and  gonorrhoeal  pyaemia, 
273 
attacked   in   gonorrhoeal    rheumatism, 

263 
late  syphilis  of,  777 
course  of,  777 
diagnosis  of,  777 
prognosis  of,  777 
Juxta-urethral  sinuses,  193 

K. 

Kaposi  on  inoculations  with  pus,  27 
Keloid,  stricture  at  the  meatus  following, 
364 
in  stricture  of  urethra,  339 
Kidney,  hereditary  syphilis  of,  944 
late  syphilis  of,  783 
Wagner  on,  783 
Koplik  on  the  bacteriology  of  gonorrhoeal 
vulyo-vaginitis  in  children,  321 
on  etiology  of  urethritis  in  young  boys, 
163 
Kraus  on  inoculations  in  syphilis,  24 
Krogius  on  urinary  infection,  389 

Labialites  tertiaires,  726 

Lachrymal  gland,  syphilitic   affections   of, 

682  _  '  _ 

passages,  sj'philitic  affections  of,  680 
Lacuna  magna,  38 

Lancereaux  on  syphilis  of  lungs,  756 
Lanz  on  frequency  of  posterior  urethritis, 

124 
Large  flat  papular  syphilides,  616 
Larynx,  tertiary  syphilis  of,  751 


Larynx,  caries  of,  752 

chi'onic  inflammation  of,  751 
gummata  of,  752 
perichondritis  of,  752 
ulcerations  of,  751 
Laser  on  gonorrhoea  in  the  female,  281 
Late  syphilis  of  finger,  778 
glycosuria  in,  784 
of  joints,  777 
of  kidney,  783 
Latent  gonorrhoea  in  women,  285 
Feliki  on,  286 
Koeggerath  on,  285 
Sinclair  on,  286 
Lateral  incisions   of  prepuce  in  phimosis, 
415 
advantages  of,  415 
Lavage  of  the  anterior  urethra,  123 
Lee,  Henry,  on  inoculations  in  syphilis,  23 
Legrain  on  micro-organisms  in  the  urethra, 

94 
Leloir's  signe  de  I'expression  de  sue,  429 
Lens,  syphilitic  affections  of,  699 
Lenticular  papular  syphilides,  611 
Leontiasis  syphilitique,  726 
Lesions  of  the  placenta,  975 
Letzel  on  frequency  of  posterior  urethritis, 

124 
Light-test  in  hydrocele,  469 
Lips,  chancre  of,  555 
Littre's  glands,  37 
Liver,  hereditaiT  syphilis  of,  941 
diagnosis  of  syphilis  of,  759 
prognosis  of  syphilis  of\  759 
symptoms  of  syphilis  of,  758 
tertiary  syphilis  of,  758 

Chvostek  on,  758 
lesions  of.  758 
Local  treatment  in  hereditary  syphilis,  974 
Locomotor  ataxia,  syphilitic,  802 
Long  incubation  in  gonorrhoea,  110 
Loss  of  nails  from  gonorrhoea,  275 
Lumbar  ganglia,  inflammation  of,  and  gon- 
orrhoeal peritonitis,  269 
Lungs,  syjahilis  of,  755 

Lancereaux  on,  756 
pathological  anatomy  of,  755 
symptoms  of,  756 
Lustgarten  and  Mannaberg  on  parasites  of 

the  normal  urethra,  92 
Lymphangitis,  chancroidal,  500 

treatment  of,  278 
Lymph-scrotum,  458 
Lymphatic  glands,  hereditary  syphilis  in, 

952 
Lymphatics,  induration  of,  575 

M. 

Maculse  gonorrhoeicfe,  305 
Maisonneuve's  urethrotome,  351 
Malaria,  epididymo-orchitis  in,  240 

and  syphilis,  672 
^lale  urethra,  anatomy  of,  35 
Malignant  precocious  syphilides,  634 
^lartineau  on  gonorrhoeal  folliculitis,  303 

on  gonorrhoea  of  the  uterus,  292 


INDEX. 


993 


Mastoid  process,  syphilis  of,  712 

Mathieu's  endoscope,  181 

Mauriac  on  neuralgic  herpes  progenitalis, 

426 
Meatoscope,  Weir's,  180 
Meatus,  anatomy  of,  32 
chancre  of,  551 
chancroid  of,  500 
sound,  363 
stricture  at  the,  362 
Mediate  infection  in  syphilis,  537 
Melchior,  Kobert,  on  inoculations  in  syph- 
ilis, 23  _  _ 
Membrana  tympani,  syphilis  of,  711 
Membranous  desquamative  urethritis,  189 
Meningitis  from  gonorrhoea,  275 
Mercier's  catheters,  347 
Mercurial  flannels  in  treatment  of  syphilis, 
859 
fumigations   in   treatment  of  syphilis, 

869 
plasters  in  treatment  of  syphilis,  868 
soap  in  treatment  of  sypliilis,  868 
Mercury,  method  of  giving,  844 
by  fumigation,  869 
by  hypodermic  injection,  872 
by  inunctions,  856 
by  the  mouth,  845 
by  spreading  on  of  mercurial  oint- 
ment, 858 
by  stomach-ingestion,  844 
results  of  too  prolonged  use  of  848 
Metacarpal  bones  in  hereditary  syphilis,  957 

syphilis  of,  781 
Metatarsal  bones  in  hereditary  syphilis,  957 

syphilis  of,  781 
Method  of  divulsion,  352 
Microbic  complications  of  syphilides,  598 
Micro-organisms  in   balanitis  and    balano- 
posthitis,  394 
in  gonorrhoeal  affections  of  the  spinal 
cord,  275 
cutaneous  affections,  276 
endocarditis,  271 
in  hereditary  syphilis,  952 
in  the  urethra,  95 
of  uterus,  284 
Middle  ear,  syphilis  of,  711 
Miliary  papular  syphilides,  611 
Minor  surgical  gynecology  and  pelvic  dis- 
ease. 287 
Misplaced  testis  and  epididymitis,  247 
Mitchell's  reflux  catheter,  135 
Mixed  infection  in  pelvic  gonorrhoea,  308 

treatment  of  syphilis,  843 
Mono-articular  gonorrhoeal  rheumatism,  263 
Morgagni,  crypts  of,  37 
Morgan  on  inoculations  in  syphilis,  24 
Mouth,  gonorrhoea  of,  208 
Mucous  patches,  646 

of  genital  organs,  652 
of  mouth,  646 
■seats  of,  646 
treatment  of,  647 
Midtiple  neuritis,  syphilitic,  804 
Mumps,  epididymo-orchitis  in,  239 
Murure  in  syphilis,  855 
63 


Muscular  atrophy  and  gonorrhoeal  affections 
of  the  spinal  cord,  274 
contraction  and  orchitis,  244 
syphilitic,  768 
Myositis,  gummatous,  769 

mistakes  in  diagnosis  of,  769 
syphilitic,  767 
forms,  of,  767 
mixed  forms  of,  769 
muscles  attacked  by,  767 
and  muscular  contraction,  768 
of  sphincter  of  anus,  769 
Myxoedema   and   syphilis   of    the   thyroid 
gland,  766 

Nails,  hereditary  syphilis  of,  949 
Necrotic  nodular  chancre,  545 
Neisser  on  the  cultivation  of  the  gonococcus, 
87 
on  gonococcus,  87 
Nephritis,  ephemeral,  in  early  syphilis,  591 
Nerves,  syphilis  of,  795 

of  the  eye,  paralysis  of,  706 
Nervous  system,  hereditary  syphilis  of,  953 
syphilis  of,  790 

predisposing  causes  to,  792 
Neuralgia,  production  of,  by  syphilis,  534 
of  testis,  238,  246 

treatment  of,  253 
Neuralgic  herpes  progenitalis,  426 
Neuritis,  multiple,  syphilitic,  804 
Nodes,  syphilitic,  773 
Nodular  chancres  in  women,  565 
stricture  of  the  urethra,  326 
Noeggerath  on  latent  gonorrhoea  in  women, 

285 
.Normal  urethra,  calibre  of,  367 

o. 

Qlldema,  indurating,  533  ■ 

CEsophagus,  diagnosis  of  syphilis  of,  753 

gummata  of,  753 

syphilitic  stricture  of,  753 

tertiary  syphilis  of,  753 
Oil  of  santal-wood,  eruptions  from,  277 
Old  stricture,  gonorrhoeal  pyaemia  from,  272 
Olivary  bougies,  342 
Onychia,  hypertrophic,  syphilitic,  660 

syphilitic,  660 

diagnosis  of,  665 
prognosis  of,  665 
treatment  of,  665 
Ophthalmia,  gonorrhoeal,  254 
Optic  nerve,  syphilitic  affections  of,  704 

neuritis  from  gonorrhoea,  275 
Orbital  bones,  syphilitic  aflections  of,  679 
Orchi-epididymitis,  diagnosis  of,  247 

treatment  of,  248 
Orchitis,  chronic  hydrocele  in,  238 

from  muscular  contraction,  244 

syphilitic,  790 
Osseous  aflections  in  early  syphilis,  586 
Osteochondritis  in  hereditary  syphilis,  953 
Osteomyelitis,  gummatous,  774 


994 


INDEX. 


Osteoperiostitis,  gummatous,  774 

syphilitic,  772 
Os  uteri,  chancre  of,  567 

stenosis  of,  from  syphilis,  787 
syphilis  of,  786 

syphilitic  exulcerative  hypertrophy 
of,  786 
Otis's  dilating  urethrotome,  350 
endoscope,  181 
endoscopic  tube,  180 
Ovaries,  gonorrhcea  of,  307 

syphilis  of,  787 
Over-dilatation  of  urethra,  permanent   in- 
jury from,  368 
Ovular  infection  in  syphilis,  926 


P. 

Pancreas,  hereditary  syphilis  of,  944 

syphilis  of,  766 
Papular  hereditary  syphilide,  934 
syphilides,  610 

treatment  of,  916 
Papule  seche  of  Lancereaux,  544 
Paralysis  of  nerves  of  eye,  syphilitic,  706 
Paraphimosis,  anatomy  of,  417 
anomalous  form  of,  418 
causes  of,  417 

chancroidal  treatment  of,  424 
curvature  of  penis  in,  419 
definition  of,  417 
and  gangrene,  420 
and  hard  chancre,  421 
mechanism  of,  418 
methods  of  reduction  of,  422 
Bardinet's,  423 
Colles's,  423 
and  preputial  frill  or  chin,  420 
prognosis  of,  421 
sequelae  of,  420 
treatment  of,  421 
in  young  boys,  417 
Paraplegia  and  gonorrhoeal  affections  of  the 
spinal  cord,  274 
syphilitic,  801 
Parasites  of  the  normal  urethra,  Lustgarten 

and  Mannaberg,  92 
Parchment-like  chancres,  545 
Parenchvmatous  inflammation  of  prostate, 

2i2 
Parotid  gland,  syphilis  of,  765 
Paternal  transmission  of  syphilis,  925 
Pelvic  disease  and  minor  surgical  gynecoi- 
ogy,  287 
organs,  sequelae  of  gonorrhoea  of,  307 
Penis,  amputation  of,  453 
cancer  of,  442 

chancroid  of  integument  of,  57 
curvature   of,   from   cutting  and  over- 
dilatation,  368 
of,  in  paraphimosis,  419 
from  phimosis,  405 
extirpation  of,  455 
gummatous  infiltration  of,  785 
horny  growths  of,  440 
inflammation  of,  278 


Penis,  inflammation  of  follicles  of  skin  of,  193 
sarcoma  of,  456 
syphilitic  affections  of,  785 
Peptonuria  in  early  syphilis,  593 
Periarteritis  and  gangrene  in  syphilis,  744 
Pericarditis,  gonorrhoeal,  270 

syphilitic,  757 
Pericardium,  gummata  of,  757 
Perichondritis  of  larynx,  752 
Perihepatitis,  syphilitic,  760 
Perineal  tube,  380 

Period  of  incubation  of  gonorrhcea,  107 
Perionychia,  syphilitic,  662 
forms  of,  662 
difliise,  662 
non-ulcerative,  662 
ulcerative,  662 
Periostitis  in  hereditary  syphilis,  955 
Perrin  on  gonorrhoeal  cutaneous  affections, 

275 
Peritoneum,  gonorrhoea  of,  307 
hereditary  syphilis  of,  941 
syphilis  of,  767 
Peritonitis  in  the  male  due  to  gonorrhoea, 

268 
Periurethral  abscesses,  196 
follicles  in  women,  284 
course  of,  303 
fistulfe  following,  303 
negative  history  in,  303 
objective  symptoms  of,  303 
seat  of,  303 
sinus  following,  303 
Phagedena  and  chancres,  550 
Phagedenic  chancroid,  500 
Phalanges,  syphilis  of,  783 
Pharynx,  gummata  of,  750 
tertiary  syphilis  of,  750 
Phimosis,  401 

accidental  or  acquired,  404 
and  balano-posthitis,  403 
chancroidal,  407 

lateral  incisions  for,  415 
treatment  of,  408 
cicatricial,  405 
circumcision  for,  410 
methods  of,  410 
congenital,  401 
results  of,  402 
symptoms  of,  402 
dorsal  incision  of  prepuce  in,  414 
in  elderly  men,  406 
and  fibroid  preputial  ring,  406 
forms  of,  401 
and  gangrene,  405 
gonorrhoeal,  405 

lateral  incision  of  prepuce  in,  415 
from  obesity,  406 
and  pointing  chin,  403 
and  short  frtenum,  404 
and  small  preputial  orifice,  404 
syphilitic,  406 

treatment  of,  408 

by  dorsal  incision,  414 
Phlebitis  complicating  gonorrlioeal  rheuma- 
tism, 266 
and  svpiiilis,  745 


INDEX. 


995 


Pia  mater,  syphilis  of,  793 
Pick  on  inoculations  in  syphilis,  24 
Pigmentary  syphilide,  637 
forms  of,  639 
diagnosis  of,  641 
Pineal  gland,  syphilis  of,  767 
Placenta,  lesions  of,  975 

syphilis  of,  975 
Plaques  des  fumeurs,  647 
Pleurisy  in  secondary  syphilis,  588 
Pneumonia,  epidynio-orchitis  in,  241 
Pointed  condyloma,  431 
Poisoning,  urinary,  387 
Polyarticular  gonorrhoeal  rheumatism,  263 
Post-mortem  findings  in  gonorrhoeal  peri- 
tonitis, 269 
Precocious  gummata,  642 
osseous  affections,  586 
synovitis,  585 
tertiary  syphilis,  717 
Pregnant   syphilitic   m.other,  treatment   of, 

960  ' 
Prehistoric  syphilis,  18 
Prepuce,  follicular  abscess  of,  192 
Preputial  follicles,  inflammation  of,  190 
Primitive  gangrene  in  tertiary  syphilis,  744 
Prophylaxis  of  gonorrhoea  in  the  female, 
309 
Broese  on,  309 
Rosthorn  on,  309 
Sanger  on,  309 
Prostate,  abscess  of,  212 
congestion  of,  211 
enlargement  of,  359 
parenchymatous  inflammation  of,  212 
gland,  anatomy  of,  40 
Prostatic  abscess,  gonorrhoeal  pyaemia  from, 
272 
urethra,  anatomy  of,  41 
Prostatorrhoea,  214 
course  of,  215 
'  symptoms  of,  214 
treatment  of,  218 
Protoiodide  of  mercury,  its  scope  and  limi- 
tations, 839 
pills,  839 
when  it  fails,  839 
when  of  therapeutic  effect,  839 
Pseudo-chancre  indure,  548 
Purpura  due  to  gonorrhoea,  275 
Pustular  syphilides,  624 
diagnosis  of,  626 
peculiarities  of,  624 
prognosis  of,  626 
treatment  of,  917 
Pyaemia,  epididvmo-orchitis  in,  242 
foci  of,  272' 
in  gonorrhoea,  272 

R. 

Eauzier  on  micro-organisms  in  the  urethra, 

94 
Raw-beef  form  of  chancres  in  women,  564 
Raynaud's  disease  and  sypliilis,  744 
Rectal  injections   of  iodide   of   potassium, 

907 


Rectum,  chancroid  of,  500 
gonorrhoea  of,  204 
gummata  of,  763 
parasyphilitic  productive  inflammation 

of,  765 
syphilitic  stricture  of,  765 
tertiary  syphilis  of,  762 
forms  of,  762 
Reder  on  inoculations  in  sypliilis,  24 
Reflex   disturbances  in  secondary  syphilis, 
585 
neuralgias  in  epididymo-orchitis,  238 
Reinfection  with  syphilis,  666 
Relapsing  indurations,  548 
Retention  of  urine,  385 

aspiration  in,  386 
Bumstead's  catheter  in,  385 
care  in  relief  of,  in  old  men,  386 
forms  of,  385 
relief  of,  385 

in  stricture  of  the  urethra,  335 
Thompson's  catheter  in,  385 
Retinitis,  syphilitic,  703 
Retrojections  in  gonorrhoea,  146 
Retzius,  anatomy  of  space  of,  39 
Rheumatism  in  early  syphilis,  587 
acute,  587 

epididymo-orchitis  in,  242 
gonorrhoeal,  260 
Rheumatoid  pains  in  early  syphilis,  587 
Ribs,  gummata  of  the,  775 
Ricord's  divisions  of  syphilis,  521 

on  the  etiology  of  gonorrhoea,  101 
on  gonorrhoea  of  the  os  uteri,  294 
law,  666 
RoUet  on  the  duality  of  syphilis  and  chan- 
croid, 22 
on  gonorrhoea  of  the  uterus,  292 
Rona   on  etiology  of   urethritis   in   young 
boys,  163 
on   frequency   of    posterior   urethritis, 
124 
Roseolous  syphilide,  604  ■ 
Rosthorn  on  prophylaxis  of  gonorrhoea  in 

the  female,  309 
Rubber-bag  injector,  135 
Rubidium  iodide  in  the  treatment  of  syph- 
ilis, 853 
Rupia,  forms  of,  740 
course  of,  741 
prognosis  of,  742 
Rupial  syphilide,  740 

tertiary  syphilides,  740 
Rupture  of  bladder  from  stricture  of  urethra, 
336 
of  strictures,  351 
of  the  urethra  from  stricture,  337 

S. 

Sarcocele,  syphilitic,  790 

Sarcoma  of  penis,  456 

Salivation    in    treatment  of   syphilis,   847, 

920 
Sanger  on  gonorrlupa  in  the  female,  281 
on  prophylaxis  of  gonorrhoea   in  the 

female,  309 


996 


INDEX. 


Savon  Napolitain  in  syphilis,  868 
Scaling  syphilides  of  palms  and  soles,  619 
Scapula,  gummata  of  the,  775 
Scarenzio's  calomel  injections  in   syphilis, 

873 
Scarlatiniform  eruptions,  276 
Schwartz  on  gonorrlicea  in  the  female,  281 

on  gonorrhoea  of  the  vagina,  296 
Sciatica   and  gonorrhoeal   affections  of  the 
spinal  cord,  274 
rheumatism,  266 
Sclera,  syphilitic  affections  of,  689 
Scleroderma,  stricture  at  the  meatus  follow- 
ing, 364 
Sclerosis   of  glans   in  stricture  of  urethra, 
339 
of  the  tongue  in  tertiary  syphilis,  746 
Scrotum,  chancre  of,  551 

gangrene  of,  238 
Seborrhoeic  process  and  syphilis,  608 
Secondary  syphilitic  afi'ections  of  the  ear, 
709 
syphilis,  524 
Semifibrous  stricture  of  the  urethra,  325 
Seminal  vesicles,  anatomy  of,  52 

in  gonorrhosal  peritonitis,  269 
hydrocele  of,  221 
inflammation  of  219 
vesiculitis,  acute,  219 
chronic,  221 
diagnosis  of,  224 
gonorrhoeal  pygemia  from,  272 
pathology  of,  226 
jM'ognosis  of,  226 
symptoms  of,  222 
treatment  of,  226 
tuberculosis  of,  223 
Separation  of  the  nails  in  syphilis,  661 
Sequelae  of  gonorrhoea  of  the  pelvic  organs, 
307 
of  indiscriminate   cutting   of  urethra, 
368 
Sero-vascular  conjunctivitis,  259 
course  of,  260 
prognosis  of,  260 
symptoms  of,  260 
treatment  of,  260 
Serpiginous  chancroid,  498 
syphilide,  737 

course  oi^  739 
deep,  738 
diagnosis  of,  739 
prognosis  of,  739 
superficial,  737 
treatment  of,  918 
Sinclair  on   latent    gonorrhoea  in   women, 

286 
Silver  catheter,  347 
Simple  buboes,  514 
Sims's  urethral  speculum,  female,  311 
Skene's  glands,  283 

in  chronic  urethritis,  291 
morbid  appearances  of,  301 
symptoms  of  inflammation  of,  302 
Skull-bones,  syphilis  of,_7_92 
Small  flat  papular  syphilides,  611 
Small-pox,  epididymo-orchitis  in,  240 


Smirnoff  on  the  hypodermic  use  of  calomel 

in  syphilis,  874 
Soft  chancre,  481 

palate,  gummatous  infiltration  of,  748 
stricture  of  the  urethra,  325 
Sounds,  Beneque's,  342 
conical  steel,  341 
curve  of,  342 
Sources   of  error   in   so-called   stricture  of 

large  calibre,  370 
Space  of  Retzius,  anatomy  of,  39 
Spasmodic  stricture  of  urethra,  330 
Specificity  of  the  gonococcus,  95 
Speculum,  urethral,  180 

Brown's,  281 
Spermatic  cord,  hydrocele  of,  477 
infection  in  syiihilis,  925 
veins,  excision  of,  463 
Spermatocele,  471 
Spleen,  gummata  of,  760 

hereditary  syphilis  of,  943 
syphilitic  inflammation  of,  760 
tertiary  syphilis  of,  760 
Spreading  of  mercurial  ointment  on  skin  in 

syphilis,  858 
Staining,  gonococcus,  method  of,  58 
Staphylococci  as  a  cause  of  gonorrhoea,  61 
Steinschneider  on  gonorrhoea  in  the  female, 
281 
on   gonorrhoea  of  the  female  urethra, 
289 
of  the  uterus,  292 
of  the  vagina,  295 
Stenosis  of  os  uteri,  syphilitic,  787 
Stewart  on  the  fallacies  of  the  urethrameter, 

366 
Stomach,  round  ulcers  of,  in  syphilis,  762 

tertiary  syphilis  of,  761 
Stomatitis,  treatment  of',  919 
Strangulation  of  the  testis  and  epididymis 

from  torsion  of  the  cord,  245 
Strauss  on  micro-organisms  in  the  urethra, 
95 
on  virulent  buboes,  514 
Streptobacillus,  Ducrey-Unna,  491 
Streptococci  as  a  cause  of  gonorrhoea,  61 
Streptococcus  in   gonorrhojal   rheumatism, 
261 
and  staphylococcus  in  the  vagina,  288 
Strictures  beyond   the   peno-scrotal   angle, 
371 
ditulsion  in,  375 
forms  of,  371 

gradual  dilatation  in,  372 
instruments  for,  375 
internal  urethrotomy  for,  375 
treatment  of,  372 
congenital,  339 
examination  of,  353 
instrumental  examination  of,  354 
of  large  calibre,  365 

alleged  cases  of,  367 

frequency  of,  368 
conservative  examination  of,  369 
false  views  as  to,  366 
faulty  diagnosis  in,  367 
indiscriminate  cutting  of,  368 


IXDEX. 


99" 


Strictures   of   large   calibre,   indiscriminate 
over-dilatation  of,  3t)8 
instruments  for,  370 
sources  of  error  in  diagnosing,  370 
at  the  meatus,  362 
false  views  as  to,  362 
following  hard  cliancre,  363 
chancroids,  364 
keloid,  364 
scleroderma,  364 
injudicious  cutting  of  362 
meatus  sound  for,  363 
treatment  of,  362 
in  the  pendulous  urethra,  364 
treatment  of,  371 

instruments  for  the,  371 
varieties  of,  364 
of  rectum,  syphilitic,  765 
essential  cause  of,  765 
of  the  urethra,  79,  323 
abscesses  behind,  336 

of  prostate  from,  336 
age  at  which  it  develops,  329 
bands  and  rings  in,  329 
of  bulbous  portion,  325 
causes  of,  339 
changes  in  bladder  in,  337 
Civiale's  concealed  bistoury  in,  348 

urethrotome  in,  349 
condition  of  kidneys  in,  337 

of  membranous  vu-ethra  in,  329 
of  ureters  in,  337 
of  urine  in,  337 
course  of,  332 
definitions  of,  324 
degrees  of  severity  in,  326 
development  of,  332 
divulsion  in,  351 
electrolysis  in,  385 
epididymitis  complicating,  335 
epididymo  -  orchitis   complicating, 

335 
evolution  of,  332 

statistics  of  the,  332 
excision  and  transplantation  of  mu- 
cous membrane,  384 
extent  and  depth  of,  324 
extravasation  of  urine  from,  337 
fistula;  behind,  336 
Fluhrer's  modification  of  Maison- 

neuve's  instrument,  348 
forms   of  extravasation    of    urine 

from,  337 
frequency  of  involvement  of  regions 

in,  328 
Gerster's  urethrotome  in,  348 
ill-health  from.  337 
incontinence  of  urine  complicating, 

335 
inflammatory,  330 
inodular,  326 
instrumental  incision  of,  347 

for  rupture  of,  347 
keloid  in,  339 

Maisonneuve's  urethrotome  in,  351 
Otis's  dilating  urethrotome  in,  350 
pathological  complications  of,  336 


Strictures  of  the  urethra,  peculiar  form  of, 
327 
of  pendulous  portion,  325 
pouches  behind,  336 
regions  of  the  canal  attacked  in, 

328 
retention   of    urine    complicating, 

335 
rupture  in,  352 

of  bladder  from,  336 
of  the  urethra  in,  337 
sclerosis  of  glans  in,  339 
scope  and  limitation  of  term,  331 
semifibrous,  324 
so-called  inflammatory,  330 

spasmodic,  330 
soft,  324 

of  subpubic  portion,  325 
sufferings  from,  337 
symptoms  of,  333 
trauma  in,  340 
ulceration  behind,  336 
varieties  of,  330 
in  women,  291 
Subcutaneous  ligature  in  varicocele,  464 
Sublimate  baths  in  the  treatment  of  syph- 
ilis, 914       _ 
spray  in  syphilis,  915 
Sublingual  gland,  syphilis  of,  766 
Subpreputial  chancroids,  502 
Superficial  and  deep  lymphatic  ganglia  in 
secondary  syphilis,  578 

in  tertiary  syphilis,  579 
Suppurating  hydrocele,  471 
Suprarenal  capsule  and  Addison's  disease, 
gummata  of,  766 

hereditary  syphilis  of,  945 
syphilis  of,  766 
Swollen  testicle,  228 

diagnosis  of,  247 
Symbiosis  of  syphilis  and  seborrhoeic  pro- 
cess, 607 
of  syphilis  and  tuberculosis,  675 
Syme's  method  of  external  uretiirotomy,  381 
Symmetrical  gangrene  in  syphilis,  744 
Sympathetic  buboes,  513 

nerves,  syphilis  of,  797 
Synovial  sheaths,  hereditary  syphilis  of,  949 
Synovitis  in  secondary  syphilis,  585 
Syphilides,  absence  of  itching  and  pain  in, 
598 
acneform,  625 
bullous,  742 

color  and  pigmentation  of,  599 
course  of,  597 
diagnosis  of,  602 
ecthymaform,  631 

varieties  of,  632 
erythematous,  603 
forms  of,  606 
annular  forms  of,  607 
general  considerations  of,  595 
impetigoform,  629 

influence  of  intercurrent  diseases  upon, 
600 
of  mercury  on,  599 
large  flat  papular,  616 


998 


INDEX. 


Syphilides,  lenticular  papular,  611 
localization  of,  601 
malignant  precocious,  634 
microbic  complications,  598 
nomenclature  of,  596 
miliary  papular,  611 
papular,  610 

diagnosis  of,  618 

prognosis  of,  618 

vegetating,  618 
pathology  of,  595 
pigmentary,  637 
polymorphism  of,  598 
pustular,  624 
roseolous,  604 
rupial,  740 

scales  and  crusts  of,  601 
scaling  of  palms  and  soles,  619 
small  flat  papular,  611 
tendency  to  circular  form,  599 
treatment  of,  916 
ulcers  and  cicatrices  of,  602 
unusual  modes  of  evolution,  600 
variolaform,  627 
vesicular,  628 
Syphilis,  519 

abortion  of,  by  early  mercurialization, 

813 
accidental,  538 
acquired,  521 
and  acute  diseases,  671 
agents  of  mediate  infection  in,  539 
analogically  considered,  520 
and  aneurysm,  678 
and  animals,  670 
of  aponeuroses,  770 
of  arachnoid,  793 
of  arteries  of  brain,  794 
atrophy  of  tongue  in.  748 
by  auto-infection,  539 
of  Blandin-Nuhn  gland,  766 
of  bones,  772 
of  brain,  794 
of  bursie,  770 
and  cancer,  676 
and  chancroid,  520 
of  cochlea,  713 
condylomatous  stage  of,  524 
constitutional,  524 
of  cord,  794 

of  corpora  cavernosa,  785 
course  of,  519 
d'emblee,  fallacy  of,  521 
diabetes  insipidus  in,  785 
divisions  of,  521 

Ricord's,  521 
of  dura  mater,  793 
early,  albuminuria  in,  591 

ephemeral  nephritis  in.  591 

glycosuria  in,  592 

hypersemia  of  pharynx  in,  588 

hyperplasia  of  pharynx  in,  588 

jaundice  in,  591 

osseous  affections  in,  586 
,  peptonuria  in,  593 

^J  rheumatism  in,  587 

acute,  in,  587 


Syphilis,  early,  acute  articular  rheumatism 
in,  587 

rheumatoid  pains  in,  587 
of  Fallopian  tubes,  787 
first  period  of  incubation  of,  526 
forms  of,  521 
galloping,  635 
gangrene  of  foot  in,  744 

of  tongue  in,  744 
and  gout,  671 

gummatous  infiltration  in,  925 
of  heart,  757 

hemiatrophy  of  tongue  in,  748 
hemorrhagic,  593 
ignored,  720 

as  an  infectious  disease,  520 
of  the  innocent,  538 

its  pathological  resemblances,  519 

probable  microbic  origin,  520 
at  late  periods  of  life,  668 
of  liver,  758 
of  lungs,  755 
and  malaria,  672 
of  mastoid  process,  712 
mediate  infection  in,  539 
of  metacarpal  bones,  781 
of  metatarsal  bones,  781 
mode  of  beginning,  522 

of  onset,  523 
modes  of  infection  in,  537 

by  direct  contact,  537 
nature  of,  519 
of  nerves,  795 
nervous  system,  790 

treatment  of,  919 
normal  secretions  of,  536 

not  infectious,  536 
occulta,  721 
of  OS  uteri,  786 
of  ovaries,  787 
ovular  infection  in,  926 
of  pancreas,  766 
of  parotid  gland,  765 
paternal  transmission  of,  925 
pathology  of,  528 
periods  of  incubation  of,  526 

length  of,  526 
of  peritoneum,  767 
of  phalanges,  783 
of  pia  mater,  793 
of  pineal  gland,  767 
of  the  placenta,  975 
processes  of,  528 
production  of  neuroglia  in,  534 
and  pus-microbes,  520 
and  rlieumatism,  671 
second  period  of  incubation  of,  526 
secondary,  524,  577 

analgesia  in,  584 

angina  pectoris  in,  589 

asthenia  in,  582 

cachexia  in,  581 

chloro-ana^mia  in,  582 

course  of,  578 

disturbances    in    the   sympathetic 
nerves  in,  577 

h?emoglobinuria  in,  593 


INDEX. 


999 


Syphilis,  secondary,  hyperfemia  of  spleen 
in,  590 

hysteria  in,  583 

insomnia  in,  577 

neuralgia  in,  577 

pleurisy  in,  588 

superficial    and    deep     lymphatic 

ganglia  in,  578 
typhoidal  conditions  in,  582 
of  skull-bones,  792 
spermatic  infection  in,  925 
sequelfe  of,  527 

stage  of  general  manifestations  of,  524 
of  sublingual  gland,  766 
symmetrical  gangrene  in,  744 
of  sympatiietic  nerves,  797 
symptoms  of,  at  evolution  of  secondary 

stage,  576 
of  tendinous  sheaths,  770 
of  tendons,  770 
tertiary,  715 

question  of  infectiousness  of,  722 
of  thyroid  gland,  766 
and  traumatisms,  672 
treatment  of,  accessory  means  of,  840 
advantages  of  delay  until  onset  of 

secondary  symptoms,  824 
blood-serum  in,  871 
blue  pill  in,  837 
calomel  in,  837 

plasters  in,  868 
soap  in,  869 
by  continuous  tonic  plan,  828 
fallacies  of,  829 
shortcomings  of,  830 
dangers  of,  831 
care  of  patient  in,  840 
cocoa  extract  in,  855 
Donovan's  solution  in,  853 
by  expectant  plan,  826 

fallacies  and   dangers  of, 
828 
in  first  year,  843 
Fournier's  method  of,  831 
gallate  of  mercury  in,  838 
general  methodical,  833 
heat  in,  913 
hot  batlis  in,  912 
water  in,  841 
hygiene  of  patient  in,  835 
hypodermic  injections  in,  872 

advantages  of,  872 
indications  for  very  early,  823 
interrupted  method  of,  831 
by  inunction,  856 
iodide  of  potassium  in,  848 
by  iodide  of  rubidium,  853 
by  iodol,  853 
length  of   time  of   initial  course, 

841 
by  mercurial  flannels,  859 
mercurial  fumigation  in,  869 
plasters  in,  868 
soap  in,  868 
by  mercury,  824 
mixed  formula,  842 
murure  in,  855 


Syphilis,   treatment  of,  necessity  for  iodide 
of  potassium  in  early,  841 
opportune  time  for,  838 
preliminary  matters  in,  834 
protoiodide  of  mercury  in,  837 
salivation  in,  847 
in  second  year,  844 
sublimate  solution  in,  914 
electric,  915 
spray,  915 
succus  alterans  in,  854 
tannate  of  mercury  in,  838 
thyroid  extract  in,  871 
time  of  beginning,  821 
vegetable  mercury  in,  855 
vegetables  in,  854 
Zittman's  decoction  in,  854 
and  tuberculosis,  675 
of  uterus,  787 
vaccinal,  539 

various  diseases  and  morbid  condi- 
tions, 671 
vehicles  of  infection,  535 
vulnerability  of  skin  in,  674 
mucous  membranes  in,  674 
Syphilitic  affections  of  the  ciliary  body,  700 
of  the  conjunctiva,  685 
of  the  cornea,  687 
of  the  eye,  679 
of  the  eyelids,  683 
of  the  hair,  656 

forms  of,  656 
pathology  of,  659 
of  the  lachrymal  gland,  682 

passages,  680 
of  the  larvnx,  early,  649 
of  the  lens,  699 
of  the  nails,  660 
of  the  nose,  early,  649 
of  the  optic  nerve,  704 
of  the  orbital  bone,  679 
of  the  penis,, 785 
of  the  sclera,  689 
of  the  tongue,  superficial,  647 
of  the  vitreous,  705 
aphasia,  802 
asthenia,  582 
bones,  fragility  of,  776 
cachexia,  581 
chloro-ansemia,  582 
chorea,  802 
choroiditis,  700 
dementia,  803 
endocarditis,  757 
epilepsy,  800 
exostoses,  773 
fever,  580 

course  of,  580 
prognosis  of,  581 
types  of,  580 
gangrene  of  tiie  extremities,  744 
general  paralysis,  803 
hair,  pathology  of,  659 
treatment  of,  ()59 
prognosis  of,  659 
diagnosis  of,  659 
hemiplegia,  798 


1000 


INDEX. 


Syphilitic  hepatitis,  760 

horns  of  the  palm,  621 

infant  after  birth,  treatment  of,  966 

infection,  modes  of,  531 

pathology  of,  528 

vehicles  of,  535 
inflammation  of  spleen,  760 
iritis,  690 

forms  of,  691 

infantile,  698 
locomotor  ataxia,  802 
muscular  contraction,  768 
multiple  neuritis,  804 
myositis,  767 
nodes,  773 
onychia,  660 
orchitis,  790 
osteoperiostitis,  772 
paraplegia,  801 
pericarditis,  757 
perihepatitis,  760 
perionychia,  difl^use,  633 

non-ulcerative,  662 

ulcerative,  662 
phimosis,  406 
phlebitis,  745 

processes,  pathology  of,  528 
reinfection,  666 
retinitis,  703 
sarcocele,  790 
stenosis  of  os  uteri,  787 
stricture  of  bronchi,  755 

of  oesophagus,  753 

of  rectum,  765 

of  trachea,  755 
tumors  of  nervous  system,  797 
ulcus  elevatum,  543 
Syphiloma,  hypertrophic,  of  face,  726 
Syphilophobia,  805 

Syringes  for    acute   gonorrhoea,   declining, 
134 
for  gonorrhoea,  134 

T. 

Tanturri  on  inoculations  with  pus,  27 
Taylor's  syringe  in   treatment  of   chronic 
urethritis  or  gonorrhoea,  175 
urethral  speculum,  180 
Teale's  probe  gorget,  380 
Technique  of  injections  in  gonorrhoea,  135 
Tendinous  sheaths,  syphilis  of,  770 
Tendons  attacked  in  gonorrhoeal  rheuma- 
tism, 263 
syphilis  of,  770 
Tertiarism,  715 
Tertiary  syphilides,  723 
bullous,  742 
gummatous,  723 
rupial,  740 
serpiginous,  737 
syphilis,  715 

aflections  of  tongue  in,  745 
of  bronchi,  755 
course  of,  7l6 
etiology  of,  722 
evolution  of,  719 


Tertiary  syphilis,  forms  of,  719 
frequency  of,  718 
gangrene  in,  743 
ulcers  in,  743 
of  intestines,  762 
of  larynx,  751 
of  liver,  758 
nature  of,  720 
of  oesophagus,  753 
parts  attacked  by,  718 
pathology  of,  716 
of  pharynx,  750 
precocious,  717 
primitive  gangrene  in,  744 
of  rectum,  762 

sclerosis  of  tongue  in,  745,  746 
of  spleen,  760 
statistics  of,  718 
of  stomach,  761 
superficial     and    deep    lymphatic 

ganglia  in,  579 
of  testis,  790 
of  trachea,  754 
tubercular,  730 
Testicle,  hereditary  syphilis  of,  945 

swollen,  228 
Testis,  abscess  of,  237 
anatomy  of,  53 

atrophy  of,  from  gonorrhoea,  237 
gangrene  of,  238 
gummata  of,  790 
neuralgia  of,  238,  246 
strangulation   of,  from   torsion   of  the 

cord,  245 
tertiary  syphilis  of,  790 
Third  generation,  transmission  of  syphilis 

to,  930       . 
Thompson's  two-glass  test.  121 
Thornburn's  statistics  of  gonorrhoeal  pelvic 

disease,  288 
Thyi'oid  extract  in  the  treatment  of  syphi- 
lis, 871 
gland,  syphilis  of.  766 
and  myxoedetna,  766 
Time  for  beginning   treatment  of  svphilis, 

821 
Tommasoli  on  inoculations  with  pus,  28 
Tongue,  affections  of,  in   tertiary   syphilis, 
745  _ 

atrophy  of,  in  syphilis,  748 
chancre  of,  556 
early  syphilis  of  the,  648 

treatment  of,  648 
hemiatrophy  of,  in  syphilis,  748 
gummata  of,  746 

sclerosis  of,  in  tertiary  syphilis,  745 
Tonsil,  chancre  of,  557 
Tonsillitis,  epididymo-orchitis  in,  239 
Torsion  of  the  cord,  245 
Tour  de  maitre,  357 
Touton   on  the  bacteriology  of  gonorrhoea 

of  the  vulvo-vaginal  gland,  306 
Toxic  effects  of  iodide  of  potassium,  851 

on  the  .skin,  852 
Trachea,  gummata  of,  754 

syphilitic  stricture  of,  755 
symptoms  of,  755 


INDEX. 


1001 


Trachea,  tertiary  syphilis  of,  774 
Transmission   of  syphilis   to  third   genera- 
tion, 930 
Trauma  in  strictui-e  of  urethra,  340 
Traumatism  and  syphilis,  672 
Triangular  ligament,  anatomy  of,  44 
Tripperfaden,  73 
Tubercular  syphilide,  annular,  731 

colloid  degeneration  of,  733 

course  of,  731 

diagnosis  of,  736 

of  face,  732 

forms  of,  730 

hereditary,  735 

treatment  of,  918 

tertiary,  730 

vegetating,  732 
Tuberculo-gangrenons  syphilide,  744 
Tuberculosis  of  seminal  vesicles,  223 
and  syphilis,  675 
of  testis  in  children,  948 
Tubes,  gonorrhoea  of,  306 
Tunnelled  sound,  256 
Two-glass  test  in  acute  gonorrhoea,  121 
Typhoid  fever,  epididymo-orchitis  in,  242 
Tvphoidal  condition  in  secondary  syphilis, 

582 
Typhose  syphilitique,  582 
Tyson's  gland,  33 
anatomv  of,  33 


U. 

Ulcero-membranous  stomatitis,  gonorrhoea!, 

209 
Ulcus  elevatum,  chancroidal,  499 
syphilitic,  543 

in  women,  563 
Ultzmann  on  acute  anterior  urethritis,  123 
hand-syringe,  135 

syringe  in  treatment   of    chronic   ure- 
thritis or  gonorrhoea,  171 
Umbilical  vein,  hereditary  syphilis  of,  951 
Umbilicated  or  follicular  chancre,  544 
Unna  on  herpes  progenitalis  in  women,  425 
Urethra,  abscess  of  follicles  of,  198 
anatomy  of  the  female,  283 
anterior,  Aubert  on  lavage  of,  123 

chronic    gonorrhoea   or   urethritis 

in,  167 
lavage  of,  123 
calibre  of,  48 
chancre  of,  551 
dilatability  of  normal,  331 
endoscopic  findings  in,  183 
epididymo-orchitis  from   operation  in, 

242 
exploration  of,  340 
gonorrhipa  of  the  female,  289 
micro-organisms  in,  Aubert  on,  93 
Bockhart  on,  94 
Castex  on,  94 
Legrain  on,  94 
Rauzier  on,  94 
wStranss  on,  95 
Zeissl  on,  94 
over-dilatation  of,  368 


Urethra,  posterior,  chronic  urethritis  or  gon- 
orrhoea in,  167 
stricture  of,  323 
in  women,  291 
Urethral  fever,  387 
acute,  388 
fulminating,  388 

Banks  on,  388 
pathology  of,  389 
spasm,  331 
Urethrameter,  345 

Urethritis,  acute  anterior,  Guyon  on,  123 
Ultzmann  on,  123 
chronic,  infectiousness  of,  171 

Skene's  glands  in,  291 
external,  190 

in  the  female,  301 
membranous  desquamative,  189 
posterior,  156 
acute,  156 

albuminuria  in,  159 
diagnosis  of,  160 
prognosis  of,  160 
symptoms  of,  156 
treatment  of,  160 
frequency  of,  123 
Eraud  on,  124 
Heisler  on,  124 
Lanz  on,  124 
Letzel  on,  124 
Eona  on,  124 
in  young  boys,  163 
etiology  of,  163 

Koplik  on,  163 
Cseri  on,  163 
Rona  on,  163 
treatment  of,  165 
Urethro-cystitis  and  cystitis,  184 
diagnosis  of,  186 
pathology  of,  184 
sequelae  of,  185 
symptoms  and  course  of,  185 
treatment  of,  187 
urine  in,  185 
Urethrotome,  348 
Civiale's,  349 
Fluhrer's,  348 
Gerster's,  348 
Maisonneuve's,  351 
Otis's  dilating,  350 
Urethrotomy,  external,  377 

internal,  375 
Urinary  abscess,  treatment  of,  391 
fever,  chronic,  388 
fistuiffi,  treatment  of,  391 
infection,  387 

Achard  and  Hartmann  on,  389 
chronic,  388 
Halle  on,  388 
Krogius  on,  389 
pathology  of,  389 
treatment  of,  390 
various  causes  of,  389 
poisoning,  387 
Urine,  retention  of,  385 
Urticarial  eruptions,  276 
TJtero-placental  infection,  927 


1002 


INDEX. 


Uterus,  anatomy  of,  284 
guriimata  of,  786 
micro-organisms  of,  284 
syphilis  ofj  787 

V. 

Vaccinal  syphilis,  539 
Vagina,  anatomy  of,  284 
chancre  of,  566 
chancroid  of,  501 
gonorrhoea  of,  295 
gummata  of,  787 

streptococcus  and  staphylococcus  in,  288 
Vaginitis,  298 

diphtheroid,  298 

Verchere  on,  298 
its  distinction  from  gonorrhoea,  298 
Van  Swieten's  liquid  in  syphilis,  915 
Varicocele,  ablation  of  scrotum  for,  466 
Bennett  on,  460 
causes  of,  461 
classification  of,  461 
condition  of  testis  in,  462 
definition  of,  460 
diagnosis  of,  462 

epididymitis  complicated  by,  236 
and  redundant  scrotum,  466 
symptoms  of,  462 
treatment  of,  463 

by  suspensories,  463 
by  open  operation,  463 
by  ligation,  463 
Variolaform  syphilide,  627 
Vas  deferens,  gonorrhoeal  inflammation  of, 
236 
inflammation   of,  and  gonorrhoeal 
peritonitis,  269 
Vegetable  mercury  in  sy;)hilis,  855 
Vegetations  and  cancer  of  the  penis,  446 
causes  of,  431 
clinical  features  of,  433 
complications  of,  433 
contagiousness  of,  436 
definition  of,  431 
development  of,  432 
diagnosis  of,  437 
divisions  of,  431 
epithelioma  following,  435 
and  fleshy  tabs  in  women,  437 
horny  or  corneous,  434 
perforation  of  prepuce  by,  434 
prognosis  of,  437 
seats  of,  432 
soft,  432 
as  svmptomatic  of  gonorrhoea  in  female, 

298 
treatment  of,  438- 
in  women,  434 
Vegetating  papular  syphilides,  618 

tubercular  syphilide,  732. 
Vehicles  of  syphilitic  infection,  535 
Velvet-eye  catheters,  346 
Verruca  acuminata,  431 
vegetante,  431 


Vertebrae,  gummata  of  the,  777 
Verumontanum,  anatomy  of,  42 
Vesicular  hereditary  syphilide,  934 
Vidal  on  inoculations  with  pus,  27 
Virulent  buboes,  514 

Strauss  on,  514 
Vitreous,  syphilitic  afl:ections  of,  705 
Volkmann's  operation  for  hydrocele,  476 
Von  Diiring  on  Colles's  law,  929 
Vulnerability  of  the  skin  in  syphilis,  674 

of  mucous  membranes  in  syphilis,  674 
Vulva,  gonorrhoea  of,  300 
Vulvitis,  follicular,  301 

simple,  in  children,  317 
symptoms  of,  317 
morbid  appearances  of,  317 
Vulvo-vaginal  glands,  283 
abscess  of,  304 
gonorrhoea  of,  305 
Vulvo-vaginitis,  catarrhal,  316 
Epstein  on,  316 
in  children,  317 
course  of,  317 
diagnosis  of,  317 
gangrenous,  318 
gonorrhoeal,  318 
phlegmonous,  318 
symptoms  of,  317 
in  infants  and  young  children,  315 

anatomical  considerations 

of,  316 
causes  of,  315 


W. 

Wagner  on  late  syphilis  of  kidney,  783 

Warts  as  symptomatic  of  gonorrhoea  in  the 
female,  298 

Watrazewski  on  hypodermic  medication  in 
syphilis,  884 

Watson's  treatment  of  buboes,  518 

Weir's  meatoscope,  180 

Welander's  experiments  on  gonococcus,  90 
on  gonorrhoeal  vaginitis  in  young  girls, 
299 

Wertheim   on   the  bacteriology   of   pelvic 
gonorrhoea,  308 
cultivation  of  the  gonococcus  by,  88 
inoculation  of  the  gonococcus  by,  62 

Wheelhouse's  method  of  external  urethrot- 
omy, 381 

Whooping   cough,  epididvmo-orchitis     in, 
240 

Wigglesworth  on  inoculations  with  pus,  27 


Z. 

Zeissl  on  gonorrhoeal  peritonitis,  269 
on  inoculations  in  syphilis,  24 
on  micro-organisms  in  the  urethra,  94 
Zoster   and    zosteriform    eruptions    in    the 

course  of  syphilis,  663 
Zuckerkandl  on  the  musculatui-e  of  urethra, 
365 


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